Encopresis
Encopresis
Diagnostic Features
The essential feature of Encopresis is repeated passage of feces into inappropriate places (e.g., clothing or floor) (Criterion A). Most often this is involuntary but occasionally may be intentional. The event must occur at least once a month for at least 3 months (Criterion B), and the chronological age of the child must be at least 4 years (or for children with developmental delays, a mental age of at least 4 years) (Criterion C). The fecal incontinence must not be due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation (Criterion D).
When the passage of feces is involuntary rather than intentional, it is often related to constipation, impaction, and retention with subsequent overflow. The constipation may develop for psychological reasons (e.g., anxiety about defecating in a particular place or a more general pattern of anxious or oppositional behavior) leading to avoidance of defecation. Physiological predispositions to constipation include ineffectual straining or paradoxical defecation dynamics, with contraction rather than relaxation of the external sphincter or pelvic floor during straining for defecation. Dehydration associated with a febrile illness, hypothyroidism, or a medication side effect can also induce constipation. Once constipation has developed, it may be complicated by an anal fissure, painful defecation, and further fecal retention. The consistency of the stool may vary. In some individuals it may be of normal or near-normal consistency. It may be liquid in other individuals who have overflow incontinence secondary to fecal retention.
Subtypes
Encopresis is coded according to the subtype that characterizes the presentation:
- 787.6 With Constipation and Overflow Incontinence. There is evidence of constipation on physical examination (i.e., the presence of a large stool mass on abdominal or rectal examination) or a history of a stool frequency of less than three per week. Feces in overflow incontinence are characteristically (but not invariably) poorly formed, and leakage can be infrequent to continuous, occurring mostly during the day and rarely during sleep. Only part of the feces is passed during toiletting, and the incontinence resolves after treatment of the constipation.
- 307.7 Without Constipation and Overflow Incontinence. There is no evidence of constipation on physical examination or by history. Feces are likely to be of normal form and consistency, and soiling is intermittent. Feces may be deposited in a prominent location. This is usually associated with the presence of Oppositional Defiant Disorder or Conduct Disorder or may be the consequence of anal masturbation. Soiling without constipation appears to be less common than soiling with constipation.
Associated Features and Disorders
The child with Encopresis often feels ashamed and may wish to avoid situations (e.g., camp or school) that might lead to embarrassment. The amount of impairment is a function of the effect on the child's self-esteem, the degree of social ostracism by peers, and the anger, punishment, and rejection on the part of caregivers. Smearing feces may be deliberate or accidental resulting from the child's attempt to clean or hide feces that were passed involuntarily. When the incontinence is clearly deliberate, features of Oppositional Defiant Disorder or Conduct Disorder may also be present. Many children with Encopresis and chronic constipation are enuretic and may have associated vesico-ureteric reflux and chronic urinary tract infections that may remit with treatment.
Prevalence
It is estimated that approximately 1% of 5-year-olds have Encopresis, and the disorder is more common in males than in females.
Course
Encopresis is not diagnosed until a child has reached a chronological age of at least 4 years (or for children with developmental delays, a mental age of at least 4 years). Inadequate, inconsistent toilet training and psychosocial stress (e.g., entering school or the birth of a sibling) may be predisposing factors. Two types of course have been described: a "primary" type in which the individual has never established fecal continence, and a "secondary" type in which the disturbance develops after a period of established fecal continence. Encopresis can persist with intermittent exacerbations for years.
Differential Diagnosis
A diagnosis of Encopresis in the presence of a general medical condition is appropriate only if the mechanism involves functional constipation. Fecal incontinence related to other general medical conditions (e.g., chronic diarrhea, spina bifida, anal stenosis) would not warrant a DSM-IV diagnosis of Encopresis.
Diagnostic criteria for Encopresis
- Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional.
- At least one such event a month for at least 3 months.
- Chronological age is at least 4 years (or equivalent developmental level).
- The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.
Code as follows:
- 787.6 With Constipation and Overflow Incontinence
- 307.7 Without Constipation and Overflow Incontinence