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How to Treat Stool Holding

by Sue Hubbard, M.D.

On Friday, we discussed stool holding and encopresis: what it is and why kids have trouble going to the bathroom.   Now it’s time to discuss treatment.

The medicinal component of treatment begins with  cleaning out the rectum. This is typically done by using enemas (Fleets) to get rid of the large amount of old stool that has distended the rectum.  Mineral oil given orally may also help the stool to be evacuated (it is tasteless but a child can see the oil, so get a soft drink or juice and put a top on it and mix in the mineral oil and serve with a straw), you can also mix into oatmeal.

I typically use an enema to start and then keep up daily mineral oil for awhile until the stools are routinely soft and not painful.  Enemas are not well liked by anyone.  A daily laxative is also important. Milk of Magnesia and Miralax are my favorites.  The dose may be titrated but you want to ensure that your child is having a stool every day. The laxatives are not habit forming, but are serving a purpose to help the colon begin to work correctly again. Once your child is having regular bowel movements without pain, or avoidance you can slowly wean the laxative too, but do this over several months.

Dietary therapy is also important to help soften stools and decrease the transit time of stool in the colon. Healthy eating habits which incorporate high fiber foods are helpful. The formula for fiber intake is the child’s age in years + 6 = number of grams of fiber /day. You would be surprised at fiber content of foods and they are all listed on the food packages.

Benefiber is also a good source of fiber and can be used daily.  I like  to use Metamucil cookies too and if necessary put a little icing on top.  Adding more fluid to a child’s diet is equally important , and a “prune juice cocktail” made with prune juice and seven up or ginger ale is a great way to get in some more fluid with additional laxative benefit. (you taste it not bad at all!)

Lastly, behavior modification.  Begin by establishing a regular toileting schedule. This is typically after each meal (to take advantage of the gastro-colic reflex which occurs after eating and causes intestines to contract) and at bedtime.  I sometimes use a timer as a game to try and have the child “beat the clock” in pushing out their poop, and then they receive a “prize” (Dollar store is adequate, does not need to be expensive etc.). A child needs lots of positive reinforcement with charts, stickers to show their progress and even larger reward (maybe trip to bookstore, or ice cream store etc) for a week of good work.

Remember, this is not an overnight resolution but typically takes weeks to months of work, so be creative as to positive reinforcement. If your child does not stool every day, try using a suppository and increasing the laxative.  They can also practice doing the Valsava maneuver (where you hold your breath and bear down to have a bowel movement) which will also help them push out the stool which should be soft. If your child is in school you need to discuss these strategies with the teacher so that the child has adequate bathroom time when needed.

By working on all 3 areas encopresis can be treated and successfully cured while saving the child embarrassment and anxiety that often comes with it. No one wants to have “poopy pants” they just need the tools to fix the problem.

For very difficult cases you may need to ask your pediatrician about using a behaviorally trained pediatric psychologist for assistance.

That’s your daily dose for today.  We’ll chat again tomorrow.

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