Soiling Solutions

Cats, Kids, and Megacolons:

WARNING: A recent research report out of the Netherlands (see our scientific articles page) indicates that the rectum can become overly stretched and weakened from a megacolon such that the standard "top down" pediatric treatment may be rendered ineffective. In my opinion encopresis should not be allowed to continue indefinitely. Even children recovering under the standard pediatric approach may continue with distended rectums at 4 years follow up. The more aggressive Soiling Solutions protocol using suppositories and enemas with proper timing is well indicated at an earlier time to prevent this consequence. Continuing "maintenance therapy" with cavalier assurances that your child "...will grow out of it." is not a solution and only results in corroding your child's well being and your family life. DrC.

My article, Soiling Solutions(R): An Internet and Manual Based Approach to Treating Encopresis was published in the Spring, 2009 issue of "Digestive Health Matters," a publication of the International Foundation for Functional Gastrointestinal Disorders. It warranted a special Editorial Comment by Paul E Hyman, MD, a leading Pediatric Gastroenterologist. A reprint may be requested by email. My contact information is on this website at the bottom of all of our pages. RWC.

Oddly enough, cats and kids are especially subject to enlarged colons or megacolons. Cats are very easily stressed and may hold stool for prolonged periods before feeling that it is "safe" to poop. Holding back stool repeatedly can result in a build up of stool, drying out of stool with reabsorption, painful BMs,and and an enlarged colon. That is our cat above who we toilet trained. Look closely and you will spot his stool in the bowl! Cats are especially subject to stress and they are not easy to train for any behavior, period. You have to be very careful and sensitive. For our children a megacolon is most likely to occur over the course of toilet training. The second most likely onset is with the start of school or with prolonged periods of stress. Another risk factor is with children who are overly used to going in pull-ups and diapers. Parents may believe that this is a "solution," but it is not. Indeed, it may even add to the problem because it is so convenient and the children may become even more resistant to later demands to sit on the toilet stool. Children who "hide" to poop even in their diapers are at an additional risk. Incredible levels of conflict occur for everyone concerned in trying to deal with a very foul and repugnant body waste product which society is rightfully concerned about. It is literally a biohazard in spreading disease and resulting in urinary tract infections (uti's) and rashes with skin breakdown. Every now and then you will even see a newspaper report on child abuse or even the murder of a child who is soiling. The number two reason for nursing home placements for the elderly is for fecal incontinence so it is an issue at both ends of our lifespan.

The colon is that part of the large intestine above the rectal vault. "Mega" is Greek for "giant", and we all know that there is a medical tradition of using Greek in medical terminology. We may also recall that the explosive power of atomic or hydrogen bombs is so huge that the bombs are rated in megatons, with mega coming to represent a thousand fold rating for a ton of explosive TNT. A megacolon then is a very enlarged colon that results from "outlet obstruction" or a reflexive fear or habit of clamping up against voiding. This is sometimes called "stool-hoarding" on the part of children. Most recently, the term, Rectal Anal Inhibitory Response (RAIR), has shown up in the medical literature which is now regarded as an overconditioned response that can occur even under anesthesia! This response is NOT UNDER VOLUNTARY CONTROL. This backing up and resultant expansion of the colon results in a drying up of the stool and constipation. Obstipation is a term used to describe severe constipation. Fortunately, a megacolon does not refer to explosive power, though in a way it could! Rather the danger is in terms of a possible rupture of the colon and a resultant internal massive infection resulting in death. Fortunately, this is very rare. There have been recorded cases of children with up to half of their body weight in feces! In a sense then some leakage or encopresis could even be viewed as helpful in terms of reducing or leaking off excessive pressure. Maybe this is why physicians seem almost, at times, to be insensitive to problems of bowel leakage when they urge the use of "top down" oral laxatives and stool softeners (e.g., Miralax, lactulose, Milk of Magnesia=MOM, mineral oil, Senna, etc.)! But, they should also be concerned that leakage that comes with overly softening the stool would increase the likelihood of a bladder or even kidney infection, especially in girls where the anal canal and urethra are closer together than for boys.

Another complication is that megacolon is frequently associated with difficulty in bladder control because of the mixing of pressure cues, pelvic floor dysfunction, and added pressure throughout the abdominal region. So, previously bladder trained children, which is quite normal, may lose bladder control (enuresis) with bowel control difficulties (encopresis). This is a double whammy for parents. Clearly, medicine must come up with effective interventions for bladder and bowel control with an emphasis on encopresis. The earlier bowel control is achieved, the less likely an enlarged or megacolon may result and be avoided altogether.

I am a major critic of the standard "top down" pediatric approaches when they fail after 6 months of application with no practical results, especially when a perfectly acceptable alternative in the form of the Soiling Solutions manual-based protocol is available and could receive support from informed physicians or psychologists. These health professionals must first overcome their own biases in providing support to families who are caught up in cultural resistance and fears of abusing their children with the application of the perfectly appropriate medical use of over-the-counter properly timed "bottom up" suppositories and enemas. There is a complicity in encouraging the continuation of an ineffective treatment which only perpetuates failure. I get way too many older and damaged children who finally find their way to me by frustrated parents discovering this website. I suspect that many families give up on their physicians and just drop the issue leaving the physicians to believe that the issues have been resolved! Repeated and persisting failure is not a legitimate option! Parents need support and instruction by the professionals, that is why they are professionals!

OK, pardon my editorializing. My toilet trained cat (e.g., trained to go on a standard human toilet stool) was a demonstration for avoiding the problem and also a demonstration of the power and the sensitivity of my training techniques for an organism that is very, very easily stressed and not typically thought of as very trainable. Litter training cats of course is natural and easy, just as it is easy for kids to go in diapers or pull ups! Switching cats or kids to a toilet is where the rub comes in! Training dogs to go outside and not inside is a breeze by comparison! Dogs are very obedient and anxious to please by contrast to cats (or kids?). Latrine behavior is important for us and our pets for obvious reasons. Horses and cows don't have this issue, they just go whenever, wherever in their stalls or pastures!

The GI tract is similar to a garden hose, except that it is living tissue and can induce more or less coordinated wave-like actions (peristalsis) to propel foodstuff along its length. In some fairly rare instances that propogation can be quite slow or very uncoordinated resulting in a slow-transit disorder (STC), which naturally leads to constipation as moisture is absorbed into the surrounding body tissues. It is fairly rare that physicians will view the encopresis as being due to slow-transit and even assess for that possibility. The causes for a slow-transit problem would likely be fairly physiological in origin, but the mechanisms are not particularly well understood or easily corrected. I cite a number of studies on slow-transit disorders on my references page (click here). By contrast, an outlet obstruction is much more likely. It can be diagnosed from a fairly simple history and reports from the parents. Children are not reliable reporters in this area. The holding and resultant drying out of stool can lead to painful voidings, which can result in a vicious cycle of pain--more holding--more pain--more holding--more pain. The withholding, anxiety, stubborness (resistance to commands), and even anger may become so overlearned and reflexive in nature that the child will have no insight or control over it (the RAIR scenario). The emotional component may become much less obvious over time. Parental encouragement, promises, threats, and appeals to choice and willpower will have no effect. Only successful and daily voidings will result in softer stools, confidence, and trust over the process of sitting and going. How can this be arranged without delay so that the GI tract can return to normal? Also, can you at the same time train the opposite of "holding", i.e., "releasing" while sitting on the toilet stool? These children have been literally and paradoxically trained for months to "hold" on the toilet! The problem is the "gate" or "lock" at the bottom of the GI tract, not the top of it! The idea that the child will magically be cured when their megacolon returns to normal approaches neglect or malpractice!

Oh dear, more editorializing! But, did you know that the original authors of todays standard "top down" pediatric approach referred to the use of suppositories and enemas as "anal assault" in two prestigious medical journals? Unbelievable! More recent medical reports have documented how pediatricians have become more inhibited in conducting thorough examinations of children with encopresis. A clear majority of two thirds will not conduct a digital (finger) exam which is critical to checking on stool and the sphincter (gate) mechanism. Pediatric gastroenterologists do this as a regular part of their initial examination. I guess I am lucky that I am a psychologist and cannot be expected to do this!

Back to some basic physiology. Think of a garden hose with a section of thinned wall somewhere along its length. As long as a nozzle at the end of the hose is left open the water will flow easily and naturally. But, close the nozzle and you will get a bulge in the hose where the wall is thin and you will get a "megahose"! This stretched out, weakened section becomes much less capable of moving foodstuff and even results in tissue/cell damage. Here the metaphor will break down because our GI tract is alive and the nozzle at the end does not completely shut off, it will tend to leak if the pressure build up becomes too great. Also, the contents of the hose is not just water, it may be more or less putty-like or liquid-like. If held sufficiently long it can become like dried out putty or concrete! This is serious, and a basis for this author's distress over continuation of the standard treatment protocol of stool softeners, repeated sits, and reinforcement strategies when they clearly are not working. They are worthy of an initial intervention, but should default to the Soiling Solutions protocol when they fail.

Here are some observations critical to understanding and treating a megacolon:

1. If the membrane of the GI tract becomes weakened, thinned, and bulging it will become less efficient at propelling the foodstuff downward. The foodstuff (OK-"Poop")will tend to get "stuck" and dry out in the bulging area and even block the stool, except for that which may leak around it because of all of the pressure that builds up. The nozzle at the end, because it is live tissue, will tend to become fatigued and weakened staying in a slightly more open position fostering more leakage. Lately, I have been hearing more medical-like sounding terms such as "lowered bowel tone" and "lower internal anal sphincter tone" to describe the megacolon and the leaking sphincter at the end. The "internal anal sphincter" is the inside layer of muscle along the anal exit and it is typically in a light, passive, tonic state of resistance, which is ordinarily sufficient to prevent leakage. Especially, if the stool is well formed and has some solidity to it (not too much). The external anal sphincter, which is the outer layer of the double-sleeved like muscle arrangement along the anal exit, is under voluntary control, but it fatigues quickly and can sustain closure only for seconds, until you can get to the toilet. If the stool is fairly liquid the child may always be fighting the sensation of leaking, but he is often not aware of this because only his lower brain centers are reacting and they are doing so automatically. In fact, we are all socialized and conditioned to clamp up that external anal sphincter to have control over our feces and hold it until we have a safe time and place to "let go". It is almost like a poker game, you have to learn when to "hold them" and when to "fold them". Encopretic children essentially are always holding back and fearful or resistant to letting go! Their essential problem is too much holding and not knowing how and when to let go--this aspect has to be trained and conditioned using special techniques, which I have developed when standard pediatric techniques fail.

2. The traditional pediatric solution is a very reasonable biomechanical idea. Keep the stool more liquid and ease its passage with Miralax, laxatives, mineral oil, etc. so that passage is easier. So what if there is a little leakage? Give it up to a year and the walls of the hose will repair and get stronger and become more efficient and then the child will somehow magically gain control. Somewhat more sophisticated physicians may urge sittings at various times in the day to try and catch the child for pooping and relieving pressure. Often nurses or physicians may urge that parents keep star charts and "reinforce" the child for any successful voidings and ignore or disapprove of accidents. I prefer utilizing the natural reinforcers of "relief" and happiness and pleasure over successful poops which the Soiling Solutions approach assures by the use of timely and efficient "primers". All too often parents are left pretty much on their own and become discouraged dropping out of treatment or no longer bring the problem up. The physicians may also experience frustration and distress over the continuing problem and parental pressures for results. The parents are having to deal with school and child care disapproval or demands, their own frustration with odors and accidents, and over all distress and conflict within the family unit.

3. Keeping the stools more liquid may help with the megacolon, but it can also result in even more accidents. This is not just because liquid is more likely to leak, but because the sensations at the anal canal will be less easily detected if it is liquid. In fact, the submucosal membrane at the anal exit cannot discriminate between gas or liquid. Think of your own accidents or "oops" when you have diarrhea and realize that what you thought was going to be the passage of gas, was in error! Is it any wonder that your child continues to "hold" under these circumstances!? He/she does not want to disappoint you and yet everyone continues to lose when you don't change course! Your child will be more able, in time and with success, to discriminate well-formed stool at the end of his GI tract, which is a necessary and planned for result of our treatment.

4. Parents and physicians become obsessed with diet and sufficient fiber to promote well-formed stools, even while seeking to liquify stool for easier passage and to promote normal bowel tone and a return of the colon to a normal shape. Maybe I am being too cynical, but I think this is just buying more time in hopes of magic working. Everyone becomes very engaged in trying to find the perfect blends and acceptance by the child of just the right diet and fiber intake! I have lurked on encopresis discussion lists that just obsess over diet and getting mineral oil into their children. Somehow the assumption is that it will all work out and that training and learning will naturally "kick in" at some point. Enter my CAT.

5. My cat brought some lessons home even after I had developed my essential treatment protocol in the late 1970's in my clinical practice and wrote about it to some leading researchers in the early 1980's. Cats seek some privacy and calm in order to go in a litter box. When I began to attempt transitioning our cat to the toilet I discovered several things--I could not predict the most likely times he was likely to go and he became very suspicious of me following him everywhere with an eagle's eye! Guess what? Hiding behavior in children, when they need to void, is highly predictive of encopresis, even when they go in pull ups or diapers!

6. My cat had access to food all day long and so prediction for bowel movements became impossible because he would just "graze" or nibble all day long. I therefore restricted his feedings to a half-hour once in the morning and again in the evening. Boy was he friendly and cooperative when eating time came around! I am not recommending this for your child! This made prediction a snap--I just kept an eye on him during or after his feeding because his GI tract would activate and I could place him in the bathroom for his private time and focus my energy on training in a much more reasonable way and time period. Physicians who suggest sitting your child after a meal have the idea of this as the best time to take advantage of your childs most likely time for the urge to go and take advantage of his "gastrocolic reflex". The problem is that the "gastrocolic reflex" in children has become very scattered in time because of all the chronic pressure and urges he is experiencing a lot of the time anyway. Your child may be unpredictable, even with his meal times in today's busy culture. Children may have so many activities today. Also, it is best that the selected time after a meal be a quiet period for an hour or slightly longer. For most school age children the best time is usually right after school and a snack. They have been holding all day in school and likely avoiding the more public school bathrooms. They relax toward the end of the school day which causes a rebound overactivity of the GI tract promoting repeated and powerful gastrocolic urges. Hurrying and stress, any excitement, exciting computer games, and playing outside may well inhibit the "gastrocolic reflex". Finding a precious quiet time can be a real challenge for some families. The Soilings Solution approach insures that the gastrocolic reflex will occur and soiling ceases in 80-90 percent of the cases within two weeks!!!

7. OK, OK, you may have read before you got to this section that my method uses the application of suppositories and/or enemas at just the right times. I also discourage the use of all oral laxatives and complicated diets once my approach is initiated because we are assuring daily bowel movements with normal stools. Now, can't you see me chasing my cat around if I were using suppositories or enemas with him! Right, no way that would work. So my program is not easy or a quick magic solution for you to go to right away with your child. By all means try the standard pediatric approach if you want to, even use my manual for more knowledge and a better strategy on brief two or three minute sittings for your child during the best time period each day. But give up the usual approach if you wind up having to do intrusive "clean outs" anyway with powerful laxatives or suppositories or enemas. If you have to do clean outs, it is time to go to the Soiling Solutions bowel retraining approach. My approach will lead to weaning away from all laxatives, suppositories, and enemas much more systematically and quickly in any event! The training component is so much more effective and is described step by practical step in my very practical manual. The general approach and rationales are explained under the Clean Kid Treatment button above. It is all there, but my manual and joining the exclusive CKM parents' forum with its purchase remain key to success. The parents have proved to be a wonderfully supportive network for parents in assisting one another. Don't try to treat based on the information from this site; there is just too much information for you to process properly and apply. I only wish for you to be well-informed and make a wise decision on what is best for you and your child. RWC.

Cat lovers--sorry, my commitment is to children. I had earlier taken my cat's picture and information off of this website as it was getting too demanding of my time. J.R. lived to the ripe old age of 18 years and my wife and I decided that we did not want to take on a new pet obligation in order that we could enjoy the early years of our "retirement".

Soiling Solutions

an End to Encopresis!