FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

DAUGHTER'S LACK OF BOWEL CONTROL MAY BE DUE TO EMOTIONAL STRESS

Question: My 9-year-old daughter has a problem with constipation and with soiling her pants. The doctor diagnosed her with encopresis and said she should take a dose of mineral oil every day. She is unwilling to do this because of the taste, so I've switched to milk of magnesia. In spite of this, she still has some stomachache and soiling. Is there a better "natural" or herbal laxative I should be giving her, and should I take her to another doctor?

Answer: Encopresis is a "doctor term" that describes the symptom of inappropriate passage of stool in a person over 4 years old. This fairly common condition usually involves soiling the underwear, as happens with your daughter. Sometimes, though, it can be more extensive, and the person will have a complete bowel movement in an inappropriate place, including in the pants.

Encopresis -- which has a number of causes -- can be divided into two types. First are the children who never gain control of their bowel movements. Second are those who learn how to control their bowel movements and then revert back to earlier behavior. This distinction is important because those who have never had control of their bowel movements are likely to have a structural defect in the anatomy of the colon or nervous system that causes this problem. And as you might imagine, this disorder is treated differently than encopresis caused by other abnormalities.

From the way you worded your question, I assume that your daughter has previously had good control of her bowel movements and only recently developed encopresis. This may be the consequence of emotional stress. Some children, whether because of toilet training experience or because they haven't yet learned other ways of dealing with emotionally stressful situations, delay having a bowel movement. This persists until the colon is literally full. Subsequently, the stools become dry and hard. It becomes difficult to pass this impacted stool, but pressure in the bowel can force a small amount of more liquid stool around the impaction. This "leakage" can soil the underwear.

Other conditions that can lead to chronic constipation and encopresis in children include an anal fissure and rectal stenosis. The former is a small tear in the rectal tissue and the latter is a narrowing of the rectal canal. Both of these disorders cause pain with bowel movements, which can make a child avoid them and, thereby, develop chronic constipation. Dietary problems can also cause encopresis. Excessive consumption of proteins or milk, or inadequate amounts of fiber or water can do it. I even took care of a young man who ate one pound of prunes every day. Guess what caused his encopresis?

As you might have guessed by now, most encopresis is associated with constipation, and relieving that underlying constipation is a necessary first step. Often it is necessary to "clean out" the colon first, using strong laxatives and/or enemas. Afterwards, it is necessary to keep the stools soft and slippery for about six months for the colon to become "reeducated." This is best accomplished by a combination of diet and medication. A diet high in fiber -- at least 30 grams each day -- can act as a "natural" laxative and adequate water intake can also help keep the stools soft. Mineral oil is the preferred medicine to keep the stools soft and slippery.

Certainly you should take your daughter back to her doctor so that both you and she clearly understand the cause of her encopresis and the treatment plan to correct the problem.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701. Past columns are available online at http://www.FamilyMedicineNews.org.