Kids Who Soil Pants Need Medical Help, Not Scolding

What do you do about an otherwise happy, intelligent 4-year-old who poops his pants several times a day?

Encopresis is the medical term when children soil their underwear with stool after the age they are expected to be toilet-trained (usually 4 years). At Children's Hospital we see about 150 children each year with the problem.

There are two types of children with encopresis.

About 10 percent soil on purpose. These children have emotional problems and with their families need to be involved with a psychologist who can identify and manage the underlying problem.

But most children we see have lost control of their rectal muscles and normal rectal sensation due to long-standing constipation over a period of weeks.

There are many causes of constipation. A young infant may develop hard stools when solids are started, breast milk is stopped, or when a formula is changed.

Toddlers become constipated when they develop fear of toilets or parents try to push them to toilet train when they are not ready. Children may become constipated when they run a fever or don't drink adequate fluids.

Some children don't like to use toilets outside the home and try to hold their stools during travel. School-age children may not be allowed to leave class to use the bathroom. They may be embarrassed because there are no doors on the stalls or other children laugh at them. Some children develop a painful bottom from passing hard stools or from sexual abuse, and hold stools to avoid pain.

Whatever the initial event, the result is the same. The child holds the stool and this causes the stool to get larger and harder. It becomes even more painful to pass - which reinforces the desire of the child to hold back even more.

Eventually a ball develops in the rectum. The body adapts by shutting down the normal urge to get rid of it. Liquid stool may leak around the ball causing soiling. Often the child doesn't feel the leak and adapts to the smell.

Parents, teachers and friends are usually horrified by the smell and mess. Even those who try to be supportive convey subtle messages of disgust and disappointment.

The child can do nothing because the condition has now gotten out of control. The rectum is weak and stretched out so it can't push out the ball. The child develops a poor self-image and is rejected by people.

The treatment for encropresis involves medically cleaning out the rectum and rebuilding the muscles. The rebuilding is a slow process which usually takes about a year. The child must practice daily toileting habits to keep it from occurring again.

The child needs encouragement and support during the treatment process. A healthy diet and laxatives are prescribed. Occasionally biofeedback training is used to improve control of the rectal muscles. About 80 percent of children recover with the standard treatment.

So often parents think their child is lazy. They criticize them for not taking responsibility for their own body function. I hear over and over that they went to their doctor and were told, "He will outgrow it."

Encopresis is a medical condition with a treatment that works. Emotional trauma can result from the condition, but is rarely the cause. Children can't keep from feeling bad when parents scold them, friends tease and reject them and their body won't cooperate.

The Encopresis Clinic at Children's Hospital can be reached at 526-2049.

Dr. Jeffrey Wright is chief of general pediatrics services at Children's Hospital and Medical Center in Seattle and acting assistant professor of pediatrics at the University of Washington. This column runs every third week. You can write to him c/o Scene, The Seattle Times, P.O. Box 70, Seattle, WA 98111.