If a child over 4 years of age has been toilet trained, and still passes stool and soils clothes, it is called encopresis. The child may or may not be doing this on purpose.

Soiling; Incontinence - stool; Constipation - encopresis; Impaction - encopresis

The child may have constipation. The stool is hard, dry, and stuck in the colon (called fecal impaction). The child then passes only wet or almost liquid stool that flows around the hard stool. It may leak out during the day or night.

Other causes may include:

• Not toilet training the child
• Starting toilet training when the child was too young
• Emotional problems, such as oppositional defiant disorder or conduct disorder

Whatever the cause, the child may feel shame, guilt, or low self-esteem, and may hide signs of encopresis.

Factors that may increase the risk of encopresis include:

• Chronic constipation
• Low socioeconomic status

Encopresis is much more common in boys than in girls. It tends to go away as the child gets older.

Symptoms can include any of the following:

• Being unable to hold stool before getting to a toilet (bowel incontinence)
• Passing stool in inappropriate places (as in the child's clothes)
• Keeping bowel movements a secret
• Having constipation and hard stools
• Passing a very large stool sometimes that almost blocks the toilet
• Loss of appetite
• Urine retention
• Refusal to sit on toilet
• Refusal to take medicines
• Bloating sensation or pain in the abdomen

The health care provider may feel the stool stuck in the child's rectum (fecal impaction). An x-ray of the child's belly may show impacted stool in the colon.

The provider may perform an examination of the nervous system to rule out a spinal cord problem.

Other tests may include:

• Urinalysis
• Urine culture
• Thyroid function tests
• Celiac screening tests
• Serum calcium test
• Serum electrolytes test

The goal of treatment is to:

• Prevent constipation
• Keep good bowel habits

It is best for parents to support, rather than criticize or discourage the child.

Treatments may include any of the following:

• Giving the child laxatives or enemas to remove dry, hard stool.
• Giving the child stool softeners, such as magnesium hydroxide, lactulose, or polyethylene glycol powder, as recommended by the provider.
• Having the child eat a diet high in fiber (fruits, vegetables, whole grains) and drink plenty of fluids to keep the stools soft and comfortable.
• Taking flavored mineral oil for a short period of time. This is only a short-term treatment because mineral oil interferes with the absorption of calcium and vitamin D.
• Seeing a pediatric gastroenterologist when these treatments are not enough. The doctor may use biofeedback, or teach the parents and child how to manage encopresis.
• Seeing a psychotherapist to help the child deal with associated shame, guilt, or loss of self-esteem.

For encopresis without constipation, the child may need a psychiatric evaluation to find the cause.

Most children respond well to treatment. Encopresis often recurs, so some children need ongoing treatment.

If not treated, the child may have low self-esteem and problems making and keeping friends. Other complications may include:

• Chronic constipation
• Urinary Incontinence

Contact your provider for an appointment if a child is over 4 years old and has encopresis.

Encopresis can be prevented by:

• Toilet training your child at the right age and in a positive way.
• Talking to your provider about things you can do to help your child if your child shows signs of constipation, such as dry, hard, or infrequent stools.

Marcdante KJ, Kliegman RM, Schuh AM. Digestive system assessment. In: Marcdante KJ, Kliegman RM, Schuh AM, eds. Nelson Essentials of Pediatrics. 9th ed. Philadelphia, PA: Elsevier; 2023:chap 126.

Noe J. Constipation. In: Kliegman RM, Toth H, Bordini BJ, Basel D, eds. Nelson Pediatric Symptom-Based Diagnosis. 2nd ed. Philadelphia, PA: Elsevier; 2023:chap 19.

Roy D, Akriche F, Amlani B, Shakir S. Utilisation and safety of polyethylene glycol 3350 with electrolytes in children under 2 years: A Retrospective Cohort. J Pediatr Gastroenterol Nutr. 2021;72(5):683-689. PMID: 33587408 pubmed.ncbi.nlm.nih.gov/33587408/.