Fecal Incontinence
What is it?
Fecal incontinence is a relatively common condition among children, characterized by the involuntary leakage of stool in children over the age of 4. It can result from chronic constipation or congenital conditions such as spina bifida, anorectal malformations, or Hirschsprung's disease, which disrupt bowel control.
Many families are surprised to learn that the most common cause of fecal incontinence in clinics is constipation. In children with constipation, stools accumulate and cluster at the end of the bowel, completely covering the inner lining. The constant presence of hard, dry, and large stools in the bowel increases the sensitivity of the specialized cells that detect stool, leading to the leakage of fresher, softer, and larger stools without the child's awareness. Many parents mistake fecal incontinence for diarrhea, but clinically, it is a consequence of constipation. Leakage may appear as smearing in the underwear or as small pellets.
Unfortunately, fecal incontinence can cause significant embarrassment and social issues for children. While it is a distressing condition for both parents and children, proper treatment methods can help children overcome it.
Stool incontinence may result from medical conditions such as chronic constipation or from congenital disorders that impair bowel control, such as spina bifida, anorectal malformations, and Hirschsprung disease. It can also occur in children who have developmental delays, neurological disorders, or physical impairments compared to their peers.
Soiling in children over age 4—after toilet training is complete—is generally attributed to constipation, but in rare cases may have psychological origins. To determine whether soiling is psychological or physiological, evaluation by specialist clinicians is required. If a psychological basis is identified, a multidisciplinary approach involving mental-health professionals should be included in the treatment plan.
In situations of family tension or parental emotional distress, some children may soil as a behavioral pattern. During early childhood, children learn to control two organs voluntarily: bladder and bowel. They may use wetting or soiling (or withholding) as a way to send an emotional message to caregivers. However, it is difficult for parents to distinguish at home whether soiling has an emotional or a physical cause. Therefore, securing professional support and beginning appropriate treatment promptly is essential. If soiling is found to be psychological in origin, a multidisciplinary treatment plan should be implemented.
When children become ill or take certain medications, their stool may lose consistency and become loose or watery, making bowel control difficult. In such cases, soiling can be considered a normal response. However, if soiling persists after the diarrhea has resolved, evaluation by a specialist is recommended.
Evaluation should begin with a detailed history and physical examination by the appropriate specialist. Important questions include:
- How often does your child have a bowel movement?
- Does your child experience pain during bowel movements?
- Have you recently started toilet training?
- What foods and drinks does your child consume?
- Have there been any recent stressful events in your child’s life or family, such as divorce or loss?
- How often does your child soil their clothing?
Based on this assessment, the specialist may order imaging tests (ultrasound, abdominal X-ray), blood tests, functional studies (rectal manometry, colon transit studies), and endoscopic exams (sigmoidoscopy, colonoscopy) to investigate soiling in more detail.
A 7-day bowel diary—in which the child records the time, frequency, amount, and severity of soiling and stool characteristics each day for one week—is often described by children as a fun activity. Episodes of soiling (frequency, volume, severity) should be noted. Pediatric urology specialists use this diary to plan the most effective treatment based on the child’s age, symptoms, and clinical findings.
If soiling is caused by constipation, the first step is to treat the constipation itself, with multimodal treatment plans as needed.
- Urotherapy Education (Healthy Bladder & Bowel Training) is delivered by specialized physiotherapists focusing on behavioral changes. It includes proper toileting posture, healthy eating and drinking habits, age-appropriate fluid intake, bowel-emptying techniques, and establishing regular routines, all tailored to each child’s needs.
- Medication Therapies such as stool softeners, laxatives, and rectal medications may be prescribed by the treating physician according to the child’s age and weight and monitored closely.
- Pelvic Floor Muscle Rehabilitation is performed by expert pelvic floor physiotherapists to retrain the muscles responsible for bowel function. It includes massage techniques, diaphragmatic breathing, biofeedback-assisted exercises, stabilization exercises, and neuromodulation.
Untreated soiling is a serious health problem that can lead to psychological issues. In school-aged children, it may result in social isolation and significant self-esteem loss. Because effective treatments exist, children should not be expected to cope alone; early professional support is crucial.
