Encopresis

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As encopresisin humans, the repeated arbitrary or involuntary defecation in clothing or the dumping of faeces in places not intended for this in the socio-cultural milieu of the respective person. The disease can occur in isolation or as part of a wider disorder. On the one hand, the phenomenon can also occur without an adequate bowel control being observed beforehand. Here, the disorder is understood as a longer duration of normal childhood incontinence that deviates from the norm and is sometimes also referred to as “primary” encopresis. On the other hand, it is possible that the disorder occurs after a standard-compliant bowel control had previously existed. This can be understood under the term “secondary encopresis”. Overall, physiological or psychological factors or a combination of both can turn out to be causes or triggers of encopresis. 

diagnosis

The encopresis is one of the so-called excretion disorders, which should be diagnosed as a rule only after a certain age. A disorder is only assumed if the period of the psychophysiological maturation variants with regard to the elimination control has been clearly exceeded when the findings were made. A diagnosis of "encopresis" should therefore usually be made in children from the age of 4 years at the earliest. As two further diagnostic criteria, it should be ascertainable that, firstly, bowel movements or defecation is the leading phenomenon of the entire disorder, and secondly, that it occurs more than once a month.

In the event of corresponding complaints, signs or symptoms, organic causes must first be ruled out. The findings should be as invasive and stressful as possible, especially for children. Diagnostics based on physical examinations, ultrasound and questionnaires on excretion and feces are usually sufficient.

frequency

There are different information on the frequency in the specialist literature, but it is considered certain that boys are affected significantly more often than girls.

In children around eight years of age, the incidence is 1.5%. It occurs most frequently between the ages of 7 and 9.

Enkopresis mostly only occurs during the day. In 25% of cases, enuresis (wetting) occurs in addition to encopresis .

to form

As with wetting, a distinction is made between primary and secondary forms:

  • Primary defecation affects children over 3 years of age who have never learned to control their bowel movements - stool control should be performed in the 2nd – 3rd Be completed.
  • Secondary feces affect children of all ages who have been clean before and suddenly “relapse” again.

A distinction is made between 2 types of feces:

  • 1. Retentive encopresis , which is caused by chronic constipation (80–95% of cases).
  • 2. Non-retentive encopresis , with psychological causes (5–20% of cases).

Organic diseases e.g. B. Hirschsprung's disease (Megacolon congenitum) or spina bifida can be the cause of encopresis, but encopresis is the first manifestation of these diseases only in extremely rare cases.

Retentive encopresis (feces associated with constipation)

Vicious circle of constipation and stool retention
Constipation Scheme

80–95% of cases of encopresis are caused by constipation and stool retention (stool retention), i.e. by a physical dysfunction (German synonym overflow encopresis , English retentive encopresis or soiling ).

root cause

This is a simple dysfunction that maintains itself as a vicious circle .

  1. Long-term constipation (chronic constipation ), which can often occur in children, is the starting point of the vicious circle .
  2. This causes large and hard masses of stool to form in the rectum and lower colon .
  3. The emptying of these hard stool masses through the anus ( anus ) is painful. The pain is increased considerably if cracks in the anus ( anal fissures ) have arisen from the hard stool . Infections of the anus, e.g. B. Fungal ( Candida ) or streptococci can cause pain during bowel movements.
  4. Fear of the pain when defecating, the children hold back the feces ( stool retention ). This, in turn, makes constipation worse . Another cause of stool retention can also lie in disgust or irrational fears of the child in front of the toilet (e.g. monsters, abyss). When children find it difficult to hold back the chair, they sometimes take positions that make it easier (for example, crouching or standing still for long periods of time). In order to have an alibi for this, they then pretend that they are looking for something on the floor or tying their shoes ( chair retention behavior ).
  5. With the expansion and slackening of the intestinal wall, there is also a loss of sensitivity. This means that the children lose the feeling that the bowels are full and need to be emptied. You also no longer notice when the chair pushes itself outwards due to the pent-up pressure.
  6. The soft stool in the upper part of the large intestine that has not yet thickened can slide past the hard stool masses unnoticed by the high pressure ( intestinal overflow ). The children only notice this when they feel the warm excrement in their pants.

consequences

Apart from the practical circumstances that it creates in everyday life, the defecation means an enormous emotional burden both for the children concerned and for the parents.

  • In children it causes shame, feelings of inferiority and fear of punishment or ridicule. It can lead to fear of failure, prevent social contacts and trigger mental disorders. Trying to keep it a secret can lead to actions that may be misinterpreted as intentional by the parents, e.g. B. Hiding the soiled clothes in "impossible" places.
  • For their part, parents are often shocked because they believe that their child is "abnormal". If you assume that your child is doing it on purpose, this can lead to the child being punished or even chastised. Reciprocal accusations can result and even break up families.

Typical symptoms

  • Several soft stools a day: overflow incontinence (often misinterpreted as diarrhea)
  • occasionally very large masses of stool with partial discharge of the thickened feces
  • Pain when defecating from large and hard stool
  • Blood in the stool from occasional anal fissures or infections (from candida or streptococci )
  • Stool retention behavior:
    • For example, children are observed who stand in a corner for a long time before being pooped.
    • This can be misinterpreted as exerting pressure, which leads to the assumption that the pooping is intentional.
  • Children with severe constipation often appear powerless, pale and easily irritable.
  • Improvement of symptoms in previous doses of laxatives (laxative)

Examination by the doctor

The examination by the doctor aims to rule out the (rare) possible psychological and organic causes and to make a positive diagnosis of constipation with feces. The following questions play a role:

  • Ask about the typical symptoms
  • Questions about the milestones in child development: Were there any gross behavioral problems that suggest a psychological cause?
  • Questions about any physical injuries, for example in the event of an accident or sexual abuse
  • Was the newborn's first stool later than normal, i.e. H. later than 24–48 hours after the birth? (This could be an indication of Hirschsprung's disease .)
  • Dependence of the symptoms on special situations
  • Development of the symptoms
  • Fluctuations in the frequency of occurrence
  • previous pre-treatments
  • previous attempts at coping by the child and the family.

This is followed by a physical exam:

  • Examination of the abdomen ( abdomen ). When palpating the abdomen, special attention is paid to skybala (hard lumps of stool). Abdominal sonography is in no way stressful for the child and is part of the standard program for unclear abdominal complaints.
  • Inspection of the anal region (area around the anus) where attention must be paid to fissures and inflammation.
  • Whether a rectal examination (palpation of the rectum) should be carried out is a matter of dispute among doctors: The filling status of the rectum and the rectoanal reflex (internal relaxation) are checked. However, some medical specialists are of the opinion that this does not provide any necessary knowledge, but that it means additional and unnecessary trauma, especially for the children who are already traumatized at this point.
  • Examination of the back and the tendon reflexes of the legs. Any abnormalities here would indicate spina bifida .
  • Stool examination for hidden blood
  • In individual cases and if serious physical illnesses are suspected, further apparatus-based methods can be considered. Invasive examination methods that are stressful for the child, such as sphincter manometry and the like, will only be required in exceptional cases.

treatment

Unless another cause is obvious, all cases of faeces should be treated in the first instance as a consequence of constipation. Psychological causes should only be looked for if the faeces persist after successful treatment of the constipation. More extensive and invasive examinations for organic diseases should only be undertaken if the simple medical examination also provides specific information.

It is important to educate and encourage those affected. This brings about an important reduction in guilt and feelings of shame in parents and children, and the atmosphere changes from “irritable-hostile” to “understandable-supportive”.

  • Killing is not intended! (The child doesn't notice anything until it happens.)
  • The child is not abnormal! (Mental health problems are the result and not the cause.)
  • It can be treated successfully!
  • Detailed explanation of the relationships with the help of a sketch that illustrates the "intestinal overflow" mechanism. Parents are sometimes difficult to convince their child to start treatment for constipation when they look more like diarrhea.

The treatment of constipation consists of three parts:

  1. Defecation with a strong laxative (e.g. bisacodyl for 3 days). An enema is usually not necessary. It is best to start when the child does not have to go to school or kindergarten, as it naturally increases the feces at first.
  2. Avoidance of renewed constipation . Since the intestines are greatly dilated and intestinal sensitivity is reduced, it is only a matter of time before the intestine overfills and the problem starts all over again. This can be avoided by continuing to administer laxatives or stool softeners without interruption for 4 - 6 months. After this treatment time, the applied drug dose must be slowly reduced. The long treatment duration is necessary so that the intestine returns to its original size and elasticity and so that the intestinal sensitivity is restored. Another sensible measure is to give the child plenty of fluids and fiber (e.g. fruit). However, a high-fiber diet plays a less important role in children than in adults. It is not sufficient as the sole treatment measure for constipation.
  3. Chair training is necessary for the child to learn how to use the toilet regularly. It starts after successfully emptying the bowel. Regular use of the toilet should be carried out for at least 5 minutes and at least once a day at the same time of day (preferably after breakfast, as the gastrocolic reflex makes it easier to empty the bowel), regardless of whether or not an urge to defecate is felt. It is important to ensure that you sit relaxed on the toilet (comfortable, firm toilet seat, possibly supporting your feet with a footrest to enable relaxed sitting without tensioning the pelvic floor). Any fears or disgust the child may have in front of the toilet should also be addressed and, if necessary, clarified.

Non-retentive encopresis (feces without constipation)

Only 5–20% of encopresis cases can be traced back to psychological problems. One can distinguish internal and external causes:

Internal causes

Strong internal nervous tension in the child is cited as one of the causes of feces . It is difficult to answer why this is expressed in the form of potting. One can assume, however, that it represents a call from the child for affection and love, which can possibly be traced back to a disturbed parent-child relationship , sibling rivalry, excessive demands or overly accentuated performance behavior.

So, like wetting the bed, defecation often begins when a sibling is born, and the older child experiences that all of the love and attention is supposedly directed towards the newborn.

Children with hyperkinetic disorder may have an increased risk of encopresis because of the attention disorder, which also relates to proprioception (insufficient awareness of the filling pressure in the rectum).

Obsessive-compulsive disorder or fear of the toilet can lead to the retention of the stool and subsequent retentive encopresis (see above) .

External causes

Stress and changes are often the triggers for killing, e.g. B. a move, a new sibling, a hospital stay, change of school, divorce. The intestine is sensitive to all emotions. Conflicts and stressful situations express themselves in children mainly physically and in motivation to achieve, while the area of ​​relationships is underdeveloped. In affected families, great value is often placed on secondary virtues such as politeness, diligence and conscientiousness. But order, cleanliness, punctuality and obedience also play a major role.

The elementary basic experiences are rather underdeveloped. There is often a mother-child relationship that fluctuates between attachment (closeness) and detachment (distance). Basic experiences such as love and trust are particularly in need of development. The psychosomatic processing of the inner conflict is expressed in the decoction. Since children, like seismographs, show the actual family atmosphere, the symptom takes on a meaning in the family structure that needs to be made clear. In times of crisis, the child draws attention to areas of conflict in the family through early childhood behavior. Passively and speechlessly, the child shows through organ language that problems have become unbearable.

diagnosis

The anamnesis begins with a detailed questioning of the child and the parents. This is followed by a detailed physical examination to rule out the much more common physical causes of the pooping described above.

Important points of the survey are the frequency of the faeces, peculiarities of the faeces or whether the parents already had problems with drying out. Questions are also asked about how the cleanliness training has been carried out so far or which treatment measures have already taken place. It has been found useful to have the frequency and severity recorded by both the parents and the child. It should also be recorded whether and how the child is trying to hide the symptoms (e.g. by hiding their underwear). In addition, the time of day at which the faeces occur and whether enuresis is present at the same time should be recorded. In the exploration with the child, questions should be asked about so-called "toilet fears", pain during defecation and unsuccessful attempts at self-help, about the subjective level of suffering (teasing?), About the emotional stress and about the openness with which to deal with the next Caregivers can be talked about.

An interview with the parents (separately and together with the child) must also be conducted to determine the background to the encopresis. It is an extraordinary burden for both children and their parents if rectal control is not achieved at the expected point in time or if it is lost again. Many parents then believe that they have failed educationally, but these symptoms are extremely stressful and filled with shame for the children too. As a rule, they try to hide these weaknesses from their peers and to deny the symptoms even in front of familiar people. A usable diagnosis is therefore only possible after a "warming up". It is essential to create a familiar atmosphere and to approach the symptom objectively.

By interviewing parents or legal guardians, the aim is to find out whether there were any abnormalities in the child's development. The following points are asked for:

  • How did defecation develop in infancy and toddler age (frequency, amount, consistency, expressions of pain, ...)?
  • When work began on toilet training (importance of toilet training in the family) and how is it designed?
  • Was the toilet training inadequate?
  • Are there food intolerances and irregularities in bowel movements (diarrhea, constipation)?
  • Was it preceded by emotional or behavioral disorders?
  • Is there a previous history of physical and / or psychological trauma, for example through sexual abuse?

The role of toilet training plays a greater role in encopresis than it does in enuresis. Forced and punitive training can cause the child to hold back the chair and develop an overflow copresis. The parents' assessment of the symptoms and the child's reactions to them must be recorded. Parental psychiatric disorders (obsessive-compulsive disorder, substance-related disorders, schizophrenic psychoses) should be excluded. The living conditions must also be clarified (accessibility of the toilet, age-appropriate toilet, adequate lighting and heating).

After the physical examinations, the examinations for mental disorders (intellectual disability, obsessive-compulsive disorder, hyperkinetic syndrome, phobias, acute stress reaction, psychosis) are also carried out. The child's environment plays a major role here. First of all, general tests to clarify mental development disorders and ADHD are carried out here . In the further course, other obsessive-compulsive disorder etc. are searched for. Different tests are used for diagnosis.

treatment

The child should be given as many security experiences as possible. Any appeal to the child's conscience or to his or her sense of shame is to be refrained from; it would only trigger new or further feelings of guilt. The fouling is often not only embarrassing for the children concerned, it is not uncommon for parents to come to therapy with a feeling of guilt that they are responsible for the occurrence of the problem. You see yourself partly as a contributor.

The therapeutic approach is mainly a functionally oriented treatment concept, based on the personal characteristics of the child who is pooping the poop, those of his family, as well as the pooping behavior itself. In addition to family-centered, play therapy measures, behavioral, function-specific approaches come into play.

The forms of treatment of primary and secondary encopresis do not differ. With regard to comorbidity , it should be borne in mind that if a hyperkinetic syndrome is present, this should first be treated in a targeted manner in order to create the basis for an effective treatment of encopresis; the same applies to the presence of an anxiety and / or obsessive-compulsive disorder. If there is a socialization disorder, both encopresis and socialization disorder should be treated in parallel. In the case of comorbidity with enuresis , both disorders should also be treated therapeutically at the same time.

  • Reduction of the psychological stress through counseling the parents, education about the specifics of the illness with de-anxiety and reduction of guilt and feelings of shame in children and parents, especially in the affected children, this is often only possible in a cognitive-psychotherapeutic setting.
  • Psychotherapeutic measures . At the same time, a behavior therapy program with toilet training (regular use of the toilet after meals for at least 5 minutes, even if no urge to defecate is felt) should be carried out. It is important to ensure that you sit relaxed on the toilet (comfortable, firm toilet seat, possibly supporting your feet with a footrest to enable relaxed sitting without tensioning the pelvic floor). Reinforcement through praise and care. Additional use of amplifiers when the chair is put down in the toilet, such as playing together, doing joint activities.

literature

See also

Web links

Individual evidence

  1. ^ A b c d Dilling, Horst, 1933-, World Health Organization .: International Classification of Mental Disorders: ICD-10 Chapter V (F) clinical-diagnostic guidelines . 10th edition, taking into account the changes according to ICD-10-GM 2015. Hogrefe, Bern 2015, ISBN 978-3-456-85560-8 , p. 389 ff .
  2. ↑ a b c Pschyrembel Online. Retrieved August 13, 2019 .
  3. ↑ a b c AWMF (ed.): Guidelines on mental disorders in infants, toddlers and preschoolers . No. 028/041 , September 26, 2015, p. 82-90 .
  4. ^ Pschyrembel Online. Retrieved August 6, 2019 .
  5. ^ Lieb, Klaus, Frauenknecht, Sabine, Brunnhuber, Stefan, Wewetzer, Christoph: Intensive course in psychiatry and psychotherapy . 8th edition. Urban & Fischer in Elsevier, Munich 2016, ISBN 3-437-42528-5 , p. 378 .
  6. ↑ Biljana Vuletic: Encopresis in Children: An Overview of Recent Findings . In: Serbian Journal of Experimental and Clinical Research . tape 18 , no. 2 , June 1, 2017, ISSN  2335-075X , p. 157–161 , doi : 10.1515 / sjecr-2016-0027 ( sciendo.com [accessed August 6, 2019]).