Cats, Kids, and Megacolons with Encopresis
This is a prolonged essay, but it was fun writing because I managed to get out many of the factors that are involved in chronic encopresis. Also, it is a memorial to our former beloved cat. DrC.
The Role of Stress for a Megacolon with Encopresis:
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 buildup of dried putty or stone-like stool resulting in painful bowel movements and an enlarged colon. That is our cat pictured here who we toilet trained. Look closely and you will spot his stool in the bowl! He did not form a megacolon during toilet training. Kids are exposed to considerable stress during certain times, especially during toilet training, which can result in severe holding and bathroom avoidance.
Children are especially subject to forming a megacolon over the course of toilet training. The second most likely onset is with the start of school or with prolonged periods of stress such as parents in prolonged and deep conflict. 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” for soiling, but it is not. Indeed, it may even drive the problem deeper because it is so convenient. The children may become even more stressed to later demands to sit on the toilet stool. Children who “hide” to poop even in their diapers are at an additional risk for a megacolon and encopresis.
Dr. Steve J. Hodges, a Pediatric Urologist, and author of It’s No Accident. believes that too much emphasis and early training can promote encopresis and enuresis. That could well be true, but toilet training is being more delayed today and the issue continues to persist. Also, I get many parents who report strong “holding” with considerable accompanying distress long before toilet training.
Physical Factors and Complications in Megacolon:
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 much 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. This can become “dysnergia” or “functional fecal retention” where the child is unable to coordinate lowered sensory urge recognition with the proper sequence of anal sphincter and pelvic floor relaxation when sitting on the toilet. This can become so entrenched and automatic that it is NOT UNDER VOLUNTARY CONTROL. Parents and too many doctors can see all of this as representing willful behavior, which it is not. 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 megacolons are frequently associated with difficulty in bladder control because of the mixing of pressure cues, pelvic floor dysfunction, and added pressure throughout the abdominal region. 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.
A prolonged megacolon can result in months of recovery or even lead to physical damage to the colon because it can be so weakened that urge recognition and the actual physical force to move the foodstuff to the rectum can become severely compromised. Dr. Levitt at the Nationwide Children’s Hospital in Columbus, Ohio reports a portion of the colon may have to be removed for teen-agers. So much for the cavalier notion that your child “…will grow out of it.”
A megacolon in cats was, and often still is, generally viewed as a fatal condition. More recently enemas and surgery have been employed with success when coupled with the patience and deep devotion of some modern families to their pets.
The Conflict between Oral and Bottom Up Medications for Reversing a Megacolon and Encopresis:
I am a major critic of the standard top down pediatric approaches when they fail after 6 months of application with no remission of soiling, Encopresis is itself more damaging in reality than all of the speculations and fears of using bottom up medications based on unexamined cultural taboos. 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 leaving them to believe that they have successfully treated the child. 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 Garden Hose Analogy for Developing a Megacolon with Encopresis:
The GI tract is similar to a garden hose, except that it is living tissue and can induce more or less coordinated large wave-like actions (peristalsis) to propel foodstuff along its length of 33 or so feet (in the adult). In some fairly rare instances that propagation can be quite slow with very uncoordinated small wave contractions resulting in a slow-transit disorder (STC). This would naturally lead 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. Also, a diagnosis of STC does not mean a change in treatment recommendations. 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.
Now 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 irrelevant reinforcement strategies when they clearly are not working.
Observations Critical to Understanding and Treating a Megacolon with Encopresis:
Holding or dysnergia leading to the complications of a megacolon is a much more likely account for most children with encopresis. It can be diagnosed from a fairly simple history and reports from the parents. Children are not reliable reporters in this area. Parents are funny; they can view their child’s words as insights to ultimate truth. Children have “theories”, but they are very colored by immaturity, a lack of language, and motivated or emotional reasoning to please or fend off their parents. The parents themselves with their implicit “theories” do a lot of distorting in translating their child’s reports. There is a great need for a more consistent and scientific theory which parents expect from their physicians.
The holding and resultant drying out of stool can lead to painful voiding, which can result in a vicious cycle of pain–more holding–more pain–more holding–more pain. The withholding, anxiety, stubbornness (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. This enlarges the colon even more. 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 voiding 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! Oh yes, there is the brain’s role that must be employed to gain new and different connections for successful voiding! We have to use a scientific theory of learning to succeed.
The Medical Source for Physicians’ Fears and Biases about “Bottom Up” Medications to Treat Megacolon and Encopresis:
The original authors of today’s standard “top down” pediatric approaches referred to the use of suppositories and enemas as “anal assault” in two prestigious medical journals: Melvin D. Levine, et. Al., The American Journal of Diseases of Children, July 1980 (Vol. 134, Pp 663-667) and Melvin D. Levine, Pediatic Clinics of North America, April, 1982 (Vol. 29, No.2, Pp 315-330)? 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!
If the membrane of the GI tract becomes weakened, thinned, and bulging it will become less efficient at propelling the foodstuff downward. The foodstuff 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 (dysnergia)–this aspect has to be trained and conditioned using special techniques, which I have developed when standard pediatric techniques fail.
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 voiding 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 bottom up “primers”. All too often parents are left pretty much on their own and become discouraged dropping out of treatment or no longer brings the problem up. The physicians may also experience frustration and distress over the continuing problem and parental pressures for results. The parent (most typically the mother) has to deal with upset schools, child care personnel, and distress and conflict within the family unit.
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 sub-mucosal 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! When the child coughs, sneezes, jumps, laughs there is often a transient squirt, oozing, poop pebble accident! Is it any wonder that your child continues to “hold” under any and all circumstances, but cannot always succeed!? 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 Soiling Solutions treatment.
Diet Magic for Megacolon and Encopresis:
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. This can delay effective and timely treatment. Enter my CAT.
Learning from My Cat and Avoiding a Megacolon:
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! I was stalking him! 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!
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, though children at toilet training time should have regular and predictable meal times. ! 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 child’s 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 that eating times are more random and hurried. 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 Soiling Solution approach insures that the gastrocolic reflex will occur and soiling ceases in 80-90 percent of the cases within two weeks!!!
Making Bowel Movements More Powerful and Predictable to Avoid a Megacolon and to End Encopresis:
OK, OK, you may have read before you got to this section that my method uses the application of suppositories and 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. This (typically) empties the colon enough so that the child is free of accidents until the next daily treatment hour. 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 Clean Kid Manual. The manual and joining the exclusive Soiling Solutions parents’ Forums remain keys 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.
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”.