Elimination Disorders and Encopresis in Children

Medically Reviewed by Smitha Bhandari, MD on February 26, 2024
5 min read

Elimination disorders occur in children who have problems going to the bathroom -- both defecating and urinating. Although it is not uncommon for young children to have occasional "accidents," there may be a problem if this behavior occurs repeatedly for longer than three months, particularly in children older than 5 years.

There are two types of elimination disorders, encopresis and enuresis.

  • Encopresis is the repeated passing of feces into places other than the toilet, such as in underwear or on the floor. This behavior may or may not be done on purpose.
  • Enuresisis the repeated passing of urine in places other than the toilet. Enuresis which occurs at night, or bed-wetting, is the most common type of elimination disorder. As with encopresis, this behavior may or may not be done on purpose.

In addition to defecating in improper places, a child with encopresis may have other symptoms, including:

  • Loss of appetite
  • Abdominal pain
  • Loose, watery stools (bowel movements)
  • Scratching or rubbing the anal area due to irritation from watery stools
  • Decreased interest in physical activity
  • Withdrawal from friends and family
  • Secretive behavior associated with bowel movements

The most common cause of encopresis is chronic (long-term) constipation, the inability to release stools from the bowel. This may occur for several reasons, including stress, not drinking enough water (which makes the stools hard and difficult to pass), and pain caused by a sore in or near the anus.

When a child is constipated, a large mass of feces develops, which stretches the rectum. This stretching dulls the nerve endings in the rectum, and the child may not feel the need to go to the bathroom or know that waste is coming out. The mass of feces also can become impacted -- too large or too hard to pass without pain. Eventually, the muscles that keep stool in the rectum can no longer hold it back. Although the large, hard mass of feces cannot pass, loose or liquid stool may leak around the impacted mass and onto the child's clothing.

Factors that may contribute to constipation include:

  • A diet low in fiber
  • Lack of exercise
  • Fear or reluctance to use unfamiliar bathrooms, such as public restrooms
  • Not taking the time to use the bathroom
  • Changes in bathroom routines; for example, scheduled bathroom breaks at school or camp

Another possible cause of encopresis is a physical problem related to the intestine's ability to move stool. The child also may develop encopresis because of fear or frustration related to toilet training. Stressful events in the child's life, such as a family illness or the arrival of a new sibling, may contribute to the disorder. In some cases, the child simply refuses to use the toilet.

Encopresis is fairly common, although many cases are not reported due to the child's and/or the parents' embarrassment. It is estimated that anywhere from 1.5% to 10% of children have encopresis. It is more common in boys than in girls.

If symptoms of encopresis are present, the doctor will begin an evaluation by performing a complete medical history and physical exam. The doctor may use certain tests -- such as X-rays -- to rule out other possible causes for the constipation, such as a disorder of the intestines. If no physical disorder is found, the doctor will base a diagnosis on the child's symptoms and current bowel habits.

The goal of encopresis treatment is to prevent constipation and encourage good bowel habits. Educating the child and family about the disorder is another important part of treatment.

Treatment often begins by clearing any feces that has become impacted in the colon, also called the large intestine. The next step is to try to keep the child's bowel movements soft and easy to pass. In most cases, this can be accomplished by changing the child's diet, using scheduled trips to the bathroom, and encouraging or rewarding positive changes in the child's bathroom habits. In more severe cases, the doctor may recommend using stool softeners or laxatives to help reduce constipation. Psychotherapy (a type of counseling) may be used to help the child cope with the shame, guilt, or loss of self-esteem associated with the disorder.

A child with encopresis is at risk for emotional and social problems related to the condition. They may develop self-esteem problems, become depressed, do poorly in school, and refuse to socialize with other children, including not wanting to go to parties or to attend events requiring them to stay overnight. Teasing by friends and scolding by family members can add to the child's self-esteem problems and contribute to the child's social isolation. If the child does not develop good bowel habits, they may suffer from chronic constipation.

Encopresis tends to get better as the child gets older, although the problem can come and go for years. The best results occur when all educational, behavioral, and emotional issues are addressed. A child may still have an occasional accident until they regain muscle tone and control over their bowel movements.

Encopresis caused by constipation can often be prevented by ensuring the child is drinking adequate amounts of water and maintaining a high fiber diet.  Although it may not always be possible to prevent encopresis, getting treatment as soon as symptoms appear may help reduce the frustration and distress, as well as the potential complications related to the disorder. In addition, being positive and patient with a child during toilet training may help prevent any fear or negative feelings about using the toilet.