HOW TO TREAT ENCOPRESIS (SOILING) 2025

HOW TO TREAT ENCOPRESIS (SOILING) 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 32

ENCOPRESIS (SOILING)

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 32

ENCOPRESIS (SOILING)

I. DEFINITION  

Encopresis is defined as the repeated passage of feces into inappropriate places (e.g., clothing or elsewhere), occurring at least once monthly for 3 consecutive months, whether intentional or unintentional. It typically involves bowel dysfunction (e.g., irregular defecation, constipation, recurrent abdominal pain, or pain during bowel movements). This is a non-organic disorder requiring a minimum age of 4 years for diagnosis.

II. ETIOLOGY  

Encopresis arises from an interplay of physiological and psychological factors:  

– Primary Encopresis:  

  – Chronic Constipation (75%): Children may withhold defecation to avoid pain, leading to involuntary soiling.  

  – Sexual Abuse: Can disrupt normal bowel habits.  

  – Parental Factors: Harsh attitudes, strict upbringing, or punishment during toilet training.  

  – Psychiatric Conditions: ADHD, specific phobias (e.g., fear of toilets), learning disorders, conduct disorder, oppositional defiant disorder.  

– Secondary Encopresis: Occurs after a period of proper toilet habits, often triggered by significant events (e.g., parental separation, sibling birth, academic failure, relocation).

III. DIAGNOSIS  

1. Definitive Diagnosis

Encopresis is diagnosed when a child repeatedly defecates in inappropriate places (≥1 time/month for ≥3 months), with a mental age of at least 4 years. Organic causes must be excluded. DSM-IV-TR classifies it as with or without constipation and overflow incontinence.  

– Many children with encopresis (especially with constipation) have anal sphincter abnormalities, impairing relaxation during defecation; laxatives are less effective here. Those without sphincter issues often improve quickly.  

– In physiologically normal children, poor sphincter control may stem from distraction or ignorance of defecation cues; stool may be normal, near-normal, or loose.  

– Emotion-driven soiling in children with good bowel control is typically transient and sub-diagnostic.  

– ICD-10 Criteria:  

1. Repeated defecation in inappropriate places (e.g., clothing, floor), voluntary or involuntary.  
2. Chronological and mental age ≥4 years.  
3. ≥1 soiling event per month.  
4. Duration ≥6 months.  
5. No organic condition fully explains the soiling.  

– Subtypes:  

  – F98.10: Inability to achieve physiological bowel control.  

  – F98.11: Adequate bowel control with normal defecation.

2. Ancillary Testing  

– No specific test exists; focus is on ruling out organic causes (e.g., Hirschsprung’s disease).  

– Bowel Function Assessment: Abdominal X-ray for constipation, colorectal endoscopy.  

– Psychological Evaluation: Beck/Hamilton depression scales, Zung/Hamilton anxiety scales, DASS (anxiety-depression-stress), DENVER II (development), CBCL (child behavior).  

– Routine Tests: Complete blood count, biochemistry, urinalysis, ECG, abdominal ultrasound, chest X-ray.

3. Differential Diagnosis  

– Dietary Issues: Improper nutrition.  

– Gastrointestinal Disorders: Hirschsprung’s disease, anal/rectal/colonic conditions.  

– Medication Side Effects: Unintended consequences of drugs.  

– Endocrine/Neurological Disorders: Conditions affecting bowel control.

IV. TREATMENT  

1. Treatment Principles  

– Comprehensive bowel and psychological assessment.  

– Exclude organic causes.  

– Combine medical, behavioral, family/school interventions, diet, and exercise.  

– Treat co-occurring psychiatric conditions.

2. Treatment Framework  

Child with encopresis  

↓  

Clinical and ancillary evaluation  

↓  

Gastrointestinal organic condition → Treat underlying cause  

↓  

Confirmed encopresis diagnosis → Counseling and monitoring  

↓  

Develop treatment plan

3. Specific Treatments  

– Medical Interventions:  

  – Laxatives: Soften stool, ease defecation.  

  – Enemas: Relieve severe constipation.  

– Child Behavioral Interventions:  

  – Increase awareness of the disorder.  

  – Reinforce daily toilet habits.  

  – Improve diet and exercise.  

  – Reward positive behaviors (e.g., successful toileting).  

– Bowel Control Training:  

  – Daily toilet sitting (e.g., 10 minutes, 20 minutes post-meal).  

  – Praise/reward successful defecation in the toilet.  

– Family/School Interventions:  

  – Educate families to accept soiling without blame.  

  – Reduce family stress, eliminate punitive responses.  

  – School support to minimize embarrassment.  

– Diet and Exercise:  

  – High-fiber diet (bran, starches, fresh fruits, vegetables).  

  – Reduce fatty/sugary foods.  

  – Adequate hydration.

V. PROGNOSIS AND COMPLICATIONS  

1. Prognosis  

– Depends on cause, chronicity, and co-occurring behavioral issues.  

– Often resolves spontaneously; few persist into mid-adolescence.  

– Cases with physiological factors (e.g., poor gastric motility, sphincter dysfunction) are harder to treat than constipation with normal sphincters.  

– Outcomes hinge on family willingness to engage in treatment without harshness.

2. Complications  

– Physical: In constipation-related cases, risks include fecal impaction, megacolon, anal fissures.  

– Psychological: Teasing, social isolation, low self-esteem, withdrawal, anxiety, or other emotional/behavioral disorders.

VI. PREVENTION  

– Prevent constipation through regular exercise (outdoor play), a balanced diet (fruits, vegetables, whole grains), limited fast/processed foods, and ample water.  

– Early detection and intervention for psychological toileting issues to reduce constipation risk.  

– Teach toileting when developmentally ready (typically after age 2), encouraging consistent daily habits (e.g., post-meal).

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