A model incorporating physiological, behavioral, and psychological parameters are presented to explain the maintenance and consequences of pediatric encopresis. It was hypothesized that the more comprehensive a treatment in addressing these parameters, the more efficacious it would be and the more children it would benefit. Eighty-seven children between the ages of 6 and 15 with the primary complaint of encopresis were randomly assigned to one of three treatments: (a) Intensive Medical Care (IMC), receiving enemas for disimpaction and laxatives to promote frequent bowel movements; (b) Enhanced Toilet Training (ETT), using reinforcement and scheduling to promote response to defecation urges and instruction and modeling to promote appropriate straining, along with laxatives and enemas; or (c) Biofeedback (BF), directed at relaxing the external anal sphincter during attempted defecation, along with toilet training, laxatives, and enemas. Three months following initiation of treatment, ETT and BF produced similar reductions in soiling/child (76% and 65%) that were superior (p's < .04) to IMC (21%). ETT significantly benefited more children than the other two treatments, employing fewer laxatives and fewer treatment sessions at a lower cost. Consistent with the presented model, reduction in soiling was associated with an increase in bowel movements in the toilet, reduction in parental prompting to use the toilet, and defecation pain. These results demonstrate that ETT should be used routinely with laxative therapy in the treatment of chronic encopresis.

Anal sphincter spasm and megacolon are pathophysiologic abnormalities associated with pediatric constipation-encopresis.

Compared the additive benefits of laxative, behavior, and biofeedback treatments for encopresis, while attempting to identify treatment mechanisms and predictors of treatment outcome. 44 encopretic children, ages 6-15 years, were randomly assigned to either laxative therapy (LAX), LAX plus enhanced toilet training (ETT), or LAX + ETT + anal sphincter biofeedback (BF). Daily symptom diaries were completed 14 days before, upon initiation of and 3 months following treatment initiation. ETT and BF were superior to LAX in reducing encopresis. Outcome was significantly predicted by improvement during the initial 14 days of treatment. Reduction of soiling was associated with an increase in bowel movement frequency, and reductions in defecation pain and parental prompting to use the toilet. Because of its efficacy and minimal reliance on technology, ETT should be the initial treatment of choice.

In children with chronic constipation and encopresis, sphincter spasm demonstrated with anorectal manometry is highly correlated with frequency of fecal soiling, age at onset, and duration of symptoms; however, none of the other commonly measured manometric parameters appear to correlate with symptoms of chronic childhood constipation and encopresis.

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