Faecal incontinence (previously called encopresis) is the loss of regular control of the bowels. Involuntary excretion and leaking are common for those affected, meaning underwear and clothing is often soiled. Faecal incontinence is very common, occurring in at least 1.5 per cent of children. It is one of the main reasons children are referred to a gastroenterology clinic.
The child may have stomach aches, cramps, vomiting or bloating. Some children become pale or flushed, lose their appetities, or even lose weight. Some have small tears in the anal tissue called anal fissures. These are painful and can lead to blood in the stool.
Children with this problem have different bowel habits. Some may not have any bowel movement for many days and then have a huge, hard stool, large enough to block the toilet! Other children have daily bowel movements on the toilet but also leak liquid, diarrhoea-like stool into their clothes. Some children do not stool in the toilet at all. Children may hide their soiled underwear in drawers or under the bed. This is a common coping mechanisim for a child with faecal incontinence.
What causes it?
Faecal incontinence is usually caused by constipation. Constipation often begins when a child holds back a bowel movement. The child may have experienced hard, painful stools previously and is hesitant to try again. Some children naturally have dry, hard stools. Other common causes include a diet change, nappy rash, viral illness, hot weather or travel. Cows milk allergy can be a contributing factor for between one quarter and two thirds of children with bad constipation.
Older children may start holding bowel movements when they go to school or camp and are faced with a toilet that is less private than at home. At any age, fear of discomfort or embarrassment can make a child try not to have a bowel movement. If this continues the result is constipation. The initial cause may have occurred many years before.
Withheld stool eventually fills the colon, stretching it out of its normal shape. The stool then dries out as the colon absorbs water from it. The longer the stool is held in the colon, the larger and harder it becomes, making bowel movements even more painful. This starts a vicious cycle. Normally, the colon muscles push stool out. However, the stretched-out, flabby colon muscles cannot push. Sometimes, the hard stool gets stuck and only liquid can pass around the rocklike stool. Stretched nerves become less sensitive and the child does not feel the leaking stool. The leakage looks like diarrhoea or wet staining in clothing or underwear.
Children with faecal incontience often refuse to change soiled clothing even though the odour is very unpleasant to other people. This can be upsetting for other family members but the affected child may not notice the unpleasant smell. As the child always has some stool on his or her clothes, they get used to the smell and it no longer bothers them. Many children with faecal incontinence also wet the bed at night or wet their clothing during the daytime. As a result, children with faecal incontinence may be teased by playmates or brothers and sisters. Teasing can lead to embarrassment, reluctance to attend school, fighting and other problems.
Constipation is treated with a three-part plan:
- ‘Cleanout’ to clear retained stool from the colon.
- Maintenance therapy to prevent stool build- up and allow the colon to return to its normal shape.
- Counselling to structure a treatment plan and encourage the child to cooperate.
Faecal incontinence is curable and children who follow the treatment plan will be able to regain control of their bowel movements. However, it may take many months for the intestine to regain strength and feeling after being stretched for a long time. Some children will continue to have constipation into adult life.
Continue a balanced diet with plenty of fruit and vegetables and use stool softeners as necessary. Relapsing is a common problem in long-term management. Restarting the three- step treatment process can help to bring back control.
Counselling and occupational therapy
Seeing a counsellor may help reduce tensions children and families feel because of faecal incontinence. The child’s condition often becomes a family problem. It is important to try to avoid anger or punishment around accidents, even though this may be difficult. Most often, the child is not being naughty; he or she simply cannot feel the stool coming out. It is the child’s responsibility, however, to take the medicine and do the sits without making a scene. Some children respond well to a carefully planned, consistent system of rewards for appropriate behaviours. This can be planned with the counsellor or with an occupational therapist.
Diseases which mimic faecal incontinence
Some other diseases have symptoms similar to faecal, but are much less common. However, if a child does not respond to treatment as expected, other tests may be recommended to be sure that the child has one of these other diseases. Diseases which mimic faecal incontinence include Hirschsprung’s disease, a high blood-calcium level due to parathyroid disease, hypothyroidism, spinal defects and cows milk allergy.
Lady Cilento Children’s Hospital
Level 3, 501 Stanley Street, South Brisbane
t: 07 3068 1111 (general enquiries)
In an emergency, always call 000.
If it’s not an emergency but you have any concerns, contact 13 Health (13 43 2584). Qualified staff will give you advice on who to talk to and how quickly you should do it. You can phone 24 hours a day, seven days a week.