Fecal Soiling

by Warren P. Silberstein, M.D.

Most children are bowel trained by 3 years of age and many are trained before that. Occasional accidents occur as children try to gain greater control and wait too long to go to the toilet. If an older child continues to soil his pants, he requires medical evaluation to determine the cause. Less than 5% of children who soil have a medical condition contributing to the soiling. Neurological conditions that interfere with bowel and/or bladder control are rare, but must be considered. Children with chronic diarrhea from colitis or infectious diseases may have accidents; however, on occasion, a child who is having diarrhea may actually be severely constipated with leakage of liquid stool from higher up in the intestine. I have on occasion had a patient who just didn't have the patience to sit long enough to empty his bowels, and even though he had small bowel movements regularly, the excess gradually filled his intestines and resulted in accidents. These children were anxious to end their embarrassing problem and were cooperative with a program of regular and more prolonged sitting aided by reading material or hand-held electronic games. An older child who was previously fully trained who develops soiling may simply be one of those impatient children, but if the child appears distressed, sometimes soiling may be an indication of a psychological problem or the result of a psychic trauma such as sexual abuse. The most difficult children to manage are the ones who have never been well toilet trained and are resistant to sitting on the toilet. The medical term for fecal soiling is encopresis. If your child is encopretic (soils his pants) the first step in treatment is evaluation by your pediatrician.

If your child has been examined and nothing has been found to be wrong with him, then his soiling is most likely the result of stool withholding. Often, especially when these children are younger, they appear to be struggling to have a bowel movement, when in reality, they are struggling to hold it in. The reasons that stool withholding develops are complex. For some children it may start with a painful bowel movement. After that, they become fearful of having bowel movements and hold it in. No amount of reasoning can help a young child understand that if he holds it in, the stool will become harder and even more painful to pass. Young children only understand and deal with the fear and the pain of the moment. Some children start withholding stool when toilet training begins. For them there are not only issues of control, but also, fear of the unknown and comfort with the familiar. A child who has not experienced staying clean prefers his familiar dirty diaper to the scary toilet. And some children have great difficulty having a bowel movement on the toilet, especially if they are constipated. And so the vicious cycle begins.

No matter what initially causes the child to withhold stool, the end result is the same. Stool that sits in the rectum becomes harder with time. And as time passes with out a bowel movement the child becomes more and more constipated. It becomes more painful and more difficult for him to have a bowel movement voluntarily on the toilet. Eventually there is no more room in the rectum to hold stool and liquid stool begins to leak out around the hard stool in the rectum. As a result, even though the child is severely constipated, he starts to have diarrhea in his pants. In addition, some formed stool periodically escapes into his pants when he has a cramp, but only enough stool comes out to relieve the pressure because the child is still working so hard to hold it in.

One of the biggest puzzles for parents is that children who soil themselves often insist that they didn't feel it come out. They act like they don't even know they have a mess in their pants. They don't smell it. They don't feel it. They're oblivious to it. How can a child not feel it or smell it when he sits in a mess in his pants?!? The answer is simple - denial. Denial is one of the most potent of human ego defense mechanisms. If he believes that he can't feel it and he can't smell it, then he doesn't have to deal with the problem. And he is not lying to you. He believes it. If you can't imagine anything much worse than dealing with the constant mess in your child's pants try to understand that to your child there is something infinitely more frightening and awful, namely, sitting on a toilet and having a bowel movement.

The treatment is difficult. But if your child has been soiling his pants for a long time you couldn't have expected a simple solution. You must be prepared to devote an inordinate amount of time to the solution, and you must be committed to sticking with the program, even when it doesn't seem to be working. You will need the guidance and support of a pediatric gastroenterologist or a child psychologist who deals with encopresis (fecal soiling). He will set up a treatment program which he will constantly review with you to provide reinforcement for you. The elements of the treatment will most likely be as follows:

Few things can be more exasperating to parents than dealing with soiling in an older child. It's a disgusting mess, and we all expect our older children to be toilet trained. An understanding of the problem can help parents handle it more calmly and lovingly. But encopresis is a difficult problem to manage alone. Parents dealing with this problem need the help and support of their pediatrician or gastroenterologist.

For additional information check the following articles:

Your Child and Encopresis

The Virtual Hospital: University of Iowa Family Practice Handbook:Constipation/Encopresis

A Training Program For Children With Bowel Incontinence

Problems with Soiling and Bowel Control - Psychiatric viewpoint.

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