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.

Constipation remedies

The Pediatric Insider

© 2012 Roy Benaroch, MD

Li wrote: “I saw an article you posted about potential causes for excessive urination for children.  One of the mentioned problems involved constipation.  Do you have any advice on where I can find more info on ways to relieve this problem through diet?  I was told build up of old stool is the cause of my child’s urinary problems.”

Constipation is very common, and it can lead to urinary problems like frequent urination, wetting, and painful urination. It’s no fun to be constipated, and I think parents need to treat this aggressively. Untreated constipation leads to harder, even-more-painful stools, which leads to more stool holding, which leads to worsening constipation. It’s what I sometimes dramatically call the Constipation Death Spiral—it gets worse and worse until it’s treated correctly and consistently. Fortunately, all but the most severely constipated kids can be treated with a few simple steps.

What is constipation? Normal stools might be anywhere from three times a day to once every three days—so it’s not really a matter of how often kids go. It’s what it feels like. Stool that’s firm enough or large enough to be uncomfortable is a sign of constipation. If it hurts, it’s constipated. If Junior is holding it in because it hurts, that’s worse constipation. If Junior has gotten so used to holding it that he doesn’t even realize he’s full of stool that leaks sometimes, that’s really bad constipation.

Some kids with significant constipation don’t really complain of pain much. They might have an occasional belly ache (especially after eating), or might only have urinary symptoms or stool leakage.

Why is constipation so common? I believe it comes down to diet. Our guts developed through almost all of human history to digest minimally processed foods. Even people who pursue a very “healthy” diet these days are still eating in a way that dramatically different from what our ancestors ate for thousands of years. It’s not all bad—human nutrition, at least in the developed world, has never been better. For the first time in history we suffer more now from overnutrition than from undernutrition. Still, one cost of all of this abundant, easy-to-eat-and-digest food is chronic constipation.

The first rule of treating constipation is to treat it. Do what it takes to fix it, and keep it fixed, for long enough that new patterns develop and children forget that they used to be afraid of their painful stools. Often parents make half-hearted attempts for a week or so, then give up as things maybe start to improve a little. Take my word for it: if you want to get out of the constipation spiral, you need to be consistent, and you need to be in it for the long haul.

The second rule is to try to avoid relying on enemas or suppositories. Your children do not want you anywhere near their anus. Constipation can almost always be treated orally. If you’re needing to go from the back route, you ought to be doing so while working with a doctor (though, hopefully, not in the same room.)

What can you do to treat constipation? Start by setting up a time, usually after a big meal, where your child is expected to sit on the pot for a set amount of time. The bathroom break isn’t until the child thinks his business is done—it’s until a timer goes off. These kids will sometimes squeeze off a little BM and think they’re done long before they’ve emptied, so you need to reinforce a new habit of relaxing and taking one’s time. I encourage bringing a GameBoy or iPhone or book or something for distraction. Maybe a Wall Street Journal, if your child is into investment banking. Whatever it takes.

From a diet point of view, you ought to encourage more water, more fruits and vegetables, more whole grains, and less dairy. Having said that, it’s very difficult to get children to make big changes in dietary habits, and rarely do diet changes alone fix significant constipation in kids.

Almost all families struggling with constipation will need to use a stool softener of some kind. Natural ones include fruits and fruit juices rich in sorbitol, like prunes, mango, or pears. Apple juice is popular, but isn’t a very effective stool softener. Ground flaxseeds or other sources of bran or insoluble fiber can help soften stools only if the child also drinks extra water. Without extra water, bran products themselves are constipating.

The most popular medical treatment for constipation is PEG 3350, often marketed as “Miralax” or a generic equivalent. This is a white powder mixed in a drink. Once the crystals dissolve, Miralax is flavorless. It helps constipation by drawing more water into the stool. Miralax is FDA-approved only for the short-term treatment of constipation, but it’s routinely used as a long-term maintenance drug safely. Other medicines used to treat constipation include Lactulose, Senokot, and Dulcolax. If you need to use medications, you ought to get more-specific instructions from your child’s pediatrician, who can also screen for rare-but-important medical causes of constipation that might be present.

Constipation isn’t fun, and it can cause significant problems including discomfort, embarrassment, and urinary problems. Unfortunately, some kids learn early on that pooping hurts, and those kids often continue to have issues with stool holding for years. If your child is constipated, please fix it, and keep it fixed. Talk with your pediatrician for more-specific advice, and don’t give up or stop treating it until it’s fixed for good.

A crisis for our bladders

The Pediatric Insider

© 2012 Roy Benaroch, MD

OK, listen up, people: you have to pee, at least every once in a while.

I know, I know. In elementary school, your teacher won’t let you leave class. In middle school, there isn’t enough time between classes. And in high school, well, I guess the thinking is one wouldn’t be caught dead using a toilet or something.

What happens if you don’t empty your bladder? To put in simply, Mr. Bladder doesn’t like staying full all day. Like any other muscle, if you keep it under stress it will get thick and bulky—and that’s a problem for bladders. Thick, bulky bladders can’t empty well. They squeeze too hard, and pinch off the tube that leads out. So when you finally do try to pee, you’ll get maybe just a little out. Not emptying your bladder isn’t good.

I see kids of every age in my office, every week, with these kinds of bladder issues. Running to the bathroom at the last minute, having little accidents (sometimes with laughter or coughing), pain with urination, or a feeling that you have to urinate very frequently—all of these symptoms are most often caused by a habit of not urinating frequently or completely enough. Sometimes, recurring urinary tract infections can happen, too. If you’re in the habit of holding it like a camel, you’re heading for trouble. There’s even a medical name for this: “dysfunctional voiding syndrome.”

So what should you do if you or your child is having these symptoms? Most importantly, make sure there’s unhurried time for complete bladder emptying at least every couple of hours. Don’t rush! Little kids might need something to distract them to slow them down, like a special video game that’s only played on the potty. Older children need to change their mindset: you don’t urinate just long enough to relieve the pressure. You should urinate until you’re completely done—and, to help make sure, you should probably relax and try to urinate again after you think you’re done the first time.

Schools and teachers need to rethink policies that don’t allow kids private, relaxed time to take care of their business. Four minutes between classes wouldn’t be enough time for even The Flash to get to his locker, run though the building to the one clean bathroom with working sinks, and then get back to class. Policies that keep kids squirming in their seats with their legs crossed are idiotic and unhealthy.

Make your bladder gladder. Take time to pee. Your bladder will thank you!

Frequent urination

The Pediatric Insider

© 2011 Roy Benaroch, MD

For November, I’m concentrating my writing chops on National Novel Writing Month. Fun! So I’m re-running revised versions of some classic posts. And by classic, I mean “old.” This one was originally from October, 2008—and it has been, consistently, the most-viewed “medical” article I’ve ever posted. Who would have guessed? Enjoy!

Here’s a question from AB: “Our daughter who is almost 5 years old has started a habit of wetting her pants at least once a day. She only wets a little each time and it doesn’t seem to bother her at all – she never tells us that it happened or complain about wet panties. We’ve talked to her continuously about not wetting her pants and tried all types of incentives and punishments, but nothing seems to make her stop. Could this be a medical problem? Or could it be some other behavioral issue such as an attention getter (She has a little brother who is 20 months old)? If this is only behavioral, what are your suggestions that we can use to help her stop?”

I doubt this represents a “medical” problem—she isn’t dribbling continuously or even that frequently, just once or a few times a day. And it doesn’t sound like it’s very likely to be a neurologic problem if she’s running around and otherwise acting normally. However, just to be safe, she does need to see her pediatrician for a simple urine dipstick test for infections or (far, far less likely) diabetes.

The most likely diagnosis for what’s going on is a very common problem among children called “dysfunctional voiding.” I’ve written about this before, but it comes up so often that it’s worth covering again in more detail. First, though, you should probably stop with any kind of incentive or punishment—that’s not going to get you anywhere, and may prolong the problem by making the accidents an attention-getter.

What is dysfunctional voiding?

 

Dysfunctional voiding is a term for an abnormal pattern of urination. The symptoms can include wetting during the daytime, urinating very frequently, rushing to the bathroom, or sometimes pain with urination. Some children who have these symptoms squat down on their heels, cross their legs or hold themselves between their legs to keep from wetting. Sometimes, children with dysfunctional voiding also start to ignore the urge to have a bowel movement.

 

How does dysfunctional voiding develop?

 

For many different reasons, children start holding their urine for a long time. They may be reluctant to stop doing fun activities for a bathroom break, or they might be embarrassed at school to ask for a hall pass. Kids who feel that the bathroom at school is dirty will sometimes hold their urine all day long! Once a child starts holding urine, the bladder wall becomes thicker and less able to empty completely. After a while, children begin to lose the sensation that their bladder is filling until it almost overflows. Though dysfunctional voiding may start because of habits, it does become a physical problem once the body begins these adaptations. Fortunately, these physical changes can be reversed by following good voiding habits.

 

Dysfunctional voiding with constipation

 

Children with dysfunctional voiding may also have constipation. When a child is constipated, the rectum may be full of hard stool and can irritate the bladder and keep it from holding as much as it should. Constipation makes the wetting problem worse. You cannot treat the problems of dysfunctional voiding unless you fix the constipation, too.

 

How is dysfunctional voiding treated?

 

The most important part of treated is regular bowel and voiding habits. These must be used together in order for this condition to be treated successfully Changing your child’s habits can take a long time. At school, children may need to be reminded to go to the bathroom.

Medicine is not usually needed to help with dysfunctional voiding. Sometimes, a stool softener can help with the constipation that often accompanies dysfunctional voiding.

Timed voiding schedules are a big help. Your child should urinate during the daytime every 2 hours (some children may need to go more often). This schedule will help train your child to empty the bladder before it gets full and begins to leak. It’s a good idea to use a kitchen timer to go off at set intervals, so a parent doesn’t have to be the “bad guy” enforcing trips to the bathroom. Make sure that the bathroom breaks aren’t perceived as a punishment, and that any fun activity that was interrupted for a bathroom break will continue when the child comes back—and doesn’t rush!

 

How to urinate correctly

 

It is very important for your child to relax when urinating. Relaxing helps the bladder to empty completely.

• Girls should remove pants or tights completely off of one leg so that they can spread their legs far apart.
• Girls should sit way to the back of the toilet and lean forward. Alternatively, girls can sit backwards on a toilet, facing the tank.
• While establishing good habits, boys should be encouraged to sit to urinate. This prevents rushing.
• Breathe deeply.
• Relax the muscles of the head, arms, body and legs.
• Feet should be on the floor or a footstool, not dangling.
• Imagine urine flowing (turn water on in the sink).
• Allow plenty of time for urination. The process of relaxing to empty the bladder takes time. Plan to spend 3-5 minutes in the bathroom.
• For younger kids, it can be especially helpful to bring a toy. An electronic game that is only used while sitting on the toilet will keep kids sitting for a long time!

Dysfunctional voiding is a common problem encountered in a pediatrician’s office. There are no expensive tests or medicines that need to be used. It’s a matter or re-training good habits. The best way to handle this is with relaxation and good humor—you can’t force it. Fortunately, children who have developed dysfunctional voiding habits can quickly reverse this problem with some gentle support and simple steps.

Accidents happen

The Pediatric Insider

© 2010 Roy Benaroch, MD

From Jennifer: “My daughter will be 6 in a week and is in kindergarten at a public school. She has accidents quite frequently at school and on occasion, they are poo accidents. In the past, she has waited too long to go and that is when the accidents happen. I don’t feel comfortable disciplining her because I don’t think she is doing it on purpose. But I did talk to her about how she is almost 6 and should try to not have accidents. That seemed to have stressed her though because when she came home yesterday after having an accident, she told my husband that she was a failure and couldn’t be 6. It broke my heart. I’m just at a loss. Telling her to go potty even if she doesn’t feel like she has to go is confusing for her to understand. Is it possible that she doesn’t ‘feel’ the need until it’s urgent? If so, how long does that last?”

First, let me assure you that this is a very common problem, and that it’s very unlikely that there’s anything really wrong with your daughter, either psychologically or physically. Kids are kids, and they get caught up playing, and they really don’t like to stop what they’re doing to take care of business. Accidents like these don’t happen because a child is being defiant, or willful, or even purposeful.

There are some rare “red flags” that could indicate a medical issue. A child who has a big change in habits suddenly should be evaluated at the doctor’s office, as should a child whose accidents are accompanied by painful urination, fever, or blood in the stool. Even these kids are unlikely to have a serious medical condition, but still, the physician should look.

Jennifer said, “Telling her to go potty even if she doesn’t feel like she has to go is confusing for her to understand.” That might be true, but you and the teacher still ought to do it. Don’t ask– she’ll say no– and don’t suggest it, either:

• Don’t: “Do you have to use the potty?”
• Don’t: “I think it’s time to use the potty.”
• Don’t: “You really ought to use the potty.”
• Do: “Time for everyone to stop what they’re doing for a potty break.”

She shouldn’t be singled out, and it should be clear that all fun/activity stops during the break, to resume afterwards. Do this at home, too, and include yourself:

• Do: “You know what? It’s time for you and me to take a potty break”

It can help to use a kitchen timer, so it’s not your fault that that potty time is here. You can set it to go off every few hours, or just set it to go off in 5 minutes when she isn’t looking. Nothing wrong with a sneaky trick!

“Is it possible that she doesn’t ‘feel’ the need until it’s urgent? If so, how long does that last?”

Yes, in fact it’s very likely. If she’s used to holding her stool and urine, she’s gotten used to the feeling of a full bladder and rectum. She’ll become less sensitive to her body’s own signals to tell her when she’s full. If you help her remember to keep herself empty most of the time, these sensations will soon return to normal– though it will take weeks or even a few months, not days. New habits can be learned, but sometimes not as quickly as you’d like. I don’t think this is going to be a quick fix.

If your daughter has firm or large stools, it’s very important that you treat the constipation. You ought to work with your child’s pediatrician for instructions and ongoing follow-up for these problems. You can also find more details about the treatment of urinary frequency and accidents are here.

Clueless little accidents

Here’s a question from AB: “Our daughter who is almost 5 years old has started a habit of wetting her pants at least once a day. She only wets a little each time and it doesn’t seem to bother her at all – she never tells us that it happened or complain about wet panties. We’ve talked to her continuously about not wetting her pants and tried all types of incentives and punishments, but nothing seems to make her stop. Could this be a medical problem? Or could it be some other behavioral issue such as an attention getter (She has a little brother who is 20 months old)? If this is only behavioral, what are your suggestions that we can use to help her stop?”

I doubt this represents a “medical” problem—she isn’t dribbling continuously or even that frequently, just once or a few times a day. And it doesn’t sound like it’s very likely to be a neurologic problem if she’s running around and otherwise acting normally. However, it would be very reasonable to see her pediatrician for a simple urine dipstick test for infections or (far, far less likely) diabetes.

What you’re describing is part of a very common problem among children called “dysfunctional voiding.” I’ve written about this before, but it comes up so often that it’s worth covering again in more detail. First, though, you should probably stop with any kind of incentive or punishment—that’s not going to get you anywhere, and may prolong the problem by making the accidents an attention-getter.

What is dysfunctional voiding?

Dysfunctional voiding is a term for an abnormal pattern of urination. The symptoms can include wetting during the daytime, urinating very frequently, rushing to the bathroom, or sometimes pain with urination. Some children who have these symptoms squat down on their heels, cross their legs or hold themselves between their legs to keep from wetting. Sometimes, children with dysfunctional voiding also start to ignore the urge to have a bowel movement.

How does dysfunctional voiding develop?

For many different reasons, children start holding their urine for a long time. They may be reluctant to stop doing fun activities for a bathroom break, or they might be embarrassed at school to ask for a hall pass. Kids who feel that the bathroom at school is dirty will sometimes hold their urine all day long! Once a child starts holding urine, the bladder wall becomes thicker and less able to empty completely. Also, children begin to lose the sensation that their bladder is filling until it almost overflows. Though dysfunctional voiding may begin in part because of habits, it does become a physical problem once the body begins these bad adaptations. Fortunately, these physical changes can be reversed by following good voiding habits.

Dysfunctional voiding with constipation

Children with dysfunctional voiding may also have constipation. When a child is constipated, the rectum may be full of hard stool and can irritate the bladder and keep it from holding as much as it should. The constipation can make the wetting problem worse. You cannot treat the problems of dysfunctional voiding unless you fix the constipation, too.

How is dysfunctional voiding treated?

The most important part of treated is regular bowel and voiding habits. These must be used together in order for this condition to be treated successfully Changing your child’s habits can take a long time. At school, children may need to be reminded to go to the bathroom.

 

Medicine

Medicine is not usually needed to help with dysfunctional voiding. Sometimes, a stool softener can help with the constipation that often accompanies dysfunctional voiding.

 

Timed voiding schedule

Your child should urinate during the daytime every 2 hours (some children may need to go more often). This schedule will help train your child to empty the bladder before it gets full and begins to leak. It’s a good idea to use a kitchen timer to go off at set intervals, so a parent doesn’t have to be the “bad guy” enforcing trips to the bathroom. Make sure that the bathroom breaks aren’t perceived as a punishment, and that any fun activity that was interrupted for a bathroom break will continue when the child comes back—and doesn’t rush!

How to urinate correctly

• It is very important for your child to relax when urinating. Relaxing helps the bladder to empty completely.
• Girls should remove pants or tights completely off of one leg so that they can spread their legs far apart.
• Girls should sit way to the back of the toilet and lean forward. Alternatively, girls can sit backwards on a toilet, facing the tank.
• While establishing good habits, boys should be encouraged to sit to urinate. This prevents rushing.
• Breathe deeply.
• Relax the muscles of the head, arms, body and legs.
• Feet should be on the floor or a footstool, not dangling.
• Imagine urine flowing (turn water on in the sink).
• Allow plenty of time for urination. The process of relaxing to empty the bladder takes time. Plan to spend 3-5 minutes in the bathroom.
• For younger kids, it can be especially helpful to bring a toy. An electronic game that is only used while sitting on the toilet will keep kids sitting for a long time!

Dysfunctional voiding is a common problem encountered in a pediatrician’s office. There are no expensive tests or medicines that need to be used. It’s a matter or re-training good habits. The best way to handle this is with relaxation and good humor—you can’t force it. Fortunately, children who have developed dysfunctional voiding habits can quickly reverse this problem with some gentle support and simple steps.