RISK FACTORS : Boys are more often affected, Difficulty with bowel training, Unresolved fecal retention and impaction
GENERAL MEASURES :
• Anticipatory guidance relative to toilet training beginning at 18 months
• The impaction must be eliminated before starting maintenance treatment
• Avoid redevelopment of an impaction
• Avoid frequent and repeated digital examinations, enemas, and suppositories
• Biofeedback training has been used in conjunction with standard treatment, but results are disappointing
• Child to sit on toilet twice a day at the same time each day for 10-15 minutes and 10-15 minutes after meals
DRUG(S) OF CHOICE :
. Remove stool impaction: (before starting maintenance treatment program)
. Give 1 ounce of mineral oil the first day
. On the next day, give 1-3 enemas till clear; this may need to be repeated on 1-2 subsequent days
. First give an oil retention enema
. Follow the oil retention enema with hypophosphate enemas, e.g., sodium phosphate (Fleetfs) 1 ounce
(28.4 gm) per 20 pounds (9.1 kg) of body weight, or
. Normal saline enemas - 2 tsp table salt per quart (946 mL) of warm water and give 2 ounces (60 mL) per year of age to a maximum of 16 ounces (480 mL)
. A bisacodyl (Dulcolax) suppository can be inserted to assist the evacuation
. Alternative: give an oral solution of polyethylene glycol (Colyte, Nulytely) at 20 mL/kg/hr for 4 hours on 2
consecutive days
. Maintenance treatment
. Up to 6 months or more to keep stool soft and mobile
. Give mineral oil (may mix with orange juice to make palatable)
. Fiber or other hydrophilic agents may be used to soften the stool - lactulose, methylcellulose, psyllium,
polycarbophil, malt soup extract
. Multivitamins must be given between doses of mineral oil to ensure absorption of fat soluble vitamins (A, D, E, K)
PATIENT MONITORING :
• Continue the maintenance treatment program for at least 6 months and maybe for as long as 1-2 years
• Visits every 4-10 weeks for support and to ensure compliance
• Telephone availability to prevent problems and adjust doses
• Redevelopment of impaction must be removed as above
• Counseling and/or referral for associated psychosocial issues
PREVENTION/AVOIDANCE :
• Optimal feeding practices
• Normal bowel function and recommendations for bowel training
• Early detection of problems
• Avoid Karo syrup
• Prompt treatment of perianal dermatitis to avoid painful defecation
• Look for signs of relapse which include large caliber stools, decrease in frequency of defecation, soiling
POSSIBLE COMPLICATIONS :
• Excessive enemas or suppositories may cause colitis
• Perianal dermatitis
• Anal fissure
EXPECTED COURSE/PROGNOSIS:
• Usually responds well though relapses may occur
• Children with psychosocial or emotional problems which preceded the encopresis are more recalcitrant to
treatment