Soiling

Soiling in children is the involuntary passage of stools in conjunction with constipation (abnormal if > 4 years of age, Boys : Girls = 3 : 1)

• It is a common problem among children. Its significance is often underestimated by doctors, but it is a major problem for the children and their parents.
• In the past soiling was usually thought to be psychological in origin. The term encopresis was used.
• Nowadays it is known that soiling is in the vast majority of cases a functional problem caused by a vicious circle of constipation and stool withholding. (The term soiling is used more commonly for this problem, although the terms soiling, Encopresis, and faecal incontinence in children are also used synonymously)
• Behavioural problems are a result and not the cause of soiling, brought on by the enormous strain on family and child, and disappear when soiling has been successfully treated.
• Organic causes such as Spina bifida or Hirschsprung's disease are rare.

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Mechanisms of Soiling: A Vicious Circle

Constipation is associated with hard, large stools (faeces) in the large bowels (=colon) and rectum, which become difficult and painful to evacuate. This leads to stool-withholding. A vicious circle ensues.

The rectum becomes gradually distended with accumulated stool. The distension causes a loss of sensation in the rectum. This leads to further stool-withholding, as the urge to defecate becomes more and more irregular.

Eventually, softer stools from higher up the bowels cannot be accommodated and leak around the bolus of hard stool. Due to the lack of rectal sensation, this is not noticed by the child until soiling has actually occurred.

Parents are under great stress, as they might think or suspect that their child is soiling intentionally and become irritated and even aggressive. They might have also been advised that their child is psychologically abnormal, which leads to further distress.

Both parents and child often suffer great psychological stress. Soiling can result in a disruption of relationship between the parents as well as the parents and their child.

Children who soil then become very frightened as they are punished for something over which they have no control. Soiling results in a marked loss of self-esteem in the affected children. Behavioural abnormalities develop.

History: (Typical features)

• Occasional very large stools and several soft stools daily (Parents of constipated children often insist that their child is having diarrhoea rather than constipation, and it may be difficult to convince these parents, that their child should go on treatment for constipation.)
• Painful defecation
• Blood in Stools (this is usually due to painful fissures in anus)
• Stool-withholding behaviour: Child may be noted to spend long periods of time standing in a corner prior to soiling. This can be mistaken for exaggerated attempts at defecation.
• (Major psychological or behavioural abnormalities before soiling started may suggest a psychological cause (encopresis): this is uncommon)
• (If also Day-time-wetting (urinary incontinence not at night) co-exists, an organic cause has to be sought)

Examination by the doctor include:

• Abdominal examination: The impacted bowels may be felt through the tummy, but is often not felt even in severe constipation.
• Close inspection of the Anus and perianal area: Anal fissures (=Anal tears) will support the diagnosis. There may also be signs of inflammation like Thrush (=Candidiasis) or Streptococcal infection.
• The Back should be inspected and ankle jerk reflexes tested to rule out spina-bifida.
• (A rectal examination should not be performed, especially not in young girls. The children are already traumatised enough in this area, and this would be one more emotional trauma. It also provides no useful information, as the rectum might be empty at the moment of examination.)

Management:

Soiling should always be treated as secondary to constipation (even if in doubt of another cause): 70-75% success

1. Education and Reassurance: (Relieves anger and anxiety from parents and child.)
   • Soiling is not intentional. (Child doesn't notice until soiling has occurred.)
   • Child is not psychologically abnormal. (Behavioral problems will resolve once soiling has been treated successfully.)
   • It can be treated successfully.
   • Explain mechanisms of overflow-incontinence with picture (It is important for parents to understand the mechanisms of soiling well, as they might otherwise not comply with treatment, leading to treatment-failure)
   • Involve Children if old enough. (Parents of children who have been toilet-trained for a few years have little idea about their child’s bowel habits, although they often assume great authority on the issue)
2. Dissimpaction: Removal of the hard impacted stools in the rectum with a strong Laxative (start when child is off school or nursery.) - e.g.:
   • Bisacodyl orally 5 mg in mornings for 3 days (10 mg if over 5 years of age)
   • (Enemas or Suppositories are invasive and are usually not needed. Success of treatment depends on its consequent and prolonged application, not on its invasiveness)
3. Prevention of Re-accumulation: with a stool softener (start simultaneously with dissimpaction) For 6-12 months for child to regain confidence and colon to return to original tone and shape. It is important to do this consequently, in sufficiently high doses and for a sufficient length of time. Taper off treatment gradually after. - e.g.:
   • Liquid Paraffin (= mineral oil) (10 - 60 mls at night) titrated to effect (directly from fridge, with yoghurt or ice-cream) (Contraindications: Children <1 year and children with neurological abnormalities or learning difficulties should not take Liquid Paraffin, because of risk of pulmonary aspiration)
   • Lactulose may be used in infants <1 year of age (It is less suitable because of day-to-day inconsistency of efficacy, making it difficult to titrate and possibly counterproductive to establish regular bowel pattern)
   • Dietary fibre (e.g. fruits) + Plenty of Fluids are important, but on its own these measures will not be sufficient enough once stool withholding and soiling have established!)
   • (NO enemas or suppositories. These are for Dissimpaction only. If hard stools have formed again, it means that reaccumulation has occurred and higher doses for its prevention are needed.)
4. Establishing regular bowel pattern: (start after successful dissimpaction)
   • Encourage the child to sit on toilet regularly, at the same time of day, at least once a day, for at least 5 min. Ideally done after breakfast (Gastrocolic reflex)
   • Continue on daily basis irrespective on whether or not child has passed stools.
   • Footstool or other support to ensure hips can be fully flexed, and child can sit comfortably on toilet

References

• The original article has been broadly based on a lecture for students given by Prof. Brendan Drumm, Consultant Gastroenterologist, Head of Department of Paediatrics, University College Dublin
• Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for paediatric Gastroenterology and Nutrition
• Paper for the above: by Baker SS, Liptak GS, Colletti RB, Croffie JM, Di Lorenzo C, Ector W, Nurko S
• Liquid paraffin: a reappraisal of its role in the treatment of constipation by F Sharif, E Crushell, K O'Driscoll, B Bourke