Can’t feel his poops

The Pediatric Insider

© 2013 Roy Benaroch, MD

Kathy wrote in about her son: “What can cause a nine year old boy to poop in his pants occasionally and not feel it? He was completely potty trained at age three. I have found dirty underwear, poop on the bathroom floor–and it just concerns me that he is unaware of it. It has been suggested at check ups that he may be constipated. My mother suggests he may simply not be paying attention until it’s too late and also if his bowel movements are soft (and they are) this might be part of the problem. I worry that there might be a congenital defect or the like and don’t want to overthink it, but also don’t want to ‘poo poo’ it.”

This is one of those problems that’s very, very common—as a pediatrician, I hear about this all the time—but parents don’t talk about it much among themselves. Parents sometimes think that their child is the only one who’s doing this. Believe me, he isn’t.

The name for what’s going in is encopresis, or fecal soiling. Kids with this leak soft stool, usually without noticing it at all. Very rarely, encopresis can be associated with an anatomic problem, like a serious anal malformation or spinal cord defect. But if your son is walking around and seems fine, and his pediatrician has looked at his spine and reflexes, there is no underlying anatomic or medical condition.

Encopresis is a complication of longstanding constipation. Kids hold their stool—often because it’s become hard and uncomfortable, or sometimes because they’re too busy to stop what they’re doing to have a good BM. Held-in stools become bigger and harder, and that reinforces the stool holding. Kids do not want to pass a painful stool! In time, they get so used to holding that they don’t even realize that they’re doing it. The distal colon becomes big and distended, and can hold an impressive amount of stool.

The poop, though, has to go somewhere. Eventually it will leak around the stool mass in the colon, and that’s when soiling occurs. The leaked stool is often soft—so parents may not believe us when we tell them there is constipation. Sometimes I’ll do a quick, one-view x-ray of the abdomen that shows the huge amount of stool that’s backed up.

Encopresis symptoms sometimes come and go. Some kids will eventually pass their huge backed up stool (often clogging the toilet), and then won’t leak for a few weeks. But the habits are still there, and they’ll usually get backed up again.

Treatment of encopresis begins with explaining to the parents what’s going on. Often there are some misconceptions and sometimes even some anger that that child is doing this willfully, or just doesn’t want to stop. Negative feelings and punishments never help kids with fecal soiling. If there is a lot of finger pointing, a referral to family therapy may be needed before much progress can occur to fix the encopresis.

Getting stool habits back to normal requires a comprehensive plan that everyone in the family must follow. There is no quick fix, and the longer the problem has been going on the longer it’s going to take to repair. Believe me, it is much better to face this head-on and fix it than to take halfhearted efforts that help for a little while, then back off and let the problem resurface again. The main components of therapy, in addition to family understanding, are:

  • A big clean out. Therapy will almost always start with relatively high dose stool softeners to get the old mass of stool out and let the colon return to a normal size. This is best done on the weekend!
  • Maintenance, ongoing, long term stool softeners. This is essential. Parents must keep their child’s stool soft and painless for many months or sometimes years to create a new habit. Backing off the stool softeners too early will inevitably lead to relapse and a more-difficult situation.
  • Reinforcing good stool habits. That means relaxed time on the pot, every day. Usually staying on the toilet for a set amount of time after a big meal is better than letting them go “until they’re done,” because at least at first these kids do not know when they’re done. Keep ‘em on the pot with a Game Boy or a new iPhone app. Those things are waterproof, right?

Dietary changes can also help, including more fluids and fiber. But changing diet alone will not fix the problem, and I don’t overly stress diet issues. Practically speaking, fighting with your child about bran rarely helps solve anything.

There are many good stool softeners out there that are not habit forming and can be safely taken long term. I try to stay away from enemas and suppositories unless they’re absolutely necessary. That’s a good rule of life: stay away from your child’s anus.

Encopresis can be fixed, but it takes time and consistency. Sometimes a referral to a pediatric gastroenterologist can help reinforce these instructions and help reassure parents. The most important thing: stick to the plan.

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11 Comments on “Can’t feel his poops”

  1. E. Tudakovic Says:

    Thank you for your wonderful website – we’ve been devouring your articles since we discovered it!

    Our daughter (who turns four tomorrow!) was diagnosed with encopresis some months ago. At first, we had great success with the use of laxatives (after a clear-out) and reinforcing good potty behaviour (ie. sitting on the toilet after meals, etc.).

    A few weeks ago we had a set back where she appeared constipated again so we increased her dose (as per the instructions we received from our doctor initially). She’s started having fairly frequent accidents again but we’re having trouble telling if she’s constipated and it’s fecal matter shooting out around a blockage or if the dose is overly high. For example, she’s had fairly substantial soft stools that she’s complained come out very quickly – this leads us to think that the dose is overly high. However, on the toilet, she’s passed either very small stools, or a bunch of fairly small, soft stools (that come out quickly) and then has soiling in her pull-ups or panties. It’s just tough to figure out sometimes what’s going on with her bowels! For example, do we increase the dose of laxative or decrease it?

    The wonderful physician who initially diagnosed the problem (after several visits to doctors who told us only to be patient!) is out of town and we won’t be able to see her until the end of the month.

    Thank you again for this article. We’ve had lots of frustrations explaining to friends and caregivers that she hasn’t been having accidents on purpose! Your article was also heartening as it helped us realise that other parents have had this problem.

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  2. Dr. Roy Says:

    Thanks for your feedback!

    RE: setbacks, it is usually – not always – because of a dose that’s become too low, or habits that have gotten a little less rigid. It’s perfectly understandable, once a child has done well for several months, the tendency is to back off the stool softener, and be less rigid about potty time. But that sometimes leads to setbacks.

    However, sometimes it is true that a dose is too high– how do you tell? If it’s not clear from the history and exam, sometimes a single xray of the abdomen will show if there is a lot of excessive stool. if there is, repeat the clean-out.

    Best of luck!

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  3. E. Tudakovic Says:

    Thank you! I really appreciate the quick reply and the great articles.

    Like

  4. maria Says:

    My 9 year old son started to poop in his pants when he was 7 years now its getting worse cause his doing it at school now and when I ask him he tells me he doesn’t feel it what should I do

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  5. Michelle Jackson Says:

    My son is 7 and was diagnosed with encopresis about 2 years ago. Our specialist suggested biofeedback therapy which only made things worse, not only was my son completely mortified that he had to strip down and have sensors put on his bare rear but he then began to pee in his pants which we had never had a problem with before. We have tried Miralax among other laxatives and haven’t experienced him pooping out the “plug” or “blockage”. He poops almost every 5 minutes. Once he cleans himself up and gets dressed he has done it again already. He says he doesn’t even feel it, the mushy poop just comes out on it’s own. Is it normal for a child diagnosed with encopresis to poop every 5 minutes? Or could there be something else wrong that is being over- looked? The doctors tell me to remain positive and have patience, but my house smells like a nursing home! This problem has held him back from doing so much (sports, boy scouts, going to friends houses). I’m about to make another appointment with a different specialist but if there’s nothing more I can do then I’d rather not have another specialist bill to pay! I desperately need some advice! Thanks!!

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  6. Deborah Learned Says:

    Dec.2 2016 “Specialists” and doctors love to come up with new diagnosis to pad their wallets as often as possible, then when the instructions,methods,surgeries,ect. don’t work or pay off, they back paddle faster than “Titanic” survivors with half empty lifeboats. Our kids eat breakfast. Right? o.k. So we make sure there are good things for breakfast. A little protein,carbs, and FRUIT. Gotta have the good stuff to make the “body machine” work. Banana’s are perfect for the morning, they’re fun self-peeled or sliced into “nanna-coins”. They should be ripe though, not too hard, not too soft. They provide potassium,vitamins,and natural sugar. don’t over-do them though,they can cause constipation all on their own if eaten in abundance. At school they have lunch. Be sure you know what YOUR kid is eating at lunch. If he or she is having this much trouble, find someone, a teacher,an older kid you trust, be creative if need be. know what your kid is eating for lunch. Then after school, instruct your child that this will be an EVERY DAY thing. Out of the car, in the house,backpack down where it is supposed to go, and make a B-line to the potty! not just going pee, but sitting in the appropriate position to poop, until there is no more poop in the kid. Do not let them flush until you have inspected. When it really comes down to it, they don’t want to disappoint you, or themselves, because for a while now,they have been. They want to do it right and feel good about themselves. They’re just small humans having a hard time figuring this out. So give them what they’ve needed to learn just about everything else. Simple but firm structure. Remember what our parents told us? Anything worth doing is worth doing right.Good food for the body machine, and on the potty every day at the same time, no matter what,until they get the hang of it and realize for themselves that they may have to go more than once a day, or at different times. Good luck to all! Go Potty Go!!!
    -Deb

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  7. Dr. Roy Says:

    Deb, I don’t think doctors invented constipation to make more money. I’m pretty sure if that were the case I would have heard about it at one of our secret meetings. Or maybe I was in the bathroom when that was discussed. Good Lord, that explains everything!

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  8. TANIA Says:

    Good day
    We have been having a similar problem with my son, he is 11yrs old. He started with diahrea a few weeks ago docter put him on meds. It still didnt stop the pooping it continued and we saw a pediatrician which put him in hospital with fecal impaction. He was given meds and enima to clear his colon and it seemed to help. Only for him to continue to have this runny tummy for a 7th week. He had a colonoscopy and gastroscope done 2 days ago still waiting for results, he still has diahrea. We changed his diet and excluded sugar gluten dairy and weat..what else could it be????
    So tired of all the guessing and not knowing whats wrong, poor child eats and then poops..

    Any advise as to what to do????????

    Like

  9. Dawn Says:

    What about a 9 year old that starts to poop their pants out of no where. Claiming she can’t feel it. She’ll sit in her poop until someone says something.

    Like

  10. Amberlee Brooks Says:

    Dawn, Your situation describes my daughter to a T. Did you ever figure out what to do about it?

    Like

  11. H.tosson Says:

    I really appreciate yr throughly reply its like you read my mind and worries ….thanks a lot

    Like


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