Soiling in children (encopresis)
A child has been using the toilet for a long time, and yet stool keeps turning up in their pants — sometimes as smears, sometimes runny, sometimes as hard…
On this page
- What is actually happening
- Why this is neither diarrhoea nor disobedience
- How to tell that constipation is the cause
- Why punishment and shame make things worse
- Treatment: empty first, then hold the gain
- What to do at home every day
- How long it takes and what counts as a setback
- When to seek help without waiting
- If the child was reliably clean and has started soiling again
- Online consultation
Medicines commonly prescribed for Soiling in children (encopresis)
For informational purposes only. Always consult a doctor before taking any medication.
Dosage form: ORAL SOLUTION/SUSPENSION, 0.67 g lactulose/mlActive substance: lactuloseManufacturer: Lainco S.A.Prescription requiredDosage form: RECTAL LIQUID, 45mg sodium lauryl sulfate; 450mg trisodium citrateActive substance: sodium lauryl sulfoacetate, incl. combinationsManufacturer: Jntl Consumer Health (Spain) S.L.Prescription not requiredDosage form: ORAL SOLUTION/SUSPENSION, 10 g lactulose/ 15 mlActive substance: lactuloseManufacturer: Cooper Consumer Health B.V.Prescription required
A child has been using the toilet for a long time, and yet stool keeps turning up in their pants — sometimes as smears, sometimes runny, sometimes as hard little pellets. At that point parents almost always think one of two things: that the child is being lazy and doing it deliberately, or that they have diarrhoea. Usually neither is true. In children, what sits behind this picture is long-standing constipation, and that is a medical problem with a definite treatment rather than a question of discipline.
What is actually happening
With constipation that has gone on for a long time, hard stool builds up in the rectum and does not come out. The bowel gradually stretches, and its wall stops sensing how full it is: the child simply does not feel the urge they used to have. With a stretched rectum, the muscles that hold the contents in also work less well.
New stool keeps arriving from above. The only way past the hard plug is around the edges, so it leaks out runny or semi-runny, in small amounts, many times a day. The child does not feel it and does not notice until they see their pants. Soiling in constipation, in other words, is not “diarrhoea instead of constipation” but a direct consequence of it: overflow leaking around the hard stool.
Hence the single most practical conclusion: unless the rectum is emptied, no amount of explaining, punishing or reminding will help. The soiling will stop only when the constipation goes.
Why this is neither diarrhoea nor disobedience
Runny stool in the pants looks like an upset stomach, and parents not uncommonly start treating it with anti-diarrhoeal remedies and a bland “diarrhoea diet”. That makes the constipation worse and the soiling heavier. Real diarrhoea comes in large volumes, usually with pain and often with a fever; in constipation the leak is small and the tummy is full.
The child is not doing it on purpose. In most cases they do not register the moment: a stretched rectum sends no signal, and they stop noticing the smell before anyone around them does. Children sometimes hide soiled pants or deny what has happened, and this is not lying for its own sake — it is what shame looks like. Telling a child off for hidden pants achieves nothing, because that is part of the problem rather than its cause.
It usually starts with pain. One hard, painful stool, a small tear in the skin, a bad experience in an unfamiliar toilet, a refusal to use the toilet at nursery or school — and the child begins to hold on. Holding on makes the stool harder still, the next time hurts even more, and the circle closes. Often this coincides with a house move, a new baby in the family, or starting school.
How to tell that constipation is the cause
It is worth looking for these signs; usually several of them are present at once:
- stools fewer than three times a week, or very irregular;
- very large, hard stools, sometimes big enough to block the toilet;
- or the opposite: small hard pellets;
- pain on opening the bowels; the child strains, cries out, is afraid of going;
- holding behaviour: the child goes still, stands on tiptoe, crosses their legs, presses against the furniture, hides in a corner — from the outside this often looks like an attempt to pass a stool, when in fact they are holding on with all their strength;
- a streak of bright blood on the stool or the paper, from a small tear;
- tummy pain that comes and goes and eases after a stool;
- poor appetite, a feeling of a “full” tummy, sometimes nausea;
- alongside it, needing to pass urine more often, daytime or night-time wetting, repeated urinary infections — a loaded rectum presses on the bladder.
On examination the doctor may be able to feel the accumulated stool through the abdomen; sometimes that alone settles the question. Where the picture is typical, tests are usually unnecessary: neither an X-ray nor blood tests refine the diagnosis.
Why punishment and shame make things worse
Punishments, withdrawing treats, telling-off and “wash it yourself” do not work for a simple reason: the child does not physically control the moment, so there is nothing for them to learn from a punishment. They work in one direction only — they increase shame and fear, so the child holds on harder, hides the pants more carefully and says less. The constipation grows on the back of that.
Telling the child the truth is already half the job: this is happening not because they are bad or babyish, but because their bowel is overloaded, and that can be treated. From there, keep an even tone. Clearing up happens without commentary or grimaces, in the same way soiled clothes are changed for a baby. There is plenty to praise, but not clean pants — praise what the child did themselves: sat on the toilet at the agreed time, told you, used the toilet at school. Stickers and a simple chart help precisely because the reward is given for something the child can actually do.
It is also worth agreeing arrangements with nursery or school: permission to use the toilet when needed, spare clothes, and somewhere to change without an audience. Many children hold on all day only because the school toilet is out of reach or frightening.
Treatment: empty first, then hold the gain
Treatment comes in two stages, and the order matters.
The first stage is emptying the bowel. The doctor prescribes laxatives, usually osmotic ones, at a dose that will clear the accumulated stool; the dose is set by weight and by response, and over those days it is often quite high. There is a warning that has to be known in advance: during those days the soiling usually increases, the stool becomes loose and frequent, and there may be cramps. This is not a deterioration or a side effect gone wrong — it is precisely what is meant to happen. Parents who have not been warned most often abandon treatment at exactly this point, concluding that “the medicine did not suit them”.
The second stage is maintenance. Once the bowel is empty, the laxative continues at a lower dose so that stools stay soft and regular and the stretched rectum can gradually shrink back and start sensing fullness again. This is where things fall apart most often: stools settle, the parents stop the medicine, and within a couple of weeks everything returns. Maintenance treatment lasts months, sometimes more than a year, and it is reduced gradually and on the doctor's decision, not as soon as things look better. Osmotic laxatives are designed for exactly this: they do not “get the bowel used to tablets” and they do not stop working.
In addition, the doctor may suggest emptying the rectum directly if medicines by mouth have not been enough. Referral to a specialist is considered when treatment is not working or another cause is suspected.
What to do at home every day
- Regular sitting on the potty or toilet after meals — the most important of the home routines. After breakfast and after the evening meal, for 5 to 10 minutes, every day, whether or not there is an urge. After eating, the bowel pushes its contents downwards of its own accord, and that is worth using.
- A comfortable position: feet flat on the floor or on a step stool, knees a little higher than the hips, back relaxed. With the feet dangling, straining is awkward and ineffective.
- Do not let sitting become a punishment: a book or a quiet game alongside, and never “you are staying there until you do it”.
- A diary: note each day whether there was a stool, what it was like, how many times the pants were soiled, and what dose was given. It is tedious for exactly the first week; after that it is the thing that shows the doctor whether the dose is working, and shows the family that there is progress.
- Drink enough through the day and eat vegetables, fruit and cereals. This is support, not treatment: diet alone will not clear accumulated stool, and adding fibre abruptly while the bowel is still loaded increases pain and bloating. The laxative comes first; diet goes alongside.
- More movement and ordinary play outdoors.
- Spare pants and wipes to hand — and no drama around them.
How long it takes and what counts as a setback
Expect months. The first changes are usually visible within a week or two, but the sense of urge returns slowly: the rectum needs time to shrink back to its normal size. While that is happening, the soiling decreases gradually and unevenly.
Setbacks are a normal part of recovery rather than a failure. They are triggered by an illness with a fever, a trip away, the holidays, a change of toilet, the start of the school year, any disruption of routine. At the first signs — stools scarce or hard again, marks in the pants again — do not wait: go back to the previous dose and the sitting routine, and contact the doctor. Picking treatment back up early takes days; leaving it takes months all over again.
When to seek help without waiting
Some signs mean a laxative and watchful waiting are not enough. Have the child seen by a doctor, and in an acute situation call an ambulance — in Spain, Italy, Portugal, Poland and Ukraine on the single European number 112:
- constipation or soiling from the first months of life, in an infant, or in a child who has never been continent;
- no stool in the first days after birth (meconium not passed) — a start like that means a congenital bowel disorder has to be looked for;
- a distended abdomen and vomiting, especially green vomit, refusing food, severe pain that does not let up — this may be an obstruction;
- blood that is not a streak on the surface but present in quantity, or dark blood mixed through the stool;
- weight loss, faltering growth, listlessness, pallor, a fever that persists;
- weakness in the legs, a change in the way the child walks, a dimple, a tuft of hair or a patch of skin over the base of the spine, urine leaking along with the stool — grounds for looking at the spinal cord;
- treatment has been prescribed and is being followed, and after several weeks nothing has changed.
If the child was reliably clean and has started soiling again
Soiling that appears for the first time in a child who has managed without it for years is looked at separately and more closely. Here too the commonest cause is constipation that went unnoticed: it may have set in after an illness, a trip, a course of antibiotics, or simply because the child stopped using the toilet at school.
But the range of causes is wider. A start like that can have a neurological cause, which is why weakness in the legs, a change in walking and urinary leakage matter. It can also follow something hard to live through, or a change in the child's life — a separation, a move, bullying at school, a new baby. And sometimes there is abuse, including sexual abuse. It is an uncomfortable thought, and the great majority of cases have nothing to do with it, but the possibility must not be passed over. If a doctor asks about the circumstances of the child's life, that is not suspicion directed at the family but part of a check that has to be made.
Tell the doctor plainly if the child has become afraid of particular people or places, has withdrawn, has changed behaviour abruptly, or if there are complaints, pain or injuries in the genital and anal area.
Online consultation
This is easier to start talking about away from a consulting room, particularly when the child feels embarrassed. Remotely you can go through the history day by day: how often there is a stool, what it is like, what the soiling looks like, what has already been tried, whether there is holding behaviour. The doctor will help separate constipation from other causes, explain the treatment plan and what to do about the increase in soiling during the first stage, suggest how to set up the diary and the sitting routine, and name the signs that call for examination or urgent care. At follow-up it is convenient to adjust the dose from the diary, and that rarely needs an appointment in person.
This material is for information only and does not replace medical advice.
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