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OVERVIEW

What are the causes of stool soiling?

Stool soiling, also called encopresis, happens when children who are already toilet trained accidentally leak feces into their underwear. Constipation is often the cause of stool soiling. Usually, the amount of soiling is small and just stains the underwear. In almost all cases, stool soiling is involuntary – your child does not mean to soil their pants. If soiling happens often – every day or many times a day – your child may need to be treated for it.

Other causes of stool soiling include:

• Need for more toilet training
• Toilet “phobia” (scared of using the bathroom)
• Irritable bowel syndrome

In very few children stool soiling is caused by disease or birth defects.

How are stool soiling and constipation related?

Constipation may cause painful or incomplete bowel movements. If bowel movements are painful, a child may try to “hold” their stools, making constipation worse. In children who have constipation, formed, soft or liquid stools can leak from the anus (the opening to the rectum) around a mass of stool stuck in the lower bowel and cause soiling. This happens because the amount of stool can become so large that it leaks out of the anus, causing soiling. Often, these stools have a very bad smell.

What causes constipation in a child?

Constipation may occur if your child is not eating enough high-fibre foods, drinking enough fluids or getting enough exercise. In many children, a cause for constipation cannot be found. Painful bowel movements may cause a child to begin resisting the urge to have a bowel movement. Not having a bowel movement when the urge occurs can lead to constipation. Your child could be scared of being alone in the bathroom or scared of the toilet. Some children just don’t want to stop playing to go to the bathroom.

An illness that leads to poor food intake, physical inactivity or fever can also result in constipation and stool soiling. This problem can remain even after the illness goes away.

Symptoms of Constipation:

• Extreme straining during a bowel movement
• Abdominal pain and bloating
• Crankiness
• Tiredness
• Loss of appetite between bowel movements
• Wetting during the day or night
• Extreme reluctance to use the toilet

Is this just a phase?

It’s possible that your child is going through “a phase.” Your child may not have the skills yet to use the toilet. But, if your child keeps soiling after about 3 months of being able to use the toilet to urinate, it’s probably time for them to learn to use the toilet for bowel movements. Your healthcare provider can offer advice.

How should I start toilet training my child for bowel movements?

1. Keep a toilet diary. Keep a “diary” showing when, where and what kind of bowel movements your child has. It will help you and your healthcare provider see patterns in your child’s bathroom habits. Try to keep a toilet diary for at least 1 week before going on to step 2. If your child is in day care, ask the teacher to help you look for patterns in your child’s toilet behavior. At the end of this handout there’s a sample toilet diary you can print out and use to help you.
2. Teach your child to sit on the toilet. Play in the bathroom with your child to show them that the bathroom is not a bad place. Allow your child to sit on the toilet with pants on for a few minutes at a time. It may be helpful to have a foot stool so your child can rest their feet. Allow your child to have their favorite books, dolls or small toys during bathroom time.

Read to, play with and talk to your child when you’re in the bathroom together. Don’t expect–or ask–your child to have a bowel movement on the toilet yet. Remember, he or she is still getting used to the idea of sitting on a toilet. Start with a very short amount of time (about 30 seconds) and slowly work up to 5 minutes. A kitchen timer can be the signal for the end of “bathroom fun.” Move to step 3 once your child is sitting on the toilet 3 to 5 times a day, for 5 minutes each time.

3. Make sure your child’s bowel movements are soft and well-formed. It helps if you give your child less dairy food and more high-fibre foods. Ask your family healthcare provider about diet changes.

At first, your child may have more soiling accidents. Have your child help clean up messes, but don’t yell or punish your child for soiling. Being angry with your child when he or she soils only makes toilet training harder. Try to stay calm and relaxed when your child soils, so he or she won’t feel bad.

4. Have set times for sitting on the toilet. Once your child is having healthy bowel movements and is used to sitting on the toilet, start having your child sit on the toilet at regular times during the day. Time the sits to start about 10 to 20 minutes after each meal and during times when your child usually has a bowel movement. You’ll be able to tell these times from the toileting diary. Your child should sit on the toilet at least 3 to 5 times per day, for about 5 minutes each time.
5. Reward bowel movements in the toilet. The first time your child has a bowel movement in the toilet, give your child a reward. Good rewards are stars on a chart or fun activities. At first, give a reward after every bowel movement in the toilet. Later, give the reward after every few bowel movements. Pretty soon your child will be trained. Then you can stop giving rewards.

Next, teach your child to know when it’s time to go to the toilet. Teach your child to tell you, instead of waiting for you to ask. Young children should tell a parent before they use the bathroom, in case they need help.

What is the treatment for stool soiling caused by constipation?

If your child doesn’t have a bowel movement for 3 or 4 days in a row, you should contact your healthcare provider. They will probably want to remove the stool that has collected in the lower bowel. Your healthcare provider can do this in the office by giving your child an enema or a suppository. It is also possible that your healthcare provider may have you give your child high doses of laxatives to remove the stool.

After the stool has been removed, it is important to be sure that your child can have bowel movements easily. Easy bowel movements will help prevent another large collection of stool. Treatment may include changing your child’s diet to include more fluids and fibre‑rich foods, having your child sit on the toilet several times a day and giving your child stool softeners every day to help soften the stools.  Don’t use any suppositories or enemas without your healthcare provider’s advice.

Toileting Diary

Day/date	Time	Time	Time	Time	Time	Time
Mon/22	9 a.m. BMB, UB	12 p.m. PS, UT	2 p.m. BMP, UP

 

Directions: When your child has a bowel movement or urinates:

• Put day of week and date in the first column.
• Put time of day in “Time” column.
• Add the code to the “Time” column.
• Continue each day.

Codes:

BMT=bowel movement in toilet

BMP=bowel movement in pants

BMB=bowel movement in bed

PS=practice sits

UT=urinates in toilet

UP=urinates in pants

UB=urinates in bed

FOR MORE INFORMATION

Toronto Hospital for Sick Children Website at:
http://www.aboutkidshealth.ca/En/HealthAZ/HealthandWellness/Elimination/Pages/Toilettraining.aspx

Nova Scotia Department of Health and Wellness Website (Loving Care) at:
https://novascotia.ca/dhw/lovingcare

Sources

Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal by BR Kuhn, PH.D., BA Marcus, PH.D., and SL Pitner, M.D., M.P.H. (04/15/99, http://www.aafp.org/afp/990415ap/2171.html)