Definitions & types

• Encopresis: repeated passage of stool into clothing or inappropriate places in children ≥4 years for at least 1 month (DSM‑5: specify with or without constipation/overflow).
• With constipation/overflow: most common — chronic stool retention, impacted rectum, and overflow leakage of liquid stool.
• Without constipation: less common — may reflect behavioural withholding, sensory issues, developmental disorders or organic pathology.

Common causes & risk factors

• Chronic functional constipation leading to stool withholding, rectal dilatation and overflow incontinence.
• Toilet training difficulties, painful defecation history, psychosocial stressors (school, family changes), neurodevelopmental conditions (autism, ADHD), and low fluid/fibre intake.
• Rare organic causes: Hirschsprung disease, spinal dysraphism, celiac disease, inflammatory bowel disease, neurological disorders—consider when atypical features present.

Clinical features — history & examination

1. History: stool frequency and consistency (use Bristol stool chart), onset, toilet training history, pain with defecation, withholding behaviours, daytime vs nighttime soiling, urinary symptoms and psychosocial stressors.
2. Examination: abdominal palpation for faecal mass, perianal inspection, growth parameters, neurologic exam (sacral abnormalities), and signs of systemic disease.
3. Alarm features suggesting organic disease: failure to thrive, delayed passage of meconium, bloody diarrhoea, severe abdominal distension, or focal neurologic signs — prompt specialist referral.

Investigations — targeted

• Most cases need no extensive testing. Plain abdominal X‑ray can document faecal loading when clinical uncertainty exists.
• Consider urine analysis, celiac serology, thyroid tests, or spinal imaging when alarm features or atypical history present.
• Specialist referral for anorectal manometry or contrast studies if Hirschsprung disease or severe refractory constipation suspected.

Management — principles

1. Remove faecal impaction: initial disimpaction using oral polyethylene glycol (PEG) high‑dose regimen, enemas or supervised hospital regimen depending on severity.
2. Maintenance therapy: regular osmotic laxative (PEG) with dose titration to produce soft, regular stools; continue for months while rectal tone normalises and re‑establish toileting habits.
3. Toileting program: scheduled toilet sits after meals (10 minutes), positive reinforcement, comfortable posture (foot support), and use of reward charts; avoid punishment or humiliation.
4. Behavioural interventions: education for family, addressing withholding behaviour, motivational strategies, and consider psychologist input when emotional/behavioural factors predominate.
5. Dietary measures: increased fibre and fluids, reduce constipating foods; ensure balanced diet and appropriate portion for age.
6. Follow‑up: regular monitoring (weight, stool pattern), gradual weaning of laxatives when stable stooling achieved, and long‑term plan to prevent relapse.

When to refer / red flags

• Alarm features: delayed meconium, severe abdominal distension, systemic illness, failure to thrive, neurologic signs, or bloody diarrhoea — urgent paediatric/surgical referral.
• Refractory encopresis despite adequate bowel management, significant psychosocial factors, or suspicion of underlying neurodevelopmental disorder — refer to paediatric gastroenterology, child psychiatry or multidisciplinary continence services.

Key takeaways

• Most encopresis is caused by functional constipation with overflow; address impaction, maintain soft stools with laxatives, and implement structured toileting and behavioural strategies.
• Use a compassionate, family‑centred approach; reserve investigations for atypical or refractory cases and refer urgently for alarm features.
• Follow‑up and clear communication with caregivers are essential for sustained recovery.