The laundry that never ends, the constant stress, and the worry about your toilet-trained child who still has accidents in their underwear. One of the hardest and most stressful things for parents to deal with is encopresis, or soiling. People often think it's a behavior problem or an act of rebellion. But most of the time, encopresis is an involuntary medical problem that happens when someone has severe, long-term constipation. To fix this, you need a medical partner who has the time to give you thorough education and a management plan that is patient, supportive, and ongoing. The Direct Primary Care (DPC) model is best at this.
Encopresis is when a child who is four years old or older keeps pooping in their underwear or other places where it shouldn't go. It is a common problem that affects up to 4% of kids in school.
The main reason is chronic constipation and overflow incontinence.
Encopresis is not a voluntary or defiant act in more than 90% of cases. It happens because of a physical mechanism that is part of a vicious cycle:
A child holds back their poop, usually because they had a hard, painful bowel movement in the past.
Over time, a big, hard piece of poop builds up and gets stuck in the rectum.
The rectum stretches out like an old sock, losing its normal muscle tone and, most importantly, its ability to feel nerves.
New, watery stool from higher up in the colon can't get past the hard mass, so it leaks around it and into the child's underwear.
The child frequently lacks sensation regarding this leakage and is unable to regulate it. It is a real case of overflow incontinence. The most important thing for any family to do first is to realize that this is a medical problem, not a behavioral one.
Direct Primary Care (DPC) is a membership-based model that lets families talk to their doctor as much as they want. The DPC model is a game-changer for a condition like encopresis that needs a lot of education and long-term follow-up.
This is why DPC is the best option for this condition:
The Strength of Learning: Removing the stigma from the problem:
This is the most important thing your DPC doctor does.
A Visit That Isn't Rushed and Explains: Your doctor needs a lot of time to sit down with you and your child and explain the overflow mechanism, which they can do with a simple pen-and-paper drawing.
Changing the Way You Think: This education changes lives. It turns a "behavioral problem" that is hard to fix into a "medical problem" that can be fixed. This makes parents less angry, takes away the child's shame, and sets the stage for successful treatment by making it a positive, cooperative experience.
A Treatment Plan That Is Easy to Follow:
Your DPC doctor can make the whole evidence-based protocol and take care of it themselves.
Phase 1: The "Clean-Out." They will give you a clear, written plan for the first step of disimpaction, which is to get rid of all the hard, stuck stool in the colon.
Step 2: Long-Term Care. They will be in charge of the most important part of treatment: giving a daily osmotic laxative (like polyethylene glycol/Miralax) for many months to keep the stool soft. This will let the stretched-out rectum heal and shrink back to its normal size.
Step 3: Behavioral Therapy. They will show you how to set up a schedule for "toilet sits" (usually after meals) and how to use positive reinforcement strategies in a way that works.
Follow-up that is close and easy to get to for sure success:
To deal with encopresis, you need to talk to the person often and change their medications.
A High-Touch Method: DPC is easy to reach by phone, text, or quick visits, which is great for the close follow-up needed to adjust the daily laxative dose.
Ongoing Help: This constant support gives the family hope, helps them solve any problems that come up, and makes sure you stick with the plan long enough to get a permanent cure.
Case 1: David's parents are at their wits' end with his daily accidents of soiling himself. The family's DPC doctor spends 45 minutes with them, using a whiteboard to explain what retentive encopresis and overflow incontinence are. The parents have a "aha!" moment and finally realize that David isn't being disobedient. The doctor makes a detailed plan for cleaning and upkeep. The doctor helps the parents find the right amount of laxative by texting them every other week to check in. The accidents have stopped for good after four months.
Case 2: Maria, 7, is having a hard time with her encopresis treatment, and her mom is angry. She calls her doctor at DPC. The doctor sets up a telehealth visit with just the mom to talk about a new way to reward her child for using the toilet, such as with a sticker chart and a "prize box." This behavioral coaching and support helps the family get back on the right track.
Q: Is my child doing these things on purpose?
A: Almost definitely not. In more than 90% of cases, the soiling is caused by involuntary overflow incontinence. The child may not be able to feel the liquid stool because it leaks out around the large, hard stool mass in their rectum. They are probably just as lost, angry, and embarrassed as you are.
A: But my child goes to the bathroom every day. How could they be constipated?
A: A lot of people get this wrong. A child can have a bowel movement every day (or even more than once a day) and still be very constipated. They might only be passing the new, liquid stool that is leaking around a very large, old, retained stool mass that never comes out.
Q: Why does my kid need to stay on a laxative for so long if they aren't constipated anymore?
A: This is the most important part of the treatment. The long-term maintenance phase's goal is not just to keep the stool soft, but also to give the rectum time to shrink back to its normal size and get its nerve sensation back. This process of healing takes at least a few months, and usually 6 to 12 months or longer. The most common reason for treatment failure and relapse is stopping the daily laxative too soon.
DPC has a clear advantage for this common but very stressful condition because:
Giving the Necessary Time for Education and De-stigmatization: Long appointments with the DPC model are important for explaining the overflow mechanism to families, which is the key to all successful treatment.
Doing well at high-touch, long-term management: DPC is easy to get to and stays the same, which is great for the close follow-up and frequent medication changes that are needed to get through the months-long maintenance phase.
Lessening Family Stress and Unneeded Referrals: DPC can bring peace back to your family and keep most referrals to a pediatric GI specialist from happening by expertly and compassionately treating this common condition in the primary care setting.
One of the most stressful things a family can go through is having to do laundry all the time and deal with accidents that happen. But your child isn't being bad; they're dealing with a real medical issue that has a clear answer. A patient, supportive partnership with a doctor who has time to teach, guide, and encourage you is the way to success. Direct Primary Care can help you fix this problem and bring peace back to your home by giving you the kind, hands-on care you need.
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