Encopresis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Medical Therapy
Soiling should always be treated as secondary to constipation (even if in doubt of another cause): 70-75% success
- Education and Reassurance: (Relieves anger and anxiety from parents and child.)
- Soiling is not intentional. (Child doesn't notice until soiling has occurred.)
- Child is not psychologically abnormal. (Behavioral problems will resolve once soiling has been treated successfully.)
- It can be treated successfully.
- Explain mechanisms of overflow-incontinence with pictures. (It is important for parents to understand the mechanisms of soiling well, as they might otherwise not comply with treatment, leading to treatment-failure.)
- Involve children if old enough. (Parents of children who have been toilet-trained for a few years have little idea about their child’s bowel habits, although they often assume great authority on the issue)
- Dissimpaction: Removal of the hard impacted stools in the rectum with a strong laxative (start when child is off school or nursery.) - e.g.:
- Bisacodyl orally 5 mg in mornings for 3 days (10 mg if over 5 years of age)
- Enemas or suppositories are invasive and are usually not needed. Success of treatment depends on its consequent and prolonged application, not on its invasiveness.
- Prevention of Re-accumulation: with a stool softener (start simultaneously with dissimpaction) for 6-12 months for the child to regain confidence and for the colon to return to it's original tone and shape. It is important to do this consequently, in sufficiently high doses, and for a sufficient length of time. Taper off treatment gradually after. - e.g.:
- Liquid Paraffin (mineral oil) (10 - 60 mls at night) titrated to effect (directly from fridge, with yogurt or ice-cream) (Contraindications: Children <1 year and children with neurological abnormalities or learning difficulties should not take liquid Paraffin, because of risk of pulmonary aspiration)
- Lactulose may be used in infants <1 year of age. It is less suitable because of day-to-day inconsistency of efficacy, making it difficult to titrate and possibly counterproductive to establish regular bowel pattern.
- Dietary fiber (e.g. fruits) + plenty of fluids are important, but on its own these measures will not be sufficient enough once stool withholding and soiling have established.
- No enemas or suppositories. These are for dissimpaction only. If hard stools have formed again, it means that re-accumulation has occurred and higher doses for its prevention are needed.
- Establishing regular bowel pattern: start after successful dissimpaction.
- Encourage the child to sit on toilet regularly, at the same time of day, at least once a day, for at least 5 min. Ideally done after breakfast (gastrocolic reflex).
- Continue on daily basis irrespective on whether or not the child has passed stools.
- A footstool or other support to ensure a child's hips can be fully flexed, and then a child can sit comfortably on the toilet.
References