Feces in the with constipation and overﬂow incontinence subtype are characteristically (but not invariably) poorly formed, and leakage can be infrequent to continuous, occur- ring mostly during the day and rarely during sleep. Only part of the feces is passed during toileting, and the incontinence resolves after treatment of the constipation.
In the without constipation and overﬂow incontinence subtype, feces are likely to be of normal form and consistency, and soiling is intermittent. Feces may be deposited in a prominent location. This is usually associated with the presence of oppositional defiant disorder or conduct disorder or may be the consequence of anal masturbation. Soiling without constipation appears to be less common than soiling with constipation.
The essential feature of encopresis is repeated passage of feces into inappropriate places (e.g., clothing or ﬂoor) (Criterion A). Most often the passage is involuntary but occasionally may be intentional. The event must occur at least once a month for at least 3 months (Criterion B), and the chronological age of the child must be at least 4 years (or for children with developmental delays, the mental age must be at least 4 years) (Criterion C). The fecal incontinence must not be exclusively attributable to the physiological effects of a substance (e.g., laxatives) or another medical condition except through a mechanism involving constipation (Criterion D).
When the passage of feces is involuntary rather than intentional, it is often related to constipation, impaction, and retention with subsequent overﬂow. The constipation may develop for psychological reasons (e.g., anxiety about defecating in a particular place, a more general pattern of anxious or oppositional behavior), leading to avoidance of defeca- tion. Physiological predispositions to constipation include ineffectual straining or paradox- ical defecation dynamics, with contraction rather than relaxation of the external sphincter or pelvic ﬂoor during straining for defecation. Dehydration associated with a febrile ill- ness, hypothyroidism, or a medication side effect can also induce constipation. Once con- stipation has developed, it may be complicated by an anal fissure, painful defecation, and further fecal retention. The consistency of the stool may vary. In some individuals the stool may be of normal or near-normal consistency. In other individuals—such as those with overﬂow incontinence secondary to fecal retention—it may be liquid.
The child with encopresis often feels ashamed and may wish to avoid situations (e.g., camp, school) that might lead to embarrassment. The amount of impairment is a function of the effect on the child‘s self-esteem, the degree of social ostracism by peers, and the an- ger, punishment, and rejection on the part of caregivers. Smearing feces may be deliberate or accidental, resulting from the child’s attempt to clean or hide feces that were passed in— voluntarily. When the incontinence is clearly deliberate, features of oppositional defiant disorder or conduct disorder may also be present. Many children with encopresis and in the bladder or ureters that may lead to chronic urinary infections, the symptoms of which may remit with treatment of the constipation.
It is estimated that approximately 1% of 5-year-olds have encopresis, and the disorder is more common in males than in females.