Pudendal nerve function in normal and encopretic children

Encopresis in Children: An Overview of Recent Findings

The term ‘encopresis’, derived from ancient Greek ἐγκόπρησις / egkóprēsis, which means stool, was first introduced in 1926 by Weissenberg to describe the loss of stool in underwear as the faecal equivalent of enuresis. The soiling of underwear is defined as the accidental passage of very small amounts of faeces into underpants. Quantitatively, the content of stool between encopresis and soiling is difficult to determine, and it is especially difficult for parents assess it. Therefore, a new term was adopted – faecal incontinence – that encompasses both encopresis and soiling.

Faecal incontinence is defined as the discharge of faeces in socially awkward situations at least once per month in children ≥ 4 years old. In approximately 95% of cases, faecal incontinence in children is not organic in origin, but instead appears as a functional gastrointestinal disorder. In 80% of children with functional faecal incontinence, the symptoms are associated with functional constipation. The remaining 20% of the cases involve no signs of faecal retention and are defined as non-retentive functional faecal incontinence.

This paper aims to present the latest findings within this area of paediatric gastroenterology.

[Encopresis]

Encopresis is defined as functional faecal incontinence at 4 years of age or older and affects 1-3% of all school children. The two most important subtypes are encopresis with and without constipation. In preschoolers toilet refusal syndrome can occur. Comorbid behavioural disorders and urinary incontinence are common. The current state-of-the-art regarding aetiology, assessment and therapy is presented in this overview. A symptom-oriented behavioural approach (toilet training) is most successful, with the addition of laxatives (polyethylene glycol) if constipation is present. Biofeedback is not effective. Other forms of psychotherapy are indicated only in case of comorbid behavioural disorders. The long-term outcome has been poor and needs improvement.

Enkopresis - Prognosefaktoren und Langzeitverlauf

Zusammenfassung: Fragestellung: Diagnostische und klinische Faktoren sowie Behandlungsstrategien als prognostische Indikatoren für den Langzeitverlauf der Enkopresis im Kindes- und Jugendalter. Methodik: 85 Kinder und Jugendliche (Alter 9,6 ± 3,2 Jahre) mit Enkopresis (ICD 10 F98.1) wurden am Ende der stationären Behandlung und 35 von ihnen erneut nach einem Katamnesezeitraum von 5,5 ± 1,8 Jahren untersucht. Patienten mit geistiger Behinderung wurden ausgeschlossen. Die Therapie kombinierte stuhlregulierende und verhaltenstherapeutische Maßnahmen sowie eine Behandlung eventueller komorbider Achse-I-Störungen. Ergebnisse: Im stationären Verlauf kam es in 22% der Gesamtstichprobe zu völliger Symptomremission, in 8% bestand unveränderte Symptompersistenz. Bei den 35 Katamnesepatienten berichteten 40% Symptomfreiheit. Als signifikant entscheidend für den Erfolg stellten sich in der Nachuntersuchung Obstipationsfreiheit und die konsequente Therapie von psychiatrischen Begleiterkrankungen, v. a. des hyperkinetischen Syndroms, dar. Patienten mit einer Anpassungsstörung zeigten eine signifikant bessere Prognose als alle anderen Patienten. Diejenigen, die bereits zum Entlassungszeitpunkt symptomfrei waren, erwiesen auch in der Katamnese signifikant häufiger eine stabile Totalremission. Schlussfolgerungen: Die konsequente Behandlung einer Obstipation und die spezifische Therapie von psychiatrischen Begleiterkrankungen sind wichtige prognostische Faktoren der Enkopresis. Die stationäre Therapie führt signifikant häufiger zu langfristigem Erfolg, wenn erst bei Erlangung von Symptomfreiheit entlassen wird.

Enuresis and encopresis: ten years of progress

OBJECTIVE

To review the progress made over the past decade with regard to the treatment of enuresis and encopresis, as well as advances in the understanding of etiological mechanisms.

METHOD

Separate computerized literature (English language only) searches of Medline and PsycINFO databases were conducted under the parameter of enuresis and children-adolescents, as well as encopresis and children-adolescents.

RESULTS

There has been a substantial decrease in published research concerning the use of imipramine to treat enuresis compared with the prior two decades, accompanied by a corresponding increase in the number of papers concerning desmopressin acetate (DDAVP), which has become the primary pharmacological treatment. Genetic studies of large pedigrees have further confirmed the importance of heritable factors. With regard to encopresis, the research has focused primarily on pathophysiological factors related to the colon and anal sphincter.

CONCLUSIONS

The widespread use of DDAVP has been the primary addition to treatment strategies over the past decade. The bell-and-pad method of conditioning, the only major treatment that has enduring benefit after being withdrawn, is the most cost-effective and appears to be underutilized. Research into etiological mechanisms has focused primarily on the mechanism of action of DDAVP and advances in the understanding of genetic factors. Advances in the treatment and etiological understanding of encopresis have been less impressive.

Encopresis and anal masturbation

Current pediatric and psychiatric studies on encopresis and its treatment are heavily influenced by mechanical, physiological, and behavioral considerations. Although psychodynamic treatment has generally been considered to be of little benefit, and its findings suspect, the authors suggest that a psychodynamic approach adds substantially to the understanding of some cases of encopresis; that the anal sensations and anal erotic feelings reported by a number of encopretic children are intense, and that the encopretic symptom, soiling, in these children is the result of a conscious form of anal masturbation in which the fecal mass is used for stimulation; and that any study of encopresis is incomplete that does not include what encopretic children, engaged in a sound therapeutic relationship, know and say about their soiling. The authors further suggest that physical treatments of those children whose encopresis is psychologically driven may be contraindicated. The presence of a large stool does not in itself substantiate a physical illness. Further research is needed to elucidate the prevalence of anal masturbation in encopretic children.