How to resolve stool retention in a child

Underwear soiling is not a behavior problem

Glen C. Griffin, MD; S. Dwayne Roberts, MD; Gary Graham, MD

VOL 105 / NO 1 / JANUARY 1999 / POSTGRADUATE MEDICINE

Last of a series of articles on pediatrics coordinated by Glen C. Griffin, MD, who was editor-in-chief of Postgraduate Medicine from 1987 to 1995.

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Preview: Soiled underwear is one of those problems that everyone wants fixed but no one wants to talk about. You, as the caregiver, may have to do a little detective work to uncover the problem and should do a lot of educating of the adults in charge. The reward may well be seeing a humiliated, shunned, scolded youngster transformed into a confident and happy one. The authors discuss how and why stool retention gets started, and they summarize the complaints parents often have when they bring in the child. A complete treatment regimen is described and compiled in a form that can be sent home with parents.

A common mistake by parents and professionals is to automatically regard a child's underwear soiling as a behavior problem. This assumption is incorrect; soiling is not caused by a child's behavior. Stool retention may even be the result of inappropriate actions by parents, teachers, or other adults. When incorrect assumptions are made about why a child is soiling his or her underwear, unsuitable solutions may be tried, which may make the problem worse.

Soiling is termed encopresis when it occurs in the absence of underlying disease in a child who has learned to voluntarily control his or her bowel habits (1). This discussion focuses on the 95% or more of children with underwear soiling who do not have one of the rarely seen physical causes (eg, Hirschsprung's disease, myelomeningocele, cerebral palsy, hypothyroidism, diabetes insipidus, hypercalcemia, rectal prolapse) (2).

Causes of stool retention

The most common cause of underwear soiling in children is stool retention. When a child waits to have a bowel movement, the urge may go away. As he or she continues to eat, stool builds up, and the rectum stretches to accommodate the extra stool. With rectal dilation, semiliquid stool is able to leak around the accumulated stool and onto underclothing. It is common for stool retention to cause considerable rectal dilation by the time medical attention is sought.

It is our experience that stool retention in a child begins insidiously, for one or more common reasons (table 1). One of the most common reasons for a child to wait to have a bowel movement is lack of a convenient, private, or clean toilet. For example, if a youngster is on a long ride in an automobile, a toilet may not be available. Even if one is available (eg, on an airplane, boat), it may seem strange or not very private. Camping trips may require use of an outhouse that is neither familiar nor clean. Even at home, a toilet may not always be readily available if it is shared by several family members.

Table 1. Common initial causes of stool retention in children

Unavailability of toilet Long car, bus, or airplane ride; long shopping trip Hiking, camping excursion Need to share with several family members Unpleasant facility Unclean or smelly public restroom Portable toilet or outhouse Embarrassment or lack of privacy School restrictions on bathroom use No doors on stalls Teasing from classmates Past humiliating experience Discomfort with unfamiliar facility Inactivity Illness forcing long-term bed rest Lack of mobility Dietary factors Consumption of constipating foods Inadequate intake of liquids, dehydration Inadequate intake of stool-softening foods Use of constipating medications Methylphenidate HCl (Ritalin) Anticholinergic agents (eg, imipramine HCl [Tofranil]) Narcotics (eg, codeine, morphine) Phenytoin (Dilantin) Antacids Rectal or anal fissure Previous large stool Infection (candidal, viral, bacterial) Trauma

Access to toilets at school can be a particular problem. Some bathroom rules are probably reasonable to discourage unnecessary comings and goings. However, a child who is worrying about spill-over from an overloaded bladder or rectum is not learning much. Few teachers know what can happen when a child is asked to wait or is discouraged through intimidation from using the toilet. One teacher required students to hold up a "toilet ticket" before leaving the room, and the child was then included in a list on the board of those who would have to miss recess. It is little wonder that stool retention and encopresis developed in two children in this class. Intimidation that discourages a child from asking to go to the toilet is not only counterproductive, it also violates a child's rights.

Another common deterrent to use of the toilet in some schools is the lack of doors on toilet stalls. The intention is to discourage smoking, drinking, and drug use, but an additional outcome is loss of privacy, which is a big problem for some children.

Inactivity, dehydration, inappropriate diet, and use of certain medications are common initial causes of constipation, leading to stool retention. If not well managed, constipation in a child from any cause can lead to chronic constipation (3). Typically, parents do not mention constipation or soiling unless specifically asked, so unless professionals pose the right questions, they may miss the opportunity to solve the problem in early stages (4).

Rectal fissures (from passing large stools, infection) may make defecating painful. As a result, a child may avoid defecating, causing more stool to accumulate and more pain when stool is finally passed. This can become a vicious cycle.

Reasons a child is brought for care

Involuntary leakage of putrid liquid feces around retained stool may occur at completely unpredictable times, such as while a child is playing or in class. Humiliated children may believe they have done something wrong and are usually so shamed by soiling their underwear that they certainly do not want to talk to anyone about the problem. Often, they hide soiled underwear under the bed or in the trash. Friends often add to embarrassment by teasing, and parents or other family members may scold or punish.

Usually, parents have no idea that their youngster is retaining stool and bring the child to see a physician for other problems. Stool retention is often discovered only after some questioning, so physicians should be alert to clues, such as signs and symptoms discussed in the following text, and ask parents about soiling and stool frequency.

Abdominal pain
Children who are retaining stool often have obscure abdominal pain. It may begin as minor discomfort, but as stool builds up, the pain can become severe. Often, antacids or other medicines have been given but have not relieved the pain. Unless a rectal examination is done, retained stool or a dilated rectum may be missed, extensive and unnecessary tests may be done, and abdominal pain may be misdiagnosed. We have seen children with stool retention who had been mistakenly identified as having pinworms, ulcers, pancreatitis, and appendicitis.

Offensive body odor
A child who is retaining stool often smells so bad that playmates and others begin to avoid him or her. The longer the stool is retained, the more putrid it becomes and the worse it smells when it leaks out onto underwear. Teachers, the school nurse, and parents may berate the child for poor hygiene or for not changing underwear. Therefore, it is important to explain to everyone involved with the child exactly what is going on, to correct misinformation, and to enlist support in helping solve the problem instead of adding to it.

Stools that plug the toilet
Sometimes, a child with stool retention passes stools that are so large they actually plug the toilet. Parents reporting this problem should not be dismissed with the suggestion that they buy a plunger. The problem should be considered a tip-off that the child needs to be examined.

Lack of appetite
Eating may add to abdominal discomfort in a child with stool retention. Therefore, the problem should be considered when a parent brings in a youngster who does not want to eat.

Urinary incontinence or frequency
Stool backed up in the rectum may cause pressure on the bladder or reflex relaxation of urinary sphincters. As a result, one in three children with encopresis also has bed-wetting and one in five also has daytime dribbling or urinary frequency (5). Sometimes these children cannot even go for a short car ride without asking to stop to empty their bladder. Therefore, whenever urinary incontinence or frequency is reported, be sure to ask parents whether soiling or other evidence of stool retention is also present.

"Diarrhea"
Sometimes, parents think that stool leaking around a massive impaction is diarrhea. In such cases, parents often give the child antidiarrheal medication (eg, kaolin, bismuth), which makes stool retention even worse because it can be constipating.

How to manage stool retention

Managing stool retention and resultant underwear soiling in a child begins with understanding how these problems get started and how they are perpetuated. Sometimes, parents and even professionals erroneously conclude that soiling is the result of mis-behavior. The problem is compounded if the child is humiliated, scolded, and punished or if behavior is made the focus of therapy. To us and many others, it has become evident that the cause of stool retention and underwear soiling in children is not a psychological or behavioral problem (2,6-11). Therefore, parents, grandparents, child-care workers, and teachers should be educated that the process is mechanical and uncontrollable and that they should support strategies to solve the problem. They should also be given these precautions:

• Never scold or humiliate a child for underwear soiling.

• Never prohibit a child from going to the toilet; rather, see that a private and accessible facility is available.

• Never embarrass a child or call attention to his or her need to go to the toilet.

Physical examination
Careful physical examination is important to ensure that the child does not have appendicitis or other problem, but the most edifying procedure is a simple rectal examination. Even if history taking virtually secures the diagnosis, rectal examination is necessary to determine the presence of impacted stool or a rectal shelf caused by dilation from retained stool. Unless other factors are involved, a child brought in for underwear soiling and stool retention almost never needs x-ray studies or other expensive diagnostic procedures.

Evacuation of impacted stool
McClung and associates (11), who treat about 200 new encopretic children yearly, are convinced that psychological issues are not the primary problem in stool retention, and they successfully use a treatment protocol similar to the one we describe in the following paragraphs.

Retained stool must be evacuated. Enemas are often used, but a large amount of retained stool makes insertion of the enema tip difficult, even with the help of a lubricant. Soap and plain water enemas should never be used. Although phosphate-solution enemas are usually safe, in rare cases the solution may be retained above the impacted stool for a prolonged period, creating the potential for complications (eg, hypocalcemic tetany, cardiac arrhythmia) (12).

Even when they are successful, enemas are unpleasant. A simpler and more agreeable way to evacuate retained stool is to give several ounces, depending on the child's weight, of magnesium citrate solution. A second dose can be given if no results occur within 30 to 40 minutes. Different flavors are available in inexpensive 10-oz bottles, and the child may readily consume the bubbly liquid because it resembles a soft drink. A responsible person needs to be home with the child after magnesium citrate is administered, because passing retained stool may be quite uncomfortable.

Until stool has passed and cramping has stopped, only clear liquids should be given. Food eaten during the process just adds material to be pushed through the intestine and, thus, may increase discomfort. Parents should be instructed to call if cramping is prolonged or severe or if expected results do not occur.

In most cases, magnesium citrate is successful in evacuating stool. However, occasionally, mineral oil enemas are necessary (10), and if stool has been impacted for a long time, it may have to be removed with a gloved finger. If all these methods fail, an appropriate electrolyte solution may be given by nasogastric lavage, along with metoclopramide to decrease nausea and vomiting (13,14).

Measures used for the first week
Beginning the day after removal of retained stool, a daily elimination pattern should be established. Each day for 1 week, one fourth to one half of a bisacodyl suppository (eg, Dulcolax) should be administered at a time when the child can use the toilet without interruption. The child should be gently urged to sit on the toilet for 20 to 30 minutes after the suppository has been given.

Measures used for the first month
Also beginning the day after removal of retained stool, 1 to 2 tbsp of mineral oil should be given daily for at least a month. Although there is some concern that mineral oil may absorb nutrients, recent studies show that it is safe when used judiciously (10,15).

Mineral oil ensures adequate lubrication and facilitates passage of stool, thus preventing stool backup and allowing the dilated rectum to return to normal size. As long as stool is allowed to continue backing up, the rectum remains dilated, sometimes for months or years. One manometric study showed that in chronically constipated children, even after 3 years and disappearance of symptoms, rectal contractility was still diminished (16).

We consider use of mineral oil to be a crucial part of the treatment regimen, because if regular passage of stools is not accomplished, dependence on mineral oil, suppositories, or enemas is likely.

Measures used for several weeks
A concomitant dietary strategy is needed to ensure soft, movable stools while avoiding dependence on medications as the rectum resumes its normal size and mechanics. Dietary measures should be started early, along with the other measures described. The youngster should be encouraged to drink three full glasses of prune, grape, apricot, or pineapple juice in addition to several glasses of water each day. Snacks of raisins, prunes, and dried and fresh fruits (especially cherries and apricots) are also helpful. Fiber-containing foods (ie, oatmeal, bran, whole wheat, legumes) should be provided, and psyllium or methylcellulose (Citrucel) may be used to supplement dietary fiber if necessary. (Of course, teachers, parents, and others involved with the child must understand that immediate access to a toilet is necessary.)

With use of these dietary strategies, the child should begin to have more than one bowel movement a day. When this pattern has been consistently established for several weeks, the amounts of fruit, juice, and fiber can be tapered down. In most cases, some dietary measures to soften stool and avoid constipation should be continued for many months. In fact, fruits, vegetables, grains, legumes, and several glasses of water every day are good basic elements for all growing youngsters and should be part of the normal diet for the entire family.

Follow-up
Recurrence of stool retention is common. Often the problem occurs off and on, unknown and undetected, for years. Thus, any child who has had underwear soiling or any other symptom of stool retention should be followed for long enough to ensure that the problem has been solved.

If stool retention is detected early, the child should be examined every week or so for several weeks. If stool retention has been going on long enough for soiling to be noticed, weekly checks should be continued for several months, with at least one follow-up examination a year later. It is important on each visit to encourage the child and parents to continue the measures described and to report any problems that may arise.

Summary

Many parents do not realize their child has stool retention when they bring him or her for an office visit. Some complaints that may be a tip-off and should prompt questioning about stool frequency and underwear soiling are vague abdominal pain, urinary incontinence, and stools so large they plug the toilet. A rectal examination is usually adequate to confirm the diagnosis.

Management begins with educating parents that leaking of liquid stool around impaction and onto underwear is completely involuntary, so the child should never be scolded or embarrassed. Stool retention may begin because of unpleasant or unavailable toilet facilities, constipation, or painful elimination and often becomes self-perpetuating. Impaction must be removed immediately; magnesium citrate solution is usually effective. To allow the rectum to return to its normal size, which can take an extended time, stool must be kept soft and movable with administration of mineral oil and appropriate dietary choices (eg, fruit, juice, fiber). Recurrence is common, so ongoing measures and follow-up are important.

References

1. Fitzgerald JF. Difficulties with defaecation and elimination in children. Clin Gastroenterol 1977;6(2):283-97
2. Loening-Baucke V. Encopresis and soiling. Pediatr Clin North Am 1996;43(1):279-98
3. Fitzgerald JF. Constipation in children. Pediatr Rev 1987;8(10):299-302
4. Issenman RM, Hewson S, Pirhonen D, et al. Are chronic digestive complaints the result of abnormal dietary patterns? Diet and digestive complaints in children at 22 and 40 months of age. Am J Dis Child 1987;141(6):679-82
5. Loening-Baucke V. Factors determining outcome in children with chronic constipation and faecal soiling. Gut 1989;30(7):999-1006
6. Clayden GS. Management of chronic constipation. Arch Dis Child 1992;67(3):340-4
7. Davidson M, Kugler MM, Bauer CH. Diagnosis and management in children with severe and protracted constipation and obstipation. J Pediatr 1963;62(Feb):261
8. Levine MD. Encopresis: its potentiation, evaluation, and alleviation. Pediatr Clin North Am 1982;29(2):315-30
9. Schmitt BD. Encopresis. Prim Care 1984;11(3):497-511
10. Swanwick T. Encopresis in children: a cyclical model of constipation and faecal retention. Br J Gen Pract 1991;41(353):14-6
11. McClung HJ, Boyne LJ, Linsheid T, et al. Is combination therapy for encopresis nutritionally safe? Pediatrics 1993;91(3):591-4
12. Martin RR, Lisehora GR, Braxton M Jr, et al. Fatal poisoning from sodium phosphate enema: case report and experimental study. JAMA 1987;257(16):2190-2
13. Ingebo KB, Heyman MB. Polyethylene glycol-electrolyte solution for intestinal clearance in children with refractory encopresis: a safe and effective therapeutic program. Am J Dis Child 1988;142(3):340-2
14. Koletzko S, Stringer DA, Cleghorn GJ, et al. Lavage treatment of distal intestinal obstruction syndrome in children with cystic fibrosis. Pediatrics 1989;83(5):727-33
15. Clark JH, Russell GJ, Fitzgerald JF, et al. Serum beta-carotene, retinol, and alpha-tocopherol levels during mineral oil therapy for constipation. Am J Dis Child 1987;141(11):1210-2
16. Loening-Baucke VA. Sensitivity of the sigmoid colon and rectum in children treated for chronic constipation. J Pediatr Gastroenterol Nutr 1984;3(3):454-9

INFORMATION FOR PATIENTS

Strategies for parents to use in resolving a child's stool retention

Immediately
To remove stool impaction, give several ounces of magnesium citrate solution (responsible person must be home with child); if no results occur in 30-40 min, second dose may be given

Until stool passes and cramping stops, give only clear liquids (Jell-O, broth, water)

Call physician if cramping is prolonged or severe or expected results do not occur

Beginning day after stool impaction is removed
Each day for 7 days

• Administer 1/4 to 1/2 bisacodyl suppository each day at a time when child can use toilet without interruption (eg, right after school)
• Gently urge child to sit on toilet for 20 to 30 minutes after suppository is given

Each day for at least 1 month

• Give 1-2 tbsp of mineral oil to facilitate passage of stool

Each day for several weeks

• Give three full glasses of prune, grape, apricot, or pineapple juice to ensure soft stools and avoid constipation
• Give snacks of raisins, prunes, dried and fresh fruit
• Give high-fiber foods (eg, whole wheat, bran, oats, legumes)
• Encourage drinking several glasses of water

Ongoing
Gently encourage child to use toilet at same time each day

Continue to encourage consumption of fruits, juices, grains, legumes; adjust amount to maintain soft, movable stool without use of medications

Continue to encourage high water consumption

Dr Griffin is coordinator for pediatric education, Dr Roberts is a faculty member, and Dr Graham is chief resident, Utah Valley Family Practice Residency, Utah Valley Regional Medical Center, Provo. Dr Griffin is president of the nonprofit foundation American Family League, which provides resources for parents at the Web sites www.principles.org and www.moviepicks.org. Correspondence: Glen C. Griffin, MD, 1700 N 2000 East, Mapleton, UT 84664. E-mail: ggriffin@micron.net.

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