Joaquín Díaz Atienza
Encopresis as a symptom
We speak of encopresis when a child of appropriate age to control their bowel and bladder defecates in inappropriate places. The term encopresis was first introduced in 1926 by Weissenberg, although it had already been clinically described in the 19th century.
| PRIMARY ENCOPRESIS: ORGANIC CAUSES TO EXPLORE (Table created by chatGPT and reviewed by the author) |
| Congenital anorectal malformations: Imperforate anus (mild forms may go unnoticed in the neonatal period). Anal stenosis. Cloacal malformations. Hirschsprung's disease: A congenital ganglionosis that causes chronic constipation and fecal leakage. Spinal cord malformations and neurological disorders: Occult spina bifida. Myelomeningocele. Injuries to the spinal cord or sacral roots. Spinal dysraphisms. Neuromuscular diseases that affect sphincter function: muscular dystrophies. Other myopathies or peripheral neuropathies. Rare metabolic or endocrine disorders: Congenital or acquired hypothyroidism (may be accompanied by severe constipation). Other less common digestive pathologies: Celiac disease (if accompanied by chronic alterations in bowel habits). Cystic fibrosis (due to recurrent fecal impaction). |
| Of course, before deciding on further tests, A THOROUGH MEDICAL HISTORY MUST BE TAKEN |
When a child has not controlled the anal sphincter after three to three and a half years of age (the age limit in the DSM 5)1 (is 4 years old) we say that he/she suffers from a primary encopresis. In this case, additional medical examinations are required to rule out any medical pathology (Table 1).
But the purpose of this post is the secondary encopresis. In other words, the child had previously achieved bowel control and suddenly begins again to defecate outside the toilet, in inappropriate places, and according to the DSM-5, this should occur at least once a month for three months. Typically, it happens several times a week, or even daily.
La nocturnal encopresis, It is so infrequent that some authors do not recognize it. Usually, the child (the male-to-female ratio is 3:1) tends to experience episodes at the same time and in the same places, even at school ("school involuntary defecation").
Today they are usually classified as:
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With constipation and overflow incontinence.
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Without constipation and overflow incontinence.
I don't like the word "with/without constipation" Because the mechanism is actually different. What occurs is voluntary retention, which can even lead to fecal impaction in the sigmoid colon and cause megacolon. If these impaction fragments are excessively large, they cause retention due to partial obstruction.
The vast majority of children tend to hide it, and it's only discovered because of the foul odor of their stools. When parents discover the problem, there are three types of reactions from their children: the anxiousThe child becomes distressed and feels regretful and guilty. The perverse one, The child feels satisfied, even happy, and adopts a clearly defiant and aggressive attitude. Finally, the passive voiceHe experiences no reaction, neither positive nor negative. It's as if he couldn't care less.
It's not uncommon to find a whole ritual surrounding encopretic behavior: the child usually seeks out their spot, more or less at the same time, both to defecate and to strain intensely to prevent the stool from coming out. These are the retentive encopresis.
What temperamental traits do we find in these children?
No single psychological profile has been described. They may be children with clear socio-emotional immaturity, anxious, with affective symptoms, or clearly aggressive, defiant, selfish, "bossy", who do not tolerate setbacks and frustrations well.
However, it is important to clearly define the psychological profile, since encopresis "does not usually occur in isolation." It is typically a symptom of immense psychological distress (Table 1), the cause of which must be identified in order to implement appropriate treatment.
Families have also been described.
Typically, when mothers are excessively demanding, obsessively controlling, and intrusive with their children, we are most likely to find retentive encopresis. Some authors interpret it as a sign of protest by the child against the mother's pressure.
Conversely, we also find somewhat negligent mothers who pay little emotional attention to their child, and absent fathers with little or no involvement in the education and care of their children.
And finally, sometimes we don't find anything special in the family sphere
The treatment, Depending on the cause, it will involve individual and family psychotherapy. Or simply token economy training. It will all depend on each specific case.
Encopresis usually resolves over time, although the emotional state of the patients is a cause for concern. It will depend on the appropriateness of our intervention.
- Statistical Diagnostic Manual 5th version [↩]