A Messy Problem

Our son toilet-trained beautifully at two and a half. We let him take the initiative, and everything went smoothly. But now he's five, and he's started holding back his bowel movements. He can hold it in for many days — a week is the record so far. It's driving us nuts! He has little accidents but refuses to sit on the toilet. We try not to get angry, but we are really frustrated. He smells, the laundry is piling up, and our outings can turn into a nightmare if he has an accident. When we ask him about it, he acts like it's no big deal. What’s going on? Any ideas? The doctor suggested giving stickers or candies as a reward, but so far, no luck.

Understanding Encopresis

I was amazed when I learned the answer to this problem, which is called encopresis. Believe it or not, the most probable cause is constipation! If a child has been constipated long enough, his bowels are always full, so he can't sense when he needs to use the toilet.

The problem begins when, for some reason, the child is unwilling or unable to defecate. If he has had a particularly hard and painful stool, he may develop a small crack or fissure, which causes pain when using the toilet. To avoid this pain, he holds back his stool for as long as he can. Eventually, the anal canal feels full all the time, so he always feels the need to "go," but knows it will hurt if he tries to push the stool out. The stool becomes impacted and hard. As he continues to eat and produce more stool, it begins to leak out even though he doesn't push it out. This results in encopresis — pooping in his pants.

The Solution: Softening the Stool

The first and most important solution is to use a laxative suitable for children to make the stool soft. Here’s a step-by-step approach:

1. Explain the Situation to Your Child: Take time to explain to your son that the medication is to make the poop soft so it won’t hurt when it comes out. Encourage him to talk to you about whether he's worried about it hurting.
2. Use Soothing Creams: He may want to apply a soothing cream around his anus to help heal any soreness and prevent new pain once he starts to defecate regularly.
3. Create a Routine: Sit him on the toilet or a potty seat and read him a story when the laxative begins to work. Do this at regular times, for a few minutes. Reward him when he produces stool, and if he isn’t able to in about ten minutes, take him off and say you’ll try again later.
4. Ignore the Accidents: Focus on the successes and ignore the accidents. Once the laxative makes him able to produce soft stool that doesn't hurt, explain that it's important to notice when he needs to "go" and to go immediately so the poop doesn't get hard and painful again.
5. Monitor and Support: Tell him to let you know if it hurts so you can help him with the problem.

If you need more help in following this regimen, ask your family doctor to refer you to a pediatrician. (I learned this method from one.)

When to Seek Further Help

Occasionally, there may be other, more serious, emotional causes for encopresis. For example, children who are being sexually abused may dissociate from that area of their body, becoming unaware of any bodily sensations they need to pay attention to. If the above solution doesn't work and a pediatrician has found nothing physical to account for the behavior, consult a psychologist. Encopresis that lingers for a long time can cause serious social problems and a resultant loss of self-esteem.