Kathy wrote in about her son: “What can cause a 9-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.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.