Soiling

Overview

• Soiling in children is the involuntary passage of stools in conjunction with constipation (abnormal if > 4 years of age, Boys : Girls = 3 : 1)
• It is a common problem among children. Its significance is often underestimated by doctors, but it is a major problem for the children and their parents.
• In the Past soiling was usually thought to be pschological in origen. The term „encopresis“ was used.
• Nowadays it is known that soiling is almost always a functional problem caused by a vicious circle of constipation and stool withholding. (The term „soiling“ is used more commonly for this problem, although the terms „soiling“, „encopreses“, and „fecal incontinence in children“ are also used synonymosly)
• Behavioural problems are a result and not the cause of soiling, brought on by the enormes strain on family and child, and disappear when soiling has been successfully treated.
• Rare are organic causes such as Spina-bifida or Hirschsprung's disease.

Mechanisms of Soiling: A Vicious Circle

File:Bowel-overflow-sheme.jpg

Constipation is associated with hard, large stools in the large bowels and rectum, which become difficult and painful to evacuate. This leads to stool-withholding. A vicious circle ensues. The rectum becomes gradually distended with accumulated stool. The distension causes a loss of sensation in the rectum. This leads to further stool-withholding, as the urge to defecate becomes more and more irregular. Eventually, softer stools from higher up the bowels cannot be accomodated and leak around the bolus of hard stool (overflow). Due to the lack of rectal sensation, this is not noticed by the child until soiling has actually occurred.

File:Soiling circle2.jpg

Parents are under great stress, as they might think or suspect that their child is soiling intentionally and become irritale and even aggressive. They might have also been advised, that their child is psychlogically abnormal, which leads to further distress.

Both Parents and Child often suffer great physical and psychological abuse. Soiling can result in a disruption of relationship between the parents as well as the parents and their child.

Children who soil then become very frightened as they are punished for something over which they have no control. Soiling results in a marked loss of self-esteem in the affected children. Behavioural abnormalities develop.

History: (Typical features)

• Occasional very large stools and several soft stools daily (Parents of constipated children often insist that their child is having diarrhoea rather than constipation, and it may be difficult to convince these parents, that their child should go on treatment for constipation.)
• Painful defecation
• Blood in Stools (this is usually due to painful fissures in anus)
• Stool-withholding behaviour: Child may be noted to spend long periods of time standing in a corner prior to soiling. This can be mistaken for exaggerated attemts at defaecation.
• (Major psychological or behavioural abnormalities before soiling started may suggest a psychological cause (encopresis): this is uncommon)
• (day-time-wetting is not a feature of soiling and may suggest an organic cause: this is rare)

Examination by the doctor include:

• Abdominal examination: The impacted bowels may be felt through the tommy, but is often not felt even in severe constipation.
• Close inspection of the Anus and perianal area: Anal fissures will support the diagnosis. There may also be signs of inflammation like thrush or streptococcal infection.
• The Back should be inspected and ankle-reflexes tested to rule out spina-bifida.
• (A rectal examination as well as enemas should not be performed, especially not in young girls, as the children are already traumatised enough in this area, and this would be one more emotional trauma. It also provides no useful information, as the rectum might be empty right at that moment.)

Management:

Soiling should in first instance ALWAYS be treated as secondary to constipation (even if in doubt of another cause): 70-75% success

1. Education and Reassurance: (Removes much of the stress from parents and child. Relief of anger and anxiety. )
   • Soiling is NOT intentional (child doesn't notice until soiling has occurred. - no punishment, but support !!)
   • Child is NOT psychologically abnormal! (behavioural problems will resolve once soiling has been treated succsessfully!
   • It CAN be treated successfully!
   • Explain mechanisms of overflow-incontinence with picture (It is important for parents to understand the mechanisms of soiling well, as they might otherwise not comply with treatment, leading to treatment-failure)
   • Involve Children if old enough! Let them have their say! (Parents of children who have been toilet-trained for a few years have little idea about their child´s bowel habits, although they often assume great authority on the issue)
2. Disimpaction: with strong Laxative (start when child is off school/kindergarten)
   • e.g.: Bisacodyl (Dulcolax) orally 5 mg mane for 3 days (10 mg if >5 years of age)
   • (Enemas or Suppositories are invasive and are usually not needed. Success of treatment depends on its consequent and prolonged application, not on its invasiveness)
3. Prevention of Reaccumulation: with a stool softener (start simultaneously with disimpaction) For 6-12 months: for child to regain confidence and colon to return to original tone and shape. It is important to do this consequently and in sufficient high doses. Taper off treatment gradually after
   • e.g.: Liquid Paraffin (= mineral oil) (10 - 60 mls nocte) titrated to effect (directly from fridge, with yoghurt or ice-cream) (Contraindications: Children <1 year and children with neurological abnormalities or learning difficulties should not take Liquid Paraffin, because of risk of aspiration)
   • Dietary fibre (e.g. fruits) + Plenty of Fluids are important (but on its own it will NOT be sufficient enough once stool withholding and soiling have established!)
   • Lactulose may be used in infants <1 year of age (It is less suitable because of day-to-day inconsistency of efficacy, making it difficult to titrate and possibly counterproductive to establish regular bowel pattern)
   • (NO enemas or suppositories! These are are for Disimpaction only. If hard stools have formed again, it means that reaccumulation has failed and higher doses for its prevention are needed.)
4. Establishing regular bowel pattern: (start after successful disimpaction)
   • Encourage child to sit on toilet regularly, at same time of day, at least once, for at least 5 min, Ideally after breakfast (gastro-colic reflex)
   • Continue on daily basis irrespective on whether or not child has passed stools.
   • Footstool or other support to ensure hips can be fully flexed, and child can sit comfortably on toilet