Elimination Disorders in Children

  • Medical Author:
    John Mersch, MD, FAAP

    Dr. Mersch received his Bachelor of Arts degree from the University of California, San Diego, and prior to entering the University Of Southern California School Of Medicine, was a graduate student (attaining PhD candidate status) in Experimental Pathology at USC. He attended internship and residency at Children's Hospital Los Angeles.

  • Medical Editor: David Perlstein, MD, MBA, FAAP
    David Perlstein, MD, MBA, FAAP

    David Perlstein, MD, MBA, FAAP

    Dr. Perlstein received his Medical Degree from the University of Cincinnati and then completed his internship and residency in pediatrics at The New York Hospital, Cornell medical Center in New York City. After serving an additional year as Chief Pediatric Resident, he worked as a private practitioner and then was appointed Director of Ambulatory Pediatrics at St. Barnabas Hospital in the Bronx.

Causes of Bedwetting

The fundamental problem for children with primary bedwetting is the inability to recognize messages of the nervous system sent by the full bladder to the sleep arousal centers of the brain while asleep. In addition, bladder capacity is often smaller in bedwetting children than in their peers.

Elimination disorders in children facts

  • Constipation is defined as "a group of disorders associated with persistent, difficult, infrequent, or seemingly incomplete defecation without evidence of a structural or biochemical explanation."
  • Constipation is a relatively common event estimated to be responsible for 3%-5% of all visits to a pediatrician's office.
  • Encopresis has been defined as "the repetitive, voluntary or involuntary, passage of stool in inappropriate places by children 4 years of age and older, at which time a child may be reasonably expected to have completed toilet training and to exercise bowel control."
  • Most studies indicate approximately 4% of all children 4-17 years of age will experience encopresis.

What are elimination disorders in children?

There are two types of disorders of elimination that may affect children. One category reflects problems with stooling, relatively common constipation and less frequently occurring encopresis (also known a fecal incontinence or soiling). The other category of elimination disorders in children reflects problems with urination and is known as enuresis. The article will review only problems associated in children dealing with stooling. Problems with urination in children are reviewed elsewhere.

What are the risk factors and causes of constipation and encopresis?

Most children with encopresis have underlying constipation. Why some children develop encopresis does not seem to reflect differences in either physiology or psychology. Pediatric GI specialists have noted three areas of intestinal maturation that may set the stage (in some children) for the onset of constipation and (in some, ultimately) encopresis. These areas include the following:

  1. Changing from a pure breast milk/formula diet to one that includes and ultimately relies on the majority of calories from solid foods: The increase in solid foods promotes an increase in stool volume and consistency that may require greater effort for stool expulsion.
  2. The process of toilet training: The emotional turmoil for some families in what is generally a natural evolutionary process may engender a myriad of emotional responses in the child who is toilet training. The often conflicting desire to please parents but establish autonomy may "raise the stakes" too high for the toddler to succeed. The fact that many preschools require successfully toilet trained students may engender parental stress since many parents utilize preschool as a safe locale for their child during the adult's workday. One study demonstrated that 35% of children who refused to toilet train developed chronic constipation and were at a substantially higher likelihood of developing encopresis.
  3. School attendance: Pediatricians daily hear stories about children who refuse to use the school toilet for either urinating or bowel movements. The lack of privacy, taunting, and often noisy chaos is just too intimidating when compared with the home environment.

Regardless of the cause, many children with constipation will ultimately pass either an overly large and/or hard stool, resulting in a painful experience. The rational step (from the child's perspective) is to avoid stooling and thus avoid further pain. Consequently, stool accumulates in the rectum and becomes desiccated and thus more difficult and more painful to pass. This recurrent cycle reinforces the child's behavior to avoid stooling at all costs. Children who develop encopresis may develop abnormal stretching and enlargement of the rectal area that reduces the reflex urge to stool. As a consequence, the impacted stool mass may allow "upstream" semisolid stool to leak around the "downstream" stool obstruction, causing soiling in clothes as well as occasional chunks of stool to also be passed without the child's knowledge or desire.

Medically Reviewed by a Doctor on 3/11/2016

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