Fecal incontinence in children

Fecal incontinence in childhood is the repeated involuntary or intentional passage of stool in inappropriate places in children with a developmental age ≥ 4 years. Functional fecal incontinence is a gut-brain axis disorder and the most common type of fecal incontinence in children. Functional retentive fecal incontinence is caused by constipation and overflow fecal incontinence and is characterized by passage of small-volume semiliquid stools, a palpable abdominal and/or rectal stool mass, and other clinical features of constipation in children. Functional nonretentive fecal incontinence is less common, has no identifiable cause, and is characterized by normal stool consistency and physical examination findings. Fecal incontinence due to an organic cause (e.g., neurogenic bowel dysfunction, anorectal surgery) occurs in ∼ 5% of children. Diagnosis of functional fecal incontinence is primarily clinical; diagnostic studies may be considered in case of diagnostic uncertainty or to evaluate for an underlying cause. Functional retentive fecal incontinence typically resolves with treatment of the underlying constipation. Management of functional nonretentive fecal incontinence is more challenging and primarily involves behavioral interventions, such as a structured toileting program and rewards. Management of fecal incontinence due to an organic cause is focused on treating the underlying condition.

• Prevalence: ∼ 1–4% of children ^[1][2]
• Most commonly affects children 4–6 years of age ^[1]
• ♂ > ♀ (2:1 to 6:1) in children ≥ 5 years of age ^[1]

Epidemiological data refers to the US, unless otherwise specified.

Functional fecal incontinence (encopresis) ^[1][2][3][4]

Functional fecal incontinence is a gut-brain axis disorder and is the most common type of fecal incontinence in children. There are two subtypes: retentive and nonretentive.

• Retentive fecal incontinence (∼ 80% of cases) is caused by constipation and chronic voluntary stool withholding, which results in: ^[1][2][3]
  • Overflow fecal incontinence in patients with fecal impaction
  • Involuntary leakage of stool in patients with rectal dilation and reduced rectal sensation
• Nonretentive fecal incontinence (∼ 15% of cases) ^[3]
  • No identifiable organic cause
  • Often associated with impulse and conduct disorders (e.g., oppositional defiant disorder, conduct disorder) ^[1][2]

Risk factors for functional fecal incontinence ^[1][3]

• Psychosocial stressors (e.g., toilet training, transition to solid food, starting school)
• Child sexual abuse
• Low socioeconomic status
• Male sex
• Family history of fecal incontinence

Organic causes of fecal incontinence

• Accounts for ∼ 5% of fecal incontinence in children ^[3]
• Causes include: ^[5][6]
  • Hirschsprung disease
  • Previous anorectal surgery or injury (e.g., postsurgical Hirschsprung disease or anorectal malformation)
  • Neurogenic bowel dysfunction due to, e.g.:
    • Neural tube defects
    • Spinal cord injury or tumor
    • Cauda equina syndrome
  • Cerebral palsy
  • Muscular dystrophy, myopathy
  • Inflammatory bowel disease (e.g., ulcerative colitis)

Fecal incontinence is the passage of stool in inappropriate places in a child with a developmental age ≥ 4 years. Symptoms differ based on the type of fecal incontinence. ^[3][4]

Functional fecal incontinence

Features suggestive of an organic cause ^[2][3][6]

The following red flag features of fecal incontinence in children should prompt an evaluation for an underlying organic cause.

• Growth faltering
• Anatomical sacral or rectal abnormalities (e.g., sacral tuft or dimple, gluteal cleft asymmetry, surgical scars) ^[4]
• Decreased lower limb tone, strength, and/or reflexes
• Decreased anal tone, perianal sensation, and/or reflexes (e.g., anocutaneous reflex, bulbocavernosus reflex)
• Features of Hirschsprung disease
• Features of neurogenic bowel dysfunction

Approach ^[2][3][4][5]

• Evaluate for functional fecal incontinence in symptomatic children with a developmental age of ≥ 4 years. ^[1]
• Determine subtype: See "Retentive vs. nonretentive functional fecal incontinence."
  • Constipation present
    • Retentive fecal incontinence is likely.
    • See "DSM-5 diagnostic criteria for encopresis."
    • See also "Diagnostic approach to constipation in children."
  • No constipation
    • Nonretentive fecal incontinence is likely.
    • See "DSM-5 diagnostic criteria for encopresis" or "Rome IV criteria for functional nonretentive fecal incontinence."
• Refer to pediatric gastroenterology for additional evaluation if:
  • Red flag features of fecal incontinence in children are identified
  • There is diagnostic uncertainty
• Diagnostic studies typically include colonic transit time testing, anorectal manometry, and imaging.

Diagnostic studies are not routinely required if the diagnostic criteria for functional constipation in children are met. ^[1]

Abdominal x-rays have low specificity for constipation and are not routinely indicated to evaluate for fecal incontinence or constipation. ^[3][7]

Clinical evaluation ^[2][3][5]

• Obtain a comprehensive medical history, including:
  • Characteristics of fecal incontinence, including:
    • Stool consistency: Consider using the Bristol stool chart. ^[5]
    • Timing and frequency of symptoms
    • Complete evacuation, soiling of clothing
  • Associated symptoms, e.g.:
    • Clinical features of constipation in children
    • Urinary symptoms
    • Psychosocial stressors or other risk factors for functional fecal incontinence in children
  • Diet
  • Medication review
  • Family history
  • Past medical and surgical history
• Perform a physical examination, including:
  • Pediatric growth parameters
  • Abdominal examination: Assess for palpable fecal mass.
  • Lumbosacral examination for features of occult spina bifida (e.g., sacral dimple, hypertrichosis, lipoma)
  • Neurological examination of lower extremities
  • Perianal inspection for anal fissures and hemorrhoids
  • Digital rectal examination: Assess for stool in the rectum and evaluate anal sphincter tone and anorectal sensation.

Diagnostic criteria for functional fecal incontinence in children

DSM-5 diagnostic criteria for encopresis

All criteria must be fulfilled to confirm the diagnosis.

• Inappropriate passage of stool (involuntary or intentional) in a child with a developmental age ≥ 4 years
• At least once per month for ≥ 3 months
• Not caused by a medication or a medical condition other than constipation

Rome IV criteria for functional nonretentive fecal incontinence ^[2]

All criteria must be fulfilled to confirm the diagnosis.

• Inappropriate passage of stool for ≥ 1 month in a child with a developmental age ≥ 4 years
• No constipation or fecal retention
• No identifiable organic cause after appropriate clinical evaluation

• All patients ^[3]
  • Educate caregivers on the nature and prognosis of the condition and discourage punitive actions.
  • Review skin care and use of continence products as needed (e.g., barrier emollients, disposable underwear).
• Organic causes of fecal incontinence: Refer to an appropriate specialist for management.
• Retentive fecal incontinence
  • Treat the underlying constipation and fecal impaction.
  • See "Management of constipation in children." ^[7][8]
• Nonretentive fecal incontinence ^[2][3][4]
  • Initiate a structured toileting program.
    • Encourage children to use the toilet as soon as they feel the urge to defecate.
    • Encourage defecation by asking the child to spend 5–10 minutes on the toilet after every meal and after school.
    • Ensure toilet seat and positioning is optimal (e.g., comfortable toilet seat, proper foot support).
    • Consider implementing a reward system and a bowel diary to ensure compliance.
  • Screen all patients for psychological symptoms (e.g., with a child behavior checklist or strengths and difficulties questionnaire), and refer for management as indicated. ^[3]
  • Schedule regular follow-ups. ^[3]
    • Symptom improvement: Continue management.
    • No improvement within 6 months of initial management: Refer to pediatric gastroenterology for further evaluation and management.

If child sexual abuse is suspected, refer to a trained provider for further evaluation. ^[2]