Enuresis and Encopresis are the two primary Bedwetting and Soiling Disorders that occur in children and adolescents. People with Enuresis have trouble holding their urine (most commonly at night), while those with Encopresis struggle with containing their stool.
Children dealing with these disorders are frequently embarrassed about the incidents. They sometimes try to hide their soiled clothes or bedding if they are afraid of being punished or scolded. Sleep-overs at friends’ homes and summertime sleep-away camp are out of the question for those who fear teasing from other kids.
Enuresis, which usually happens at night, is caused by a combination of low bladder capacity, increased urine production, and the child’s failure to awaken in response to a full bladder. Urinating during sleep commonly happens when a child has a dream about going to the bathroom.
Encopresis is most commonly related to chronic constipation, which causes leaking of loose, liquid stool to relieve pressure. The constipation may have a medical explanation, such as dehydration, or a psychological one, like anxiety about using the bathroom. Much less commonly, Encopresis can also appear as part of a behavioral disorder, where children go to the bathroom in inappropriate places on purpose.
Causes and Risk Factors
Enuresis is common in early childhood, affecting up to 10% of kids, while Encopresis only affects approximately 1.5% of similarly aged kids. Children usually develop the physiological tools to control their bladder by 5 years old and their bowels by age 4, but that development can be delayed. Both disorders are at least twice as common in boys as they are in girls.
Family and twin studies show that both Enuresis and Encopresis are highly heritable. There is an increased incidence of Enuresis in children if one or both parents have a history of this disorder. In the case of Encopresis, the relevant genes are related to issues with the digestive tract that lead to constipation.
Encopresis and constipation
A child may become constipated for a wide variety of reasons, including lack of exercise, poor diet, anxiety around using the bathroom, or painful bowel movements from medical conditions. Holding back bowel movements for a long time can cause children to lose the ability to defecate normally and leads to unintentional, loose bowel movements to relieve pressure. Other medical causes such as spinal cord injury, celiac disease, or damage to the bowel can result in constipation and Encopresis. Medications, such as tricyclic antidepressants, narcotics, and iron supplements can also cause constipation that is severe enough to lead to Encopresis.
Children may develop delays in toileting due to unsuccessful toilet training as toddlers or by intrusive toilet training. Children who have received discipline for having accidents or have been encouraged into toilet training before they were ready may develop Bowel and Bladder Disorders. Negative toilet training practice can cause children to associate using the toilet with punishment. In severe cases, frequent toileting accidents may occur with a child who has had a traumatic experience, such as a sexual or physical abuse.
Both Enuresis and Encopresis are significantly associated with Attention Deficit Hyperactivity Disorder (ADHD) and Conduct Disorder (CD). Anxiety and depression may also appear from the toileting problems. Therefore, these conditions are often assessed together during the evaluation of children. Children who have behavioral problems like Oppositional Defiant Disorder or Conduct Disorder may soil themselves as a form of retaliation or to communicate their anger. If a child is experiencing anxiety, depression, or behavioral issues, these associated problems should be treated alongside the Bedwetting and Soiling Disorders. Additionally, the disorders often happen together, and urinary tract infections are a common medical complication.
Diagnosing Bedwetting and Soiling Disorders
Enuresis and Encopresis
People with Enuresis and Encopresis urinate or defecate in inappropriate places like their beds or their clothing on a regular basis for at least three months. Enuresis usually happens more frequently, about twice a week, compared to Encopresis, which usually only occurs once a month. Although many people might assume that people would only soil themselves when they are unconscious or asleep, it does happen when people are awake. These disorders can be either primary or secondary. Primary refers to children who have never been toilet trained while secondary refers to soiling after successfully attaining toilet control, usually brought upon by entering a stressful environment. The two disorders have slightly different minimum ages, 4 years for Encopresis and 5 years for Enuresis. At younger ages, these behaviors are a normal part of development.
Types of Enuresis and Encopresis
Enuresis more commonly happens at night and is often due to a combination of drinking too much late in the evening and being a heavy sleeper. Although, many medical conditions, like endocrine issues or an overactive bladder, can also contribute to the issue. When Enuresis becomes a problem during the day, it is when children avoid going to the bathroom until it is too late.
Most Encopresis occurs during the daytime and is actually an unfortunate side effect related to constipation. In these cases, the stool is loose and leaks to relieve the pressure from constipation. Children may become constipated from physical sickness, medication side effect, or for psychological reasons that cause them to compulsively hold on to their stool. However, some children do soil themselves intentionally, which is usually related to behavioral problems like those in Conduct Disorder or Oppositional Defiant Disorder.
Treating Bedwetting and Soiling Disorders
Approaches to Enuresis
Enuresis almost always resolves spontaneously over time. It is treatable, unintentional, and very common in children. Bed-wetting alarms are the oldest and most effective treatment for this condition. These devices sense moisture in the bed and wake the person right when they begin urinating. This helps them get up and go to the bathroom to finish before the bed becomes too soiled. Many adults who used these alarms when they were younger remember them as cumbersome and jarring. However, they have been modernized, and many straightforward, less disruptive options are available.
Behavior therapies for Encopresis
While Encopresis is a chronic and complex problem in many families, it is treatable. The process usually takes a matter of months and relapse is common, but 65% of people are almost completely free of symptoms in 6-months. With the assistance of a psychotherapist, behavioral modification can be an integral treatment component for encopresis. For this to be effective, family tension regarding the symptom should be reduced, and a non-punitive atmosphere established. Parents will encourage their child to sit on the toilet for 10 minutes after meals 2-3 times a day. The initial aim is to produce a bowel movement by giving the child the chance to get used to using the toilet and to be in tune with bodily cues.
Medications are rarely needed in children younger than 7 years old for nighttime Enuresis and are generally a treatment of last resort at most ages. However, when all other interventions fail, Desmopressin, also known as DDAVP, offers an effective solution. Taken just before bed, this medication slows the body’s creation of urine during the night.
For Encopresis related to constipation, a doctor may prescribe a laxative to ease the passage of the hardened stool. Once the stool has passed, fiber, enemas, or laxatives may be used to empty the colon and continue to decrease painful bowel movements.
Managing Bedwetting and Soiling Disorders
Many parents unfortunately resort to punishment and scolding when their children have trouble with Enuresis and Encopresis, but this is counterproductive and adds insult to injury for the kids. Instead, parents can create a reward system, which provides incentives for the child to use the toilet. Children can receive a star or sticker on a chart for each day they successfully go to the toilet without accidents and a special reward could be earned after success during through the week.
For Encopresis specifically, parents should encourage children to drink lots of water, eat fiber rich foods such as fruits, vegetables, and whole grains, and avoid fatty, oily junk food. With Enuresis, managing drinking fluids during the day is the key. Guide kids to drink more earlier in the day and less at night and have them try to urinate at least twice right before bed.
Even though it can be annoying to deal with the aftermath of bedwetting, it’s important to remember that the child is not doing it out of laziness. It is almost always stressful, embarrassing, and inconvenient for them. To boost their self-esteem, engage them in the process of managing the issues, such as having them help clean up after wetting the bed or soiling their clothes. Encourage kids to ask for help immediately when accidents happen and have clean clothes readily accessible.
Enuresis and Encopresis can become a family preoccupation, as parents and siblings become increasingly frustrated when family activities are disrupted. The family can be left fruitlessly battling over the child’s bladder and bowel control, and the conflicts may extend to other areas of the child’s life such as school functioning and friends. When the child becomes increasingly aware of these difficulties, they may become angry, withdrawn, anxious, and depressed and may be a victim of bullying if other peers become aware. Consider enlisting a therapist to help manage issues if the child starts experiencing shame, guilt, depression, or low self-esteem.