Encopresis is the repeated passage of feces into inappropriate places in a child who is developmentally past the expected age of toilet training, and it is one of the most underdiagnosed problems in pediatric and child psychiatric practice. The DSM-5-TR places encopresis among the elimination disorders alongside enuresis, and divides it into retentive (with constipation and overflow incontinence) and nonretentive subtypes, a distinction that drives both prognosis and treatment. Most cases — roughly 80 to 95 percent — are retentive and respond to a structured program of fecal disimpaction, sustained osmotic laxative maintenance, and behavioral toileting routines. Psychiatric comorbidity, shame, family conflict, and bullying are common and frequently missed when the focus stays on the bowel. The clinical bottom line: treat the constipation aggressively and early, and treat the child and family with the same seriousness.

Encopresis is common in school-aged children but undercounted because families present to pediatrics for constipation rather than to psychiatry for soiling. Prevalence falls steeply across childhood, and boys are affected more often than girls.

Prevalence and demographics

• Estimated prevalence is approximately 1 to 4 percent in children aged 4 to 17 years, with most studies clustering around 1.5 to 3 percent at age 5 to 6 and declining to under 1 percent by adolescence.¹
• Male-to-female ratio is roughly 3:1 to 6:1, a sex skew that persists across cultures.^1,3
• The disorder is rare under age 4 by definition because the diagnosis requires a developmental age of at least 4 years.⁴

Comorbidity

• Functional constipation underlies an estimated 80 to 95 percent of cases and is the proximate mechanism in retentive encopresis.^5,8
• Psychiatric comorbidity is common, with elevated rates of Attention-deficit/hyperactivity disorder, anxiety disorders, oppositional defiant disorder, and autism spectrum disorder reported in clinical samples.^3,6
• Enuresis co-occurs in approximately one-third of children with encopresis, reflecting shared developmental and pelvic-floor mechanisms.^1,3

Risk factors

• Painful defecation in infancy or toddlerhood, often triggered by a hard stool, anal fissure, or febrile illness, is the single most consistent antecedent.⁵
• Coercive or premature toilet training, transitions such as starting school, and reluctance to use school bathrooms are well-documented behavioral contributors.^5,7
• Low dietary fiber, low fluid intake, and family history of constipation increase risk.⁵
• Sexual abuse is associated with nonretentive soiling in a minority of cases and should be considered, though it is neither necessary nor sufficient as an etiology.^3,7

Retentive encopresis is best understood as a learned avoidance loop superimposed on a mechanical problem: a painful bowel movement teaches the child to withhold, withholding produces a larger and harder stool, and overflow liquid stool eventually escapes around the impaction. Nonretentive soiling has a different texture, with intact rectal sensation and a stronger behavioral or psychiatric signature.

Mechanical and physiologic factors

• Chronic stool retention distends the rectum, blunts rectal sensation, and weakens the urge to defecate, producing the megarectum seen on physical exam and imaging.^5,9
• Overflow incontinence is the leakage of softer stool around a retained fecal mass, often mistaken by families for diarrhea.^5,8
• Anorectal manometry in retentive encopresis frequently shows paradoxical contraction of the external anal sphincter during attempted defecation, sometimes called pelvic-floor dyssynergia.^5,9

Neurodevelopmental and psychological factors

• Children with ADHD show higher rates of functional constipation and soiling, possibly reflecting inattention to interoceptive cues and inconsistent toileting routines.^3,6
• Anxiety about painful defecation or about using school bathrooms reinforces withholding behavior.^5,7
• Shame and secondary family conflict often perpetuate the problem after the original pain stimulus has resolved.⁷

Genetic and family factors

• Functional constipation aggregates in families, and twin studies suggest a heritable component for both constipation and elimination disorders, though specific genes have not been established.⁵

DSM-5-TR places encopresis in the elimination disorders chapter and requires both a minimum frequency and a minimum developmental age. The subtype distinction is clinically essential because it changes the treatment plan.

DSM-5-TR criteria

• Repeated passage of feces into inappropriate places, whether involuntary or intentional.⁴
• At least one such event per month for a minimum of three months.⁴
• Chronological or developmental age of at least 4 years.⁴
• The behavior is not attributable to the physiologic effects of a substance such as a laxative or to another medical condition except through a mechanism involving constipation.⁴

Subtypes

• With constipation and overflow incontinence (retentive): physical exam, history, or imaging shows constipation; stools are typically poorly formed and leakage is often continuous.⁴
• Without constipation and overflow incontinence (nonretentive): no evidence of constipation; stools are usually normal in form and soiling is intermittent.⁴

Course specifiers

• Primary encopresis describes a child who has never achieved a period of fecal continence of at least one year.⁴
• Secondary encopresis describes soiling that emerges after a sustained period of continence and is more often associated with psychosocial stressors.^3-4

ICD-11 differences

• ICD-11 retains the diagnosis under the term "encopresis" within mental, behavioural and neurodevelopmental disorders, with criteria broadly aligned with DSM-5-TR.¹⁰
• ICD-11 does not formally separate retentive and nonretentive subtypes in its core definition; the clinical distinction remains essential for management.¹⁰

Presentations vary from a school-aged child with daily staining who is otherwise well to a withdrawn child with a palpable abdominal fecal mass and secondary depression. The classic clue is parents reporting "diarrhea" in a constipated child.

Typical retentive presentation

• History of infrequent, large, painful stools that may clog the toilet, alternating with near-continuous staining of underwear with soft or liquid stool.⁵
• Withholding posturing such as stiffening, crossing legs, or hiding to avoid defecation, sometimes mistaken for straining.⁵
• Palpable suprapubic or left-lower-quadrant fecal mass and a rectum loaded with stool on examination.^5,8
• Reduced appetite, intermittent abdominal pain, and irritability that improves dramatically after disimpaction.⁵

Typical nonretentive presentation

• Daily or near-daily passage of a normal-caliber stool into clothing, often in the afternoon, in a child without abdominal distension or palpable stool.^5,12
• Higher rates of comorbid behavioral problems and psychosocial stressors than the retentive group.^3,12
• Normal colonic transit on radiologic studies when measured.¹²

Red flags suggesting an organic cause

• Onset of constipation before 1 month of age, delayed passage of meconium beyond 48 hours, failure to thrive, bilious vomiting, abdominal distension out of proportion to history, or an abnormal anal position or sacral exam.^5,8
• Lower-extremity neurologic findings, sacral dimple with hair tuft, or absent anal wink should prompt evaluation for tethered cord or spinal dysraphism.⁸

Most differentials are organic causes of constipation or incontinence that masquerade as encopresis. A focused medical workup before labeling the child psychiatrically is non-negotiable.

Gastrointestinal and surgical

• Hirschsprung disease presents with delayed meconium, ribbon stools, and an empty rectal vault, in contrast to the loaded vault of functional constipation.^5,8
• Anal stenosis, anterior anus, anal fissure, and prior anorectal surgery cause painful defecation and can mimic withholding-based encopresis.⁵
• Inflammatory bowel disease, celiac disease, and cow's milk protein intolerance can present with altered bowel habits and should be considered when systemic features are present.^5,8

Endocrine and metabolic

• Hypothyroidism, hypercalcemia, hypokalemia, and diabetes insipidus can produce constipation in children.^5,8

Neurologic

• Spinal dysraphism, tethered cord, and cerebral palsy can produce fecal incontinence through impaired sensation or sphincter control.⁸

Pharmacologic

• Opioids, anticholinergics, iron supplements, and certain antiepileptics cause constipation; stimulant laxative dependence can paradoxically perpetuate the problem.⁵

Psychiatric

• Oppositional defiant disorder may co-occur with intentional soiling, but pure willful defecation in age-appropriate places without constipation is uncommon and warrants evaluation for trauma or severe family dysfunction.^3,7

The evaluation has two jobs: characterize the stool pattern accurately and rule out organic disease. Most children require no laboratory or imaging workup beyond a careful history and physical examination.

History

• Age of toilet-training initiation, age at first successful continence, and any period of sustained continence to distinguish primary from secondary encopresis.^3,5
• Stool frequency, caliber, consistency, presence of blood, and pattern of soiling, including time of day and triggers.⁵
• Painful defecation, withholding posturing, toilet refusal, and avoidance of school bathrooms.^5,7
• Diet, fluid intake, and physical activity.⁵
• Psychosocial history covering family stressors, school transitions, bullying, and trauma exposure.^3,7
• Medication and supplement review for constipating agents.⁵

Physical examination

• Abdominal palpation for a fecal mass, typically in the suprapubic area or left lower quadrant.^5,8
• Inspection of the perianal area for fissures, position of the anus, and skin tags.⁸
• Digital rectal examination is informative but not strictly required if the diagnosis is otherwise clear; when performed, it assesses anal tone, vault contents, and presence of an impaction.^5,8
• Lumbosacral inspection for dimple, hair tuft, or asymmetry; assessment of lower-extremity tone, reflexes, and the anal wink.⁸

Investigations

• Routine laboratory studies are not required in the absence of red flags.^5,8
• Abdominal radiography can document a fecal load but is not necessary for diagnosis and adds radiation exposure; it is most useful when the abdominal exam is equivocal in an obese child.^5,8
• Thyroid-stimulating hormone, celiac serology, and calcium are reasonable when systemic features or growth failure are present.^5,8
• Referral for anorectal manometry, contrast enema, or rectal biopsy is reserved for suspected Hirschsprung disease or treatment failure despite an adequate trial.^5,8

Rating scales and behavioral measures

• The Bristol Stool Form Scale standardizes stool description across visits.¹³
• The Rome IV criteria provide a structured definition of functional constipation and nonretentive fecal incontinence in children.¹¹
• Broad-band measures such as the Child Behavior Checklist can screen for comorbid behavioral and emotional problems.³

Effective management of retentive encopresis follows a three-step sequence: clean out the impaction, maintain soft daily stools for months, and rebuild a positive toileting routine. Nonretentive soiling has no role for laxatives and depends on behavioral and psychiatric treatment.

Pharmacotherapy

• Disimpaction is the first step in retentive encopresis. Oral high-dose polyethylene glycol (PEG) 3350, typically 1 to 1.5 g/kg/day for 3 to 6 days, is at least as effective as enemas for outpatient disimpaction and is the standard first-line approach.^14-15
• Enema-based disimpaction (sodium phosphate or mineral oil enemas) is an alternative when oral therapy fails or is refused, though it is more invasive and less well tolerated by children.^14-15
• Maintenance with PEG 3350 at 0.4 to 0.8 g/kg/day, titrated to one soft stool daily, is the evidence-based mainstay and should continue for a minimum of 6 months and often longer.^14-15
• Lactulose is a reasonable alternative when PEG is unavailable or not tolerated, though evidence favors PEG for both efficacy and palatability.^14-15
• Stimulant laxatives such as senna or bisacodyl can be used as rescue therapy but are not recommended as long-term monotherapy.^14-15
• Premature tapering is the single most common cause of relapse; strong evidence supports prolonged maintenance well beyond the resolution of symptoms.^14-15

Psychotherapy

• Structured behavioral toileting programs that include scheduled post-meal toilet sits of 5 to 10 minutes, a stool diary, and a positive reinforcement system are effective when combined with laxative therapy; behavioral therapy alone is less effective than combined therapy for retentive encopresis.^15,17
• Cognitive behavioral therapy and family-based interventions address shame, family conflict, and avoidance and are especially indicated for nonretentive soiling and for secondary encopresis associated with stressors.^7,17
• Biofeedback for pelvic-floor dyssynergia has not shown consistent benefit over standard medical and behavioral treatment in pediatric randomized trials and is not recommended as routine therapy.^15,18

Neuromodulation

• Transcutaneous electrical stimulation and sacral neuromodulation have been studied in refractory pediatric constipation, but evidence is limited and these techniques are not part of standard encopresis care.¹⁵

Adjunctive

• Dietary fiber intake at age-appropriate levels and adequate fluid intake are reasonable adjuncts, though fiber alone does not resolve established retentive encopresis.¹⁵
• Treatment of comorbid ADHD with stimulants does not worsen constipation and can improve adherence to toileting routines.⁶
• Family education that reframes soiling as an involuntary consequence of a stretched rectum, not willful misbehavior, reduces punitive responses and improves outcomes.^7,17

The treatment is generally safe, but the harms are shifted from the medication to the social and psychological consequences of delayed or punitive care. The evidence base is reasonable for medical management and thinner for behavioral and psychiatric components.

Common adverse effects

• Osmotic laxatives produce loose stools, flatulence, and abdominal cramping that often resolve with dose titration.^14-15
• Anal irritation from frequent soiling and aggressive cleansing is common and often improves with barrier creams and toileting routines.¹⁵

Serious or rare adverse effects

• Sodium phosphate enemas can cause life-threatening hyperphosphatemia and hypocalcemia, especially in young children and those with renal impairment.^14,16
• Mineral oil aspiration carries a risk of lipoid pneumonia and should be avoided in children at risk for aspiration.¹⁴
• Rectal perforation from manual disimpaction or repeated enemas, though rare, has been reported.¹⁴

Psychosocial harms

• Untreated or punitively managed encopresis is associated with poor self-esteem, social isolation, bullying, and depressive symptoms.^2-3,7
• Family conflict over soiling can become a primary stressor and an independent target of treatment.^7,17

Monitoring and discontinuation

• Maintenance therapy is typically continued for at least 6 months and tapered slowly after a sustained period of soft daily stools and consistent toileting.^14-15
• Premature taper is the most common cause of relapse and should be anticipated and discussed at the outset.^14-15

Limitations of the evidence base

• Most randomized trials are short, with follow-up under 12 months, limiting inferences about long-term outcomes.^14-15
• Behavioral and psychiatric outcomes are inconsistently measured across trials.^15,17
• Nonretentive soiling is studied in much smaller samples than retentive encopresis, and treatment recommendations rest largely on expert consensus.^12,15

Encopresis presents differently across developmental and medical contexts, and the treatment plan adapts accordingly.

Preschool and early school-age

• Most cases emerge between ages 4 and 7 and respond well to medical and behavioral treatment if started promptly.⁵
• Family education and reframing soiling as involuntary is especially important at this age to prevent punitive responses.^7,17

Adolescents

• Encopresis in adolescence is uncommon and carries a heavier psychiatric and psychosocial burden, including higher rates of depression and social withdrawal.^2-3,7
• Treatment principles are unchanged but require longer maintenance therapy and explicit attention to confidentiality and autonomy.^3,15

Neurodevelopmental disorders

• Children with autism spectrum disorder may have rigid toileting routines, sensory aversions to bathrooms, and limited communication of urge; visual schedules and graded exposure are helpful.^6,17
• Children with intellectual disability require developmental rather than chronological age criteria for diagnosis.^4,6
• Stimulant treatment of comorbid ADHD does not preclude laxative therapy and often improves toileting adherence.⁶

Trauma and abuse

• Nonretentive secondary soiling that emerges abruptly in a previously continent child warrants careful evaluation for sexual abuse or other trauma, though most cases of nonretentive encopresis are not trauma-related.^3,7

Cultural considerations

• Norms about toilet training age and stool-related shame vary across cultures and shape both presentation and treatment adherence; family-centered psychoeducation should be culturally attuned.⁷

Prognosis is favorable when treatment is started early and maintenance is prolonged, but relapse during taper is common.

Natural history and outcomes

• Most children with retentive encopresis achieve continence within 6 to 12 months of adequate combined treatment.^14-15
• Approximately half of children remain on maintenance laxative therapy at 1 year; 30 to 50 percent experience at least one relapse, typically during attempted taper.^14-15
• By adolescence, the majority of treated children are continent, but a minority experience persistent symptoms into adulthood, particularly when treatment was delayed or inconsistent.¹⁵

Predictors of poorer outcome

• Older age at presentation, longer duration of soiling, severe withholding behavior, and comorbid psychiatric disorders are associated with longer time to remission.^3,15
• Poor adherence to maintenance therapy is the strongest modifiable predictor of relapse.^14-15

Psychosocial outcomes

• Self-esteem, peer relationships, and academic engagement typically improve markedly within months of successful treatment.^7,17
• Persistent shame and family conflict can outlast resolution of soiling and may warrant ongoing psychotherapeutic support.^2,7

Encopresis itself is rarely an emergency, but a few presentations require urgent attention.

Acute medical concerns

• Severe fecal impaction with abdominal distension, vomiting, and inability to tolerate oral intake may require inpatient disimpaction with enemas or, rarely, manual disimpaction under sedation.^5,8
• Hyperphosphatemia, hypocalcemia, and tetany after sodium phosphate enemas are medical emergencies requiring electrolyte correction.^14,16
• Suspected bowel perforation after manual disimpaction or enemas presents with peritoneal signs and requires immediate surgical evaluation.¹⁴

Psychiatric concerns

• Children and adolescents with encopresis are at increased risk for depressive symptoms, bullying, and social withdrawal; suicide risk screening is warranted, particularly in adolescents with longstanding soiling.^3,7
• Disclosure of abuse during the evaluation triggers mandated reporting and a coordinated child-protection response.⁷

Most controversy in encopresis is not about whether to treat constipation but about how psychiatric the disorder really is and how long maintenance should continue.

Psychiatric versus gastroenterologic framing

• DSM-5-TR retains encopresis as a mental disorder, but pediatric gastroenterology guidelines frame the same children primarily as functional constipation with overflow incontinence; the substantive disagreement is small and the treatment overlaps almost entirely.^4,11,14
• Some authors argue the diagnostic label of encopresis should be reserved for nonretentive soiling, with retentive cases reclassified as functional constipation; this remains a minority position.^12,15

Duration of maintenance therapy

• Guidelines recommend at least 6 months of maintenance, but optimal duration is uncertain, and some experts advocate routine maintenance for 12 months or more to reduce relapse.^14-15

Role of biofeedback

• Pediatric trials have not shown consistent benefit of biofeedback over standard medical and behavioral therapy, despite physiologic evidence of pelvic-floor dyssynergia in many retentive cases; the gap between mechanism and outcome remains unexplained.^15,18

Trauma attribution

• Older clinical literature emphasized sexual abuse as a frequent cause of encopresis; current evidence supports a meaningful but minority role in nonretentive cases and cautions against routine assumption of abuse without specific indicators.^3,7

• DSM-5-TR encopresis requires soiling at least once per month for at least three months in a child with developmental age of at least 4 years.⁴
• The two DSM-5-TR subtypes are with constipation and overflow incontinence (retentive) and without constipation and overflow incontinence (nonretentive).⁴
• Approximately 80 to 95 percent of cases are retentive with underlying functional constipation.^5,8
• Male predominance with a 3:1 to 6:1 male-to-female ratio is characteristic.^1,3
• The most consistent antecedent of retentive encopresis is a painful defecation event that initiates withholding behavior.⁵
• First-line outpatient disimpaction is oral PEG 3350 at 1 to 1.5 g/kg/day for 3 to 6 days.^14-15
• Maintenance with PEG 3350 at 0.4 to 0.8 g/kg/day for at least 6 months is the evidence-based mainstay.^14-15
• Combined laxative plus behavioral therapy outperforms either monotherapy in retentive encopresis.^15,17
• Premature taper of maintenance laxatives is the most common cause of relapse.^14-15
• Sodium phosphate enemas can cause hyperphosphatemia and hypocalcemia and should be avoided in children under 2 years and those with renal impairment.^14,16
• Red flags for organic disease include delayed meconium passage, failure to thrive, abnormal anal position, and sacral or lower-extremity neurologic findings.^5,8
• Hirschsprung disease classically presents with delayed meconium and an empty rectal vault, in contrast to the loaded vault of functional constipation.^5,8
• Encopresis is associated with increased rates of ADHD, anxiety, and oppositional defiant disorder; comorbid psychiatric screening is part of standard evaluation.^3,6
• Biofeedback is not recommended as routine therapy for pediatric retentive encopresis.^15,18

No external funding. No conflicts of interest declared. Peer-review status: pending.