The Prevalence of Encopresis in a Multicultural Population

Abstract

Background: 

Population-based studies on the prevalence of encopresis in children are scarce and generally outdated. Prevalence estimates based on clinical studies are unreliable because parents tend to be reticent to seek medical help for this problem. Professional help is necessary, however, because encopresis can lead to serious psychosocial health problems. The authors examined the prevalence of encopresis in children, the frequency of visits made to general practitioners for encopresis and the psychosocial health problems of encopretic children.

Methods: 

This population-based study involved 13,111 parents and their 5- to 6-year-old children and 9,780 parents and their 11- to 12-year-old children, all residents of Amsterdam, the Netherlands.

Results: 

The prevalence of encopresis was 4.1% in the 5-to-6 age group and 1.6% in the 11-to-12 age group. Encopresis was more frequent among boys and children from the very depressed areas of the city. Encopresis was less frequent among Moroccan and Turkish children. A defecation frequency of less than three per week was found in 3.8% of the 5- to 6-year-olds and 10.1% of the 11- to 12-year-olds with encopresis. Only 37.7% of the 5- to 6-year-olds and 27.4% of the 11- to 12-year-olds who had encopresis had ever been taken to see a doctor for this problem. Psychosocial problems were far more common among children with encopresis than among normal children.

Conclusions: 

Encopresis is a common condition that is often associated with psychosocial health disorders but only a small proportion of the children with encopresis are taken to a general practitioner to discuss their problem.

INTRODUCTION

Encopresis is involves the involuntary loss-almost always during the daytime-of solid, semi-solid and watery excrement in the child's pants or underpants without any physical abnormality. Encopresis is usually the result of functional constipation (retentive encopresis) but it is not always accompanied by constipation (non-retentive encopresis) (¹). In serious cases, retention of feces can lead to dilatation of the colon and to psychosocial problems resulting from social stigmatization and the powerlessness of parents to rectify the complaint (²).

Encopresis occurs in 1% to 3% of all primary school children. With one exception, all published prevalence studies are more than 25 years old (^3-9). In these published epidemiologic studies, encopresis was seen two to four times more often in boys than in girls. The higher prevalence among boys is also reflected in clinical studies of children with encopresis (^9-14). Encopresis also occurs in adolescents and even among adults, but the prevalence is unknown in those age groups (^15-18).

In some western societies, including the Netherlands, large ethnic differences have been found in the incidence of bedwetting (^4,19,20). Whether the same is true of encopresis is uncertain. It is recognized that migrant children with encopresis in the Netherlands are rarely seen in the offices of general practitioners (¹⁷). This article describes the prevalence of encopresis in primary school children in relation to ethnic origin and other socio-demographic factors. We also determined how many children had been taken to their doctors for evaluation of fecal soiling. We also evaluated the relationship between encopresis and psychosocial disorders.

METHODS

The study was conducted between August 2000 and September 2003. Within that period 18,456 children aged 5 to 6 years and 16,293 children 11 and 12 years of age attended one of the twelve school health care centres in Amsterdam for routine medical checks attended by their parents. The school doctors working at these centres filled in questionnaires for the children relating to sociodemographic factors and encopresis. Where necessary, the help of telephone interpreters was enlisted.

The first encopresis-related question was: Sometimes children of this age are not toilet trained for feces. Has your child dirtied his or her pants during the daytime in the past month? If the reply was affirmative, the parent was then asked how often encopresis occurred, how often the child defecated per week and whether they had ever gone to a doctor to evaluate this complaint. Encopresis was defined as the involuntary loss of feces in the underwear once a month or more. A bowel movement frequency of three times a week to three times per day was regarded as normal (²¹).

The sociodemographic details recorded were: the child's age and gender, the number of children living at home, ethnic origin of the family and the postal code. The child's ethnic origin was determined according to the mother's country of birth. Children were grouped in districts on the basis of their postal code. The affluence of the district was determined by the percent of people 15 to 64 years old receiving social benefit in the area. These percentages were obtained from the data issued by the Dutch Central Statistical Office. Areas were divided into four affluence categories according to 10th, 50th and 90th percentile scores as: very wealthy, wealthy, poor and very poor.

Information on psychosocial problems was extracted from the child health care findings and action register. During the consultation the doctors noted whether certain health problems had been detected in the child (findings) and whether the child needed to be seen again or had been referred (action) for evaluation of such problems. On the basis of this registration system it was possible to establish whether a child had behavioral problems, emotional problems, abuse, learning difficulties or upbringing problems. These health problems were all described on the examination record.

χ² tests were used to research the univariate connections between encopresis and sociodemographic factors and between encopresis and psychosocial health indicators. Subsequently, by means of logistical regression, the relative importance of each sociodemographic characteristic to the prevalence of encopresis was determined. Logistic regression was also used to examine the relationships between encopresis and psychosocial health indicators corrected according to sociodemographic factors. The results of these analyses were given as corrected odds ratios. Differences with a P value of <0.05 were viewed as significant.

RESULTS

Encopresis details were collected from 13,111 of the 18,456 5- to 6-year-olds (71%) and for 9,780 of the 16,293 11- to 12-year-olds (60%). The non-response rate was slightly greater among immigrant children (P < 0.05) and children from poorer areas (P < 0.05).

The overall prevalence of encopresis was 3.0%. Table 1 indicates the prevalence of encopresis according to sociodemographic factors. Encopresis was found more often in boys than in girls (3.7% as opposed to 2.4%) and was less frequent among 11- and 12-year olds than 5- and 6-year-olds (4.1% versus 1.6%). After correction for other sociodemographic factors these gender and age discrepancies remained the same (adjusted odds ratios of 1.56 and 0.38, respectively). The prevalence of encopresis was lower among Moroccan and Turkish children (2.3% and 2.2%) than among Dutch children (3.5%). These differences also remained the same after corrections were made for other sociodemographic factors (adjusted odds ratios of 0.65 and 0.63, respectively). Furthermore encopresis was more common among children from very poor areas than among children from very wealthy areas. This difference was only significant after corrections had been made for the other sociodemographic factors (adjusted odds ratio of 1.55).

TABLE 1: Percentages and uncorrected and corrected odds ratios concerning the relationships among sociodemographic factors and enopresis

Stool frequencies of children with encopresis are given in Table 2. In 3.8% of the 5- and 6-year-olds and 10.1% of the 11- and 12-year-olds with encopresis frequency of bowel movements was less than than three per week. Only 29% of the children with encopresis had ever been taken to a doctor for evaluation of this problem. The extent to which children with encopresis were taken to see a doctor because of their stool problems did not differ by gender, affluence of the residential area or number of children living at home. In contrast, 11- and 12-year-olds with encopresis had been taken to the doctor more often than 5- and 6-year-olds (37.7% vs 27.4%; P < 0.05). Surinamese children with encopresis were taken to see their doctor less often than Dutch children with encopresis (21.2% vs 31.7%; P < 0.05).

TABLE 2: Defecation frequencies of children with encopresis

The relationship between encopresis and the five psychosocial health indicators is given in Table 3. School doctors detected behavioral problems, emotional problems, abuse, learning difficulties and difficulties linked to upbringing more often among children with encopresis than among normal children. Even after simultaneous correction for sociodemographic factors had been made, these differences remained (adjusted odds ratios varying between 1.71 and 4.32).

TABLE 3: Percentages, uncorrected and corrected odds ratios concerning the relationships among encopresis and psychosocial problems

DISCUSSION

The established prevalence rates of 4.1% among 5- and 6-year-olds and 1.6% in the 11- and 12-year-old age group are somewhat higher than reported in previous West European studies. In Sweden, for instance, Bellman found in 1963 that among 8683 7-year-olds there was a 2.2% prevalence of encopresis at the age of 5 (⁹). In the 1965 Isle of Wight study, a prevalence of 0.8% among 3064 10- to 12-year-olds was reported (⁷). These discrepancies may be the result of the differences in data collection, population sampling and definition of encopresis in these two studies. We suspect, however, that differences in definition of encopresis are an unlikely explanation, because these studies and ours all defined encopresis as soiling at least once a month. It seems likely that the true prevalence of encopresis has actually increased over time. In fact, in two virtually identical Dutch studies performed in 1965-1966 and in 1996, the prevalence of fecal incontinence (soiling more than once every 4 weeks) among 3-year-olds doubled over 30 years, going from 21% to 49% in boys and 13% to 26% in girls (^8,22).

As in other studies, we found that encopresis was more common in boys than girls (^3-9). The prevalence was also higher among children from very depressed areas. Davie et al. also discovered that prevalence was higher among children from lower socioeconomic groups (⁶). Other researchers have found that the prevalence of encopresis does not vary with socioeconomic status (^5,7,9). We found that encopresis among Turkish and Moroccan children was lower than among their Dutch counterparts. This is the first study to examine the prevalence of encopresis across different ethnic groups. It is possible that Turkish and Moroccan parents simply did not report encopresis for the simple reason that urine and feces are regarded as impure in Islamic culture.

In the vast majority of cases, encopresis is coupled with constipation. Our study showed that only a small proportion of children with encopresis had fewer than three bowel movements a week. It should be remembered that constipation cannot be confirmed simply by establishing the frequency of trips to the toilet (²³). Even children who go to the toilet three times a week and produce feces of a normal consistency may be suffering from fecal retention. Unfortunately such children fall outside of the recently established Rome-II criteria for constipation (²⁴). If rectal examination reveals that the rectum is filled with hard feces then retentive encopresis is probable. The periodic production of a large quantity of feces can also be an indication of retentive encopresis (²³).

Most children who have encopresis can be helped, but the treatment required may be protracted and extensive (¹⁵). Our findings indicate that many children with encopresis are not properly diagnosed and treated. Parents fail to seek help because they maintain that the soiling is a result of laziness or indifference on the part of the child or else because they feel ashamed that they have been unable to avert the problem. Treatment is essential, not only so that the encopresis can be overcome but also so that the child's psychosocial problems can be addressed (^11,25-27). We found that behavioral problems, emotional problems, abuse, learning difficulties and upbringing problems were more common among children with encopresis than among children who did not have the condition. It should be noted that parents were not uniformly questioned about the psychosocial disorders by means of standardized questionnaires. However, the psychosocial problems were carefully detailed in the protocol that has been used in the Amsterdam child health care sector for more than 10 years. To our knowledge, no other population-based studies have been published that deal with the relationship between encopresis and psychosocial health problems. As in our study, other clinical case-control studies have found a correlation among encopresis and behavioural problems (^10,25,26), emotional disorders (^10,26,28) and learning difficulties (^10,12,26,29). Several case reports have established links between sexual abuse and encopresis (^30,31).

In conclusion, encopresis is a common condition in children and is often associated with psychosocial health problems. Only a small proportion of children in our mixed ethnic population are ever taken to a general practitioner specifically to discuss this problem.