Secondary Logo

Journal Logo

CASE REPORTS

Physical Therapy for a Child With Encopresis: A Case Report

Anderson, Brittany PT, DPT

Author Information
Pediatric Physical Therapy: July 2019 - Volume 31 - Issue 3 - p E1-E7
doi: 10.1097/PEP.0000000000000631

INTRODUCTION

Encopresis (fecal incontinence) is a pediatric gastrointestinal condition with physical, psychological, and social effect.1 Encopresis affects approximately 4% of all children 5 to 12 years old in western societies.1 The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) lists 4 features that must be present to support a diagnosis of encopresis: (1) child's age must be at least 4 years, (2) a repeated passage of feces into inappropriate places (eg, clothing or floor, which can be either intentional or involuntary), (3) at least 1 such event must occur every month for at least 3 months, and (4) the behavior is not attributable to the effects of a substance (eg, laxative, or another medical condition, with the exception of a mechanism involving constipation). There are 2 subtypes of encopresis, which include nonretentive encopresis (fecal incontinence without constipation) and retentive encopresis (fecal incontinence with constipation).2 Retentive encopresis is largely correlated with chronic constipation with a recent survey reporting 80% of children with encopresis also have chronic constipation.3 Christophersen and Mortweet4 describe constipation as the passage of large or hard stools, often accompanied by complaints of abdominal pain, infrequent bowel movements (<3 per week), the presence of abdominal masses upon physical examination, and emotional upset before, during, and after defecation.

PSYCHOLOGICAL EFFECT

Encopresis is associated with negative psychosocial outcomes in children.5 Joinson et al1 found that children who experience encopresis have a significantly higher rate of emotional and behavioral problems than children without encopresis.1 Furthermore, children with encopresis are significantly more likely to report being victims of bullying behaviors.1 This can be attributed to the fact that the child is often unaware of the leakage until it is noticed by a peer due to smell or a visible stain on the child's clothing. As a result of the stigma and shame associated with encopresis, children often experience decreased self-esteem, decreased self-confidence, and limited participation with peers.1

ECONOMIC EFFECT

In the United States, approximately 25% of visits to a pediatric gastroenterology clinic are constipation related.6 Constipation is usually chronic resulting in significantly higher overall medical costs to the family. Children with constipation use more health services ($3430/year) than children without constipation ($1099/year).7 Per year, this health service spending is equivalent to an additional $3.9 billion spent on services/products for treating constipation in children.7–10

CYCLE OF ENCOPRESIS

Chronic constipation in children is caused by multiple factors including poor fiber in the diet, insufficient water intake, medications, past painful bowel movements, fear of defecating, and defecation avoidance. Often, a child will develop a fear of defecating due to a painful or large bowel movement in the past. This aversion or fear of defecation can result in the child performing purposeful holding to make the urge to defecate subside. When the child chronically performs these holding maneuvers, stool is abnormally retained in the rectum. Typically, when stool enters the rectum, the smooth muscle fibers and internal anal sphincter relax sending signals to the brain for the need to defecate. When a child relaxes the external anal sphincter, the stool will evacuate normally. If the child performs a holding maneuver and contracts the external anal sphincter, the stool remains in the rectum and the urge to defecate subsides. Suppressing the urge to defecate leads to prolongation of colonic transit times, contributing to increased stool accumulation in the colon. As the rectum/colon stretches to accommodate the chronic retention of stool, it becomes desensitized and thereby decreases colonic motor activity.11,12 The stool that remains in the rectum continues to harden, as water is reabsorbed, which can lead to fecal impaction. Overflow incontinence or soiling can occur when semiliquid stool seeps past the impaction and leaks out through the anal sphincter and is often unnoticed by the child. This soiling is involuntary; however, it is commonly interpreted as a purposeful behavior by the child, leading to the negative responses of shame and punishment. These negative responses can affect the child's self-esteem and social interactions, increase the child's anxiety and apprehension, and cause the child to continue to avoid defecation.

CURRENT TREATMENTS

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition committee published clinical practice guidelines to highlight evidence-based treatments for functional constipation. The traditional approach to treatment for functional constipation includes fecal disimpaction, laxative therapy, dietary interventions, behavior modification, and child and family education.13–15

Fecal Disimpaction and Laxative Intervention

Fecal disimpaction can be achieved by oral or rectal medication. Commonly, polyethylene glycol (PEG) is prescribed by the child's pediatrician or pediatric gastroenterologist for a “clean out” procedure. The use of PEG is shown to be effective in treating fecal impactions as well as preventing future accumulation of stool.12 Evidence suggests that children using PEG typically have fewer episodes of fecal incontinence, decreased recurrence of fecal impactions, and incur lower health care costs.16–18 Despite the benefits of PEG, further research is needed to determine the optimal dosing and long-term effects for treating chronic constipation with PEG in children.19

Dietary Intervention

Common dietary interventions for children with chronic constipation are addressing overall eating habits, water intake, and fiber intake.20 The American Academy of Pediatrics recommends a daily fiber intake formula for all children, which is the age in years plus 5 as the required number of grams of fiber/day.21 Fiber intake of less than the recommended daily amount is a risk factor for constipation; however, there is little evidence that increasing fiber intake above the recommended amount results in a decrease in constipation for children.12 Additional general dietary recommendations for children with chronic constipation are to increase the consumption of specific fruits and vegetables, decrease the consumption of foods that are high in fat and sugar, and decrease the consumption of foods that are constipating (ie, bananas, excessive dairy, applesauce, and white bread). Daily fluid recommendations are 5 glasses per day for 5- to 8-year-olds, 7 glasses per day for 9- to 12-year-olds, and 8 to 10 glasses per day for 13-year-olds and older.22

Behavior Intervention

A combination of behavioral interventions with laxative therapy is better than behavioral interventions or laxative interventions alone for children with encopresis.23,24 Due to the noninvasive nature, behavioral interventions can facilitate active participation from the child, lower the child's anxiety, and give the child positive reinforcement for achievements.

A primary behavioral modification is the implementation and maintenance of a bowel and bladder-voiding schedule. A bowel and bladder-voiding schedule involves having the child sit on the toilet for up to 10 minutes (depending on age) after meals when the child is most likely to have a bowel movement.25 A bowel and bladder-voiding schedule after eating can be effective due to the gastrocolic reflex, which triggers colon peristalsis in response to stretching of the stomach from eating. It is typically recommended for families to keep a bowel and bladder log to monitor for constipation (see Appendix 1, Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A256). Monitoring for constipation is keeping track of how often the child defecates, what time of the day or night the child defecates, and the classification of the child's stool as a guide for intestinal transit time. The Bristol Stool Chart is a 7-category scale that classifies stool based on its appearance and ease of passage. Types 1 to 2 may indicate constipation, types 3 to 4 are ideal stools, and type 5 to 7 may indicate diarrhea or urgency.26,27

Another important primary behavioral modification is the child's posture on the toilet as children often slouch or sit too erect causing the pelvic floor muscles to be contracted instead of relaxed. The puborectalis muscle is especially important in defecation, as it creates a sling around the rectum, which sits contracted and assists in maintaining fecal continence. In normal defecation, the puborectalis relaxes and opens up the rectum to allow for easier flow of stool. Children with chronic constipation and anismus (dyssynergic defecation) have a shortened puborectalis during Valsalva (straining) than same-age controls.28 When children slouch (posterior pelvic tilt) with hip flexion less than 90°, the puborectalis muscle remains shortened and can inhibit passage of stool. If the child places a small step stool under the feet, this facilitates a greater than 90° angle of hip flexion and allows the puborectalis to lengthen and opens the rectal canal.

Child and Family Education

Educational interventions include child-friendly and age-appropriate explanations to the child and family about the process of normal defecation and the pathology of functional constipation and encopresis. It is important to emphasize that encopresis is involuntary and not purposeful behavior from the child. Providing appropriate educational interventions to the child and parents can help alleviate anxiety, clarify misconceptions, and help support the family/child/therapist relationship. There are many age-appropriate educational resources for children and families in print, online, and in application form (see Appendix 2, Supplemental Digital Content 2, available at: http://links.lww.com/PPT/A257). Providing age-appropriate education to the child and the family about chronic constipation, normal and atypical defecation, and the physiology of the digestive/urinary systems can lower anxiety and stress levels, and facilitate positive dialogue between the child and the parent. Many children with fecal incontinence are negatively reinforced by shaming, scolding, or embarrassment. Since fecal soiling is predominantly involuntary, it is important that parents understand that the child is not soiling on purpose and should not receive negative reinforcement. Encouraging parents to positively reinforce their child for active improvements in their bowel and bladder continence will improve the child's self-esteem and self-efficacy. Through appropriate educational interventions and emotional support, the child can become independent in internal control and self-regulation of bowel and bladder functions.29–32

PURPOSE

The purpose of this case report is to describe the implementation and effectiveness of a multimodal therapeutic approach used to successfully treat a child with encopresis.

CASE DESCRIPTION

Child is a 9-year-old boy who was home-schooled. He was referred to outpatient physical therapy by his pediatrician to address his medical diagnosis of encopresis. Significant medical history includes attention-deficit hyperactivity disorder and a history of constipation since birth. Medications include Ritalin and probiotics. Mother reports that her son has been continent of bladder since 3-years-old; however, he has never been fully continent of bowel. This was the child's first episode of physical therapy intervention; however, he had trialed various strategies in the past including chiropractic, probiotics, diet changes, and Miralax with little to no improvement in symptoms. At the time of the evaluation, child and mother reported 1 void (bowel movement) every 7 to 10 days of hard consistency (1-2 on the Bristol Stool Chart). Fecal incontinence occurred 5 to 6 times per week during daytime hours. When using the toilet, mother reported that child is “very quick in and out of the bathroom” and when asked whether he prefers to sit or stand while voiding urine, mother states he prefers to stand. Mother reported that her son ignores the urge to have a bowel movement and strains when he tries. When asked, the child states, “I can't feel it until it's too late.” Child is aware of his encopresis and is starting to demonstrate some embarrassment with avoidance of peer activities. Mother was concerned that this will affect his confidence and social skills. The mother gave a subjective rating on the perceived severity of the problem as a 10 on a 0- to 10-point visual analogue scale, with 10 indicating the highest level of severity.

Institutional Review Board and Consent

This case report was approved by the Institutional Review Board of the University of Jamestown. Child's mother provided informed consent and the child assented.

Clinical Findings

Physical therapy systems review revealed no concerns in cognition/communication, cardiopulmonary, integumentary, or neuromuscular systems. The child had no complaints of pain, although he stated that he does have painful bowel movements. Posture screen was normal for sitting and standing. Spinal Galant primitive reflex was integrated bilaterally. Range of motion screen for lower extremities was normal, with minimal restriction in right lower extremity hip external rotation. Manual muscle testing was normal bilaterally. Light touch was intact for lower extremity dermatomes. Child and mother consented to an external pelvic floor examination by the physical therapist. From the external pelvic floor examination, the perineum appeared healthy with no redness or irritation; however, the rest position of the anus appeared abnormally contracted. Initial pelvic floor contraction demonstrated poor pelvic floor muscle awareness with 100% accessory muscle substitution of gluteals, abdominals, and quadriceps. Relaxation of pelvic floor musculature after contraction was minimal. There was minimal eccentric lengthening of the pelvic floor with a mild Valsalva maneuver and the anal wink was present bilaterally. Surface electromyography (sEMG) electrodes for biofeedback were placed around the anus, and a grounding electrode was placed on the child's right ischial tuberosity. Using Telesis, resting muscle activity was recorded for 60 seconds with an average of 2.2 μV. During baseline recording of resting pelvic floor muscle tone, the child had difficulty maintaining a resting position and demonstrated frequent pelvic floor contractions. Contract/relax exercises of pelvic floor muscles were recorded with the prompt for 5-second contract and 10-second relax. The child performed a pelvic floor muscle contraction for 1-second duration while using large accessory muscles each repetition. Contraction average was 43.4 μV and resting average was 4.9 μV.

Therapeutic Interventions

The child was seen for physical therapy treatment for 8 sessions in a 4-month period. Sessions were prescribed at once per week and then decreased in frequency as the child improved. The first 2 visits focused on body awareness, purpose, and isolation of the pelvic floor muscles, and initiating a voiding schedule every 2 to 3 hours. By the third visit, the child had been continent for 1 day and had used the toilet for a bowel movement twice during the week. He preemptively told his mother that he had to have a bowel movement before using the bathroom, indicating the child was more aware of his body signals. By visit 4, he had 4 bowel movements on the toilet and had not had any full stool leaks, only smearing. Visits 5 and 6 focused on making a sustainable routine of all his home programming activities, as he had been fully continent since visit 4. Frequency of visits decreased by visit 7, as the child continued to be fully continent and discharge planning was discussed with child and mother. Visits 8 and 9 were focused on generalization of skills, discharge planning, and celebration of progress. Therapeutic interventions are in Table 1.

TABLE 1 - Interventions, Patient Outcomes, and Home Exercise Program by Visit
Visit Interventions Patient Outcomes Home Exercise Program
1 Clinical evaluation
sEMG biofeedback in supine position for baseline measurements of PF resting tone and contract/relax
N/A Intake/output log (see Appendix 1, Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A256)
Diaphragmatic breathing
Cat/cow exercise
2—45 min Read children's book I Can't, I Won't, No Way!33
On toilet: voiding education on single void. Education on double voiding. Diaphragmatic breathing × 5.
Supine contract/relax PF exercises of
2/10 × 10 reps × 2 sets with Q-tip facilitation of anal reflex
Returned intake/output log
100% with HEP
Decreased accessory muscle use noted during contract/relax
Diaphragmatic breathing on toilet × 5
Cat/cow exercise × 10/d
Using the toilet every 2-3 h
Sitting on the toilet after supper for
3-5 min/d
Supine PF contract/relax exercises × 10/d
3—40 min Supine contract/relax PF exercises of
2/10 × 10 reps × 2 sets with Q-tip facilitation of anal reflex
Performed and demonstrated light abdominal massage to child and mother
Watched GI-Kids educational video “The Poo in You” on the digestive system and constipation34
Discussed proper sitting posture on the toilet
Discussed water and fiber intake
1 d without a stool leak
BM on the toilet 2 times
Independently informed mother that he “had to go” 1 time
Decreased accessory muscle use noted during contract/relax
Increase water intake
Diaphragmatic breathing on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 2-3 h
Coloring sheets of digestive and urinary systems35,36
Supine PF contract/relax exercises × 10/d
4—45 min Supine contract/relax PF exercises of 3/10 × 15 reps × 2 sets with Q-tip facilitation of anal reflex
Read children's book Look Inside Your Body.37
Supine and sitting diaphragmatic breathing × 10
BM on the toilet 4 times
Only slight smearing in underwear
No longer resisting cues to use the bathroom
Diaphragmatic breathing on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 2-3 h
Coming up with words to describe “having to go”
Supine PF contract/relax exercises × 15/d
5—45 min Supine contract/relax PF exercises of 3/10 × 15 reps × 2 sets with Q-tip facilitation of anal reflex
Reviewed relaxation exercises on toilet (breathing, trunk flexion/extension)
7 d without stool leak
No accessory muscle use noted
Diaphragmatic breathing on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 2-3 h
Supine PF contract/relax exercises × 15/d
6—30 min Progress note visit
Reviewed therapy and patient goals and progress with mother and child
Sitting contract/relax PF exercises of 3/10 × 15 reps × 2 sets
Diaphragmatic breathing with trunk flexion/extension in sitting × 5 reps
Discussed discharge plan with mother and child
7 d without stool leak or smear
Independently informed mother that he “had to go poop” 1 time
Verbally able to describe how he knew he needed to void a BM
Decreased frequency of visits to every 2 wk
8/11 goals met
Diaphragmatic breathing with trunk flexion/extension on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 3-4 h
Sitting PF contract/relax exercises × 10/d
7—45 min Supine contract/relax PF exercises of 4-5/10 × 8 reps
sEMG biofeedback in sitting with contract/relax exercises of 3/10 × 10
Discussed upcoming discharge with mother and child
2 wk without stool leak or smear
Independently uses the bathroom for
urine and BMs
Able to maintain supine PF
contraction × 4-5 s
Able to maintain sitting PF
contraction × 3 s
Diaphragmatic breathing with trunk flexion/extension on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 3-4 h
8—30 min Reviewed progress with child and mother
Gross motor activities while cuing for PF contraction during moments of impact (jumping) or increased intra-abdominal pressure
2 wk without stool leak or smear
Able to participate in all home-school and community activities without a leak
Decreased frequency to 1 more follow-up visit in a month to assess generalization of skill prior to discharge
Sitting PF contract/relax exercises during every car ride
Sitting on the toilet after supper for 3-5 min
Using the toilet every 3-4 h
9—60 min Reviewed goals for discharge with child and mother
sEMG biofeedback in supine with PF resting tone and contract/relax recorded
Graduation from therapy activity
11 out of 11 goals met
1 mo without stool leaks or smear
Independent in home program
Independent in continence and toileting
Decreased PF resting tone
Improved PF isolation and strength during contractions
Continue with PF exercises as able
Continue to monitor fiber and water intake
Continue to monitor for constipation
Abbreviations: BM, bowel movement; N/A, not available; HEP, home exercise program; PF, pelvic floor; sEMG, surface electromyography.

OUTCOMES

Upon discharge, the child met 11 of 11 therapy goals (Table 2). As there are no valid and reliable outcome measures for encopresis, clinical outcomes were used to measure progress. sEMG biofeedback using Telesis revealed a resting muscle activity average of 1.8 μV. The child was able to perform a pelvic floor muscle contraction for 5 seconds in duration with no accessory muscle use. Contraction average on discharge was 4.1 μV and resting average was 1.5 μV. The child is now aware of his pelvic floor muscles and their purpose and can answer simple questions about how the gastrointestinal/urinary systems work together for continence. He feels when he needs to have a bowel movement and describes how that feels to his physical therapist and parents. The child is now able to attend home-school and church events without fecal incontinence. The child participated fully during all physical therapy sessions and was highly motivated to improve. The child and family were 100% compliant in home programming. Mother states that he is fully continent of bowel in all settings and independently uses the bathroom to void when he feels his body's signals. Mother states that the child's self-esteem and confidence have also improved since becoming fully continent.

TABLE 2 - Patient Goals by Visit
Patient Goals Achieved by Visit Count
Patient and parents will complete weekly home programming activities and return the activities or data by the next session, 90% of opportunities 2
Patient will complete assessment of pelvic floor contraction/relaxation using sEMG biofeedback while voiding on the toilet during a physical therapy session 2
Patient will improve pelvic floor muscle endurance in supine position to 3-s contract, 5-s relax, for 5 consecutive sessions to improve muscle strength and endurance for continence 4
To increase pelvic floor muscle isolation, patient will decrease compensatory strategies of using accessory muscles 100% of trials, to a level of little to no observed accessory muscle activation while completing contract/relax exercises in supine position 5
Patient will decrease bowel leakage from a level of 5-6 times per week to a level of no more than 2-3 times per week 5
Patient will improve awareness of leakage as evidenced by indicating to an adult that he had a leak without verbal cues from sibling or parent, 50% of opportunities 5
Patient will improve sensation and awareness of urinary/bowel urge as evidenced by being able to describe the sensation so an adult can understand 6
Patient will attend community events with no more than one bowel or bladder leakage, across all activities 6
Patient will demonstrate understanding of urinary and digestive systems as evidenced by completing simply drawing or coloring of systems 8
Patient will improve pelvic floor muscle endurance in sitting to 3-s contract, 5-s relax, for 5 consecutive sessions to improve muscle strength and endurance for continence 8
To increase pelvic floor muscle isolation, patient will decrease compensatory strategies of using accessory muscles 100% of trials, to a level of little to no observed accessory muscle activation while completing contract/relax exercises in sitting. 8
Abbreviation: sEMG, surface electromyography.

DISCUSSION

In 8 treatment sessions, the child went from experiencing fecal incontinence 5 to 6 times per week to becoming fully continent of bowel in home and community settings. In addition to current practices, this child responded positively to use of media (device applications and videos), games, coloring anatomical diagrams, and visualization activities throughout his treatment (see Appendix 2, Supplemental Digital Content 2, available at: http://links.lww.com/PPT/A257). The available literature recommends behavioral interventions such as a toileting schedule and posture education; and with help from current technology, there are now many age-appropriate activities to encourage and motivate children to improve their continence. Since encopresis is a complex and multisystem condition, pediatric physical therapists are well equipped to provide comprehensive and age-appropriate care to these children. Our additional knowledge of behavioral interventions and child-friendly treatments can help make the difference for overcoming this embarrassing and difficult disorder.

This case report provides a description of physical therapy treatments for a child with encopresis by highlighting a multimodal delivery of care to motivate and involve the child and parents in treatment. A limitation of this case report is that currently there are no gold standard outcome measures to use for children with encopresis. Despite the limitation, this case report suggests the importance of age-appropriate motivating activities to improve outcomes in children with fecal incontinence.

CONCLUSIONS

Treating a child with encopresis is challenging due to the complex nature of the condition. Children experiencing encopresis can experience decreased self-esteem, decreased confidence, and negatively affected social relationships due to embarrassment and shaming. Retentive encopresis is largely caused by chronic constipation and the duration of treatment is often months to years. It is important that children and families are provided age-appropriate educational interventions and are positively supported throughout the duration of the treatment. This case report highlights a child who benefitted from multimodal physical therapy treatment of his retentive encopresis through pelvic floor muscle awareness, strengthening and coordination exercises, behavioral adaptations, diet modification, and use of media, art, and interactive visualization activities. This case report adds to evidence-based practice by demonstrating that pediatric age-appropriate educational and motivational tools are readily available and should be used in conjunction with current practice to improve active participation and compliance during treatment of retentive encopresis in the pediatric population.

ACKNOWLEDGMENTS

Thank you to everyone for their contributions—Dr Gregory Gass, Dr Mitch Wolden, Dr Sara Voorhees, and Marilyn Hedberg, Beyond Boundaries Therapy Services.

REFERENCES

1. Joinson C, Jeron J, Butler U, VonGontard A. Psychological differences between children with and without soiling problems. Pediatrics. 2006;117(5):1575–1584.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
3. Rajindrajith S, Devanarayana N, Benninga M. Constipation-associated and non-retentive fecal incontinence in children and adolescents: an epidemiological survey in Sri Lanka. J Pediatr Gastroenterol Nutr. 2010;51:472–476.
4. Christophersen E, Mortweet S. Treatments That Work With Children: Empirically Supported Strategies for Managing Childhood Problems. Washington, DC: American Psychological Association; 2001.
5. Freeman K, Riley A, Duke D, Fu R. Systematic review and meta-analysis of behavioral interventions for fecal incontinence with constipation. J Pediatr Psychol. 2014;39(8):887–902. doi:10.1093/jpepsy/jsu039.
6. Pashankar D. Childhood constipation: evaluation and management. Clin Colon Rectal Surg. 2005;18(2):120–127.
7. Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C. Health utilization and cost impact of childhood constipation in the United States. J Pediatr. 2009;154(2):258–262.
8. Mellon M, Natchev B, Katusic S, et al. Incidence of enuresis and encopresis among children with attention-deficit hyperactivity disorder in a population-based birth cohort. Acad Pediatr. 2013;13(4):322–327.
9. Vanderwal M, Benninga M, Hirasing R. The prevalence of encopresis in a multicultural population. J Pediatr Gastroenterol Nutr. 2005;40:345–348.
10. Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. 2007;92(6):486–489. doi:10.1136/adc.2006.098335.
11. Bampton P, Dinning P, Kennedy M, Lubowski D, Cook I. The proximal colonic motor response to rectal mechanical and chemical stimulation. Am J Physiol Gastrointest Liver Physiol. 2002;282(3):G443–G449.
12. Rowan-Legg A. Managing functional constipation in children. J Paediatr Child Health. 2011;16(10):661–670.
13. Tabbers M, Di Lorenzo C, Berger M, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258–74. doi:10.1097/MPG.0000000000000266.
14. Ritterband L, Ardalan K, Thorndike F, Magee J, Saylor D, Cox D. Real world use of an internet intervention for pediatric encopresis. J Med Internet Res. 2008;10(2):e16.
15. Dos Santos J, Lopes R, Koyle M. Bladder and bowel dysfunction in children: an update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem. Can Urol Assoc J. 2017;11(1-2, suppl 1):S64–S72.
16. Pashankar D, Bishop W. Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children. J Pediatr. 2001;139(3):428–432. doi:10.1067/mpd.2001.117002.
17. Candy D, Edwards D, Geraint M. Treatment of faecal impaction with polyethelene glycol plus electrolytes (PGE + E) followed by a double-blind comparison of PEG + E versus lactulose as maintenance therapy. J Pediatr Gastroenterol Nutr. 2006;43(1):65–70. doi:10.1097/01.mpg.0000228097.58960.e6.
18. Guest J, Candy D, Clegg J, et al. Clinical and economic impact of using macrogol 3350 plus electrolytes in an outpatientsetting compared to enemas and suppositories and manual evacuation to treat paediatric faecal impaction based on actual clinical practice in England and Wales. Curr Med Res Opin. 2007;23(9):2213–2225. doi:10.1185/030079907×210462.
19. Gordon M, MacDonald J, Parker C, Akobeng A, Thomas A. Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database Syst Rev. 2016;(8):CD009118. doi:10.1002/14651858.CD009118.pub3.
20. Kuhl E, Hoodin F, Rice J, Felt B, Rausch J, Patton S. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;35(10):1144–1151.
21. Kids need Fiber: Here's Why and How. Healthy Children Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Kids-Need-Fiber-Heres-Why-and-How.aspx. Updated October 15, 2015. Accessed March 10, 2018.
22. Choose Water as a Drink. Healthy Kids Web site. https://www.healthykids.nsw.gov.au/kids-teens/choose-water-as-a-drink-kids. Updated 2018. Accessed April 30, 2018.
23. Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for defaecation disorders in children. Cochrane Database Syst Rev. 2001;(4):CD002240. doi:10.1002/14651858.CD002240.
24. Rajindrajith S, Devanarayana N, Benninga M. Review article: faecal incontinence in children: epidemiology, pathophysiology, clinical evaluation and management. Aliment Pharmacol Ther. 2013;37(1):37–48.
25. Boles R, Roberts M, Vernberg E. Treating non-retentive encopresis with rewarded scheduled toilet visits. Behav Anal Pract. 2008;1(2):68–72.
26. Bristol Stool Chart. Continence Foundation of Australia Web site. https://www.continence.org.au/pages/bristol-stool-chart.html. Acc-essed March 9, 2018.
27. Lewis S, Heaton K. Stool form scale as a useful guide to intestinal transit time. Scan J. Gastroenterology. 1997;32:920–924.
28. Chu W, Tam Y, Lam W, Ng A, Sit F, Yeung C. Dynamic MR assessment of the anorectal angle and puborectalis muscle in pediatric patients with anismus: technique and feasibility. J Magn Reson Imaging. 2007;25:1067–1072.
29. Coehlo D. Encopresis: a medical and family approach. Pediatr Nurs. 2011;37(3):107–113.
30. Esposito M, Gimigliano F, Ruberto M, et al. Psychomotor approach in children affected by non-retentive fecal soiling (FNRFS): a new rehabilitation purpose. Neuropsychiatr Dis Treat. 2013;9:1433–1441.
31. Friman P, Hofstadter K, Jones K. A biobehavioral approach to the treatment of functional encopresis in children. J Early Intensive Behav Interv. 2006;3(3):263–272.
32. Lund R. Pediatric Incontinence and Pelvic Floor Dysfunction. Greenville, SC: Herman and Wallace Pelvic Rehabilitation Institute; 2014.
33. Vessillo T, MIkeMotz.com. I Can't, I Won't No Way! A Book for Children Who Refuse to Poop. New York, NY: Createspace Independent Publishing Platform; 2011.
    34. GI-Kids. The Poo in You—Constipation and Encopresis Educational Video—YouTube. https://www.youtube.com/watch?v=SgBj7Mc_4sc. Accessed September 12, 2018.
      35. Amsel S. Digestive System Organs Coloring Page (Younger Students). Exploring Nature Educational Resource ©2005-2018. http://www.exploringnature.org/db/view/2448. Accessed August 1, 2017.
        36. Pearson S. Coloring Page Urinary System. Edupics Web site. https://www.edupics.com/coloring-page-urinary-system-i12919.html. Accessed August 1, 2017.
          37. Stowell L, Leake K. Look Inside Your Body. Usborne. https://usborne.com/browse-books/catalogue/product/1/6418/look-inside-your-body/. Published 2012. Accessed September 12, 2018.
            Keywords:

            encopresis; incontinence; pelvic floor; sEMG

            © 2019 Academy of Pediatric Physical Therapy of the American Physical Therapy Association