ICD-116C01	ENCOPRESIS Encopresis
ICD-10F98.1	Nonorganic encopresis
DSM-5-TRF98.1	Encopresis

1. Definition and nosology

Encopresis (ICD-11: 6C01; DSM-5-TR: F98.1) — voluntary or involuntary defecation into inappropriate places (clothing, floor) persisting when the child's developmental age reaches at least 4 years. Frequency: at least once a month for ≥ 3 months.

Subtypes:

• Retentive (overflow incontinence) — based on constipation; ~80% of cases;
• Non-retentive — no constipation.

2. History

• DSM-III (1980) — Official diagnosis.
• Rome IV — consensus within the functional GI framework.
• NASPGHAN/ESPGHAN functional constipation guideline (Tabbers M.M. et al. 2014).

3. Epidemiology

• 1–4% among ages 4–17; 3–6 times higher in boys.
• ~80% are primarily constipation-related (retentive).
• Comorbidity: enuresis, ADHD, anxiety, autism spectrum.

4. Aetiology and pathogenesis

• Constipation — key mechanism (in retentive encopresis); painful defecation → retention → rectal dilatation → sensory reduction → overflow.
• Trauma, fear, discipline in toilet training process.
• Diet (low fiber, dehydration).
• Behavioral and emotional factors — oppositional, anxiety.
• In rare cases — Hirschsprung disease (rectal aganglionosis), spinal pathology.

5. Clinical features

• Fecal soiling of clothing.
• Retentive — fecal mass on abdominal palpation; tense rectum; large (massive) defecation episodes.
• Social-emotional: shame, social isolation, school avoidance.

6. Diagnosis

6.1 Unified diagnostic criteria

A. Defecation into inappropriate places (clothes, floor), voluntary or involuntary.

B. Frequency: ≥1 times per month, ≥3 months.

C. Developmental age ≥ 4 years.

D. Not fully explained by substance (laxative) or medical condition (Hirschsprung, anatomical anomaly, spinal pathology).

Qualifier: with/without constipation and overflow.

6.2 Source-specific clarifications

• NASPGHAN/ESPGHAN 2014 — functional constipation guideline (Rome IV).
• NICE CG99 (2010) — constipation in children and adolescents.

6.3 Diagnostic algorithm

1. Clinical interview — defecation frequency, pain, toilet training history.
2. Abdominal palpation — fecal mass.
3. Rectal examination — fecal impaction (or if clinically suspected final condition).
4. Defecation diary (Bristol Stool Chart)
5. Medical: thyroid (hypothyroid constipation), serum calcium, celiac disease screening.
6. Atypical presentation: ultrasound, anorectal manometry, suction biopsy (Hirschsprung).

6.4 Differential diagnosis

7. Examination and assessment

• Abdominal and rectal examination.
• Bristol Stool, defecation diary.
• TSH, calcium, anti-TTG selectively.
• Ultrasound, manometry in atypical cases.

8. Treatment

8.1 General principles (NASPGHAN/ESPGHAN · NICE CG99)

1. Removal of impaction (disimpaction) — PEG (polyethylene glycol) high dose for 3–7 days; oral superior to enema (not recommended, traumatic).
2. Maintenance — PEG monthly-yearly dose; ensures defecation frequency and painless continuation.
3. Behavioral intervention:
   • Regular toilet time (15–20 minutes after meals, gastrocolic reflex);
   • Correct foot support (defecation position);
   • Positive reinforcement (no punishment).
4. Dietary regimen: Increase fiber, water intake (moderate effect; does not replace PEG).
5. Psychological support: anxiety reduction, family training.
6. In refractory cases biofeedback, multidisciplinary approach; surgery rare (Malone antegrade colonic enema).

8.2 Source-specific clarifications

• NASPGHAN/ESPGHAN 2014 — PEG first-line; enema traumatic and second-line.
• NICE CG99 — same.
• Cochrane (Gordon M. et al. 2016) — PEG superior to lactulose.

Treatment methods

1. PEG (Polyethylene Glycol) — Osmotic laxative; disimpaction 1–1.5 g/kg/day × 3 days; maintenance 0.4 g/kg/day; months-years; side effects minimal.
2. Toilet Time and Position — 5–10 minutes toilet time 15–20 minutes after meals; foot support — hip flexion straightens the anorectal angle and reduces straining; on videomanometry the angle during defecation is ~100° when sitting and ~126° when squatting (Sakakibara R. et al. LUTS 2010).
3. Positive Reinforcement (Star Chart) — Positive behavior reward instead of punishment.
4. Biofeedback — In refractory cases; anorectal coordination training.

9. Prognosis

• PEG and behavioral intervention lead to remission in most patients (50–80% within 1 year).
• Long-term maintenance therapy is recommended; early discontinuation creates relapse risk.

10. Myths and misconceptions

Myth 1: “Encopresis results from psychological ‘stubbornness’ or emotional disorder”

Evidence: Approximately 80% of cases are primarily due to constipation; medical/behavioral consultation is the first-line approach, not psychological. The patient's explanation of “intentional” behavior is incorrect.

Myth 2: “A child can be corrected through punishment”

Evidence: NASPGHAN/ESPGHAN — punishment is contraindicated; increases self-blame and distress.

Myth 3: “Enema is a first-line intervention”

Evidence: Oral PEG is superior; enema is traumatic, second-line.

Myth 4: “Dietary change alone is sufficient”

Evidence: Fiber/water mild adjunct effect; impaction correction and maintenance require PEG.

Myth 5: “Encopresis resolves with age, requires no treatment”

Evidence: Chronic progression without treatment, social-emotional burden; active intervention recommended.

Myth 6: “Probiotics cure encopresis”

Evidence: Cochrane — the significant effect of probiotics has not been proven.

11. Sources

1. WHO. ICD-11. 6C01 Encopresis. 2024.
2. APA. DSM-5-TR. 2022.
3. Tabbers M.M. et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014;58(2):258–274.
4. NICE CG99. Constipation in children and young people. 2010.
5. Gordon M. et al. Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database Syst Rev 2016;(8):CD009118.
6. Sakakibara R., Tsunoyama K., Hosoi H. et al. Influence of body position on defecation in humans. LUTS: Lower Urinary Tract Symptoms 2010;2(1):16–21.