Fecal incontinence in children

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 19 Apr 2025

Last updated: 09 Aug 2022

Fecal incontinence in children is defined as involuntary defecation at inappropriate times, occurring after the typical age of completed toilet training (generally 4 years of age or older).

In most cases, caused by overflow soiling associated with chronic constipation and severe fecal impaction in an otherwise healthy child without underlying anatomical abnormalities.

May have a significant negative impact on the quality of life for the child and the family.

A thorough history and physical examination are the crux of diagnosis. Laboratory and radiological studies may be used on a case-by-case basis to determine the underlying etiology.

The goal of therapy is for patients to pass stool 1 to 3 times per day in the toilet with no episodes of soiling.

Treatment involves complete colon disimpaction, long-term treatment with laxatives and stool softeners, and bowel re-education. Any underlying causes should also be addressed.

Definition

Fecal incontinence in children is the involuntary passage of stool from the rectum through the anus resulting in episodes of stooling at inappropriate times, occurring at an age after which toilet training is typically complete (in most, 4 years of age or older).

History and exam

Key diagnostic factors

history of anorectal, neurologic, or spinal abnormalities, or gastrointestinal surgery
fecal soiling or diarrhea
constipation
perianal skin irritation
abnormal rectal examination
spinal deformities
weakness and decreased or absent reflexes

Full details

Other diagnostic factors

behavior problems
painful bowel movements
abdominal pain/cramping
posturing described as tightening of buttocks
enuresis
anorectal malformation
abnormal abdominal examination
history of underlying medical condition

Full details

Risk factors

chronic constipation
male sex
age: 5 to 6 years
diet lacking in fiber
inadequate fluid intake
delayed or inadequate toilet training
anorectal malformations
Hirschsprung disease
spinal abnormalities
psychological or behavioral problems due to stressful family events
psychiatric disorders
medication overuse

Full details

Diagnostic tests

1st tests to order

abdominal x-ray

Full details

Tests to consider

unprepared barium enema
spinal x-ray
MRI spine
radiopaque marker transit radiograph
colonic and rectal manometry studies
rectal biopsy
serum thyroid-stimulating hormone level
serum free thyroxine (T4) level
sweat chloride test
tissue transglutaminase IgA

Full details

Treatment algorithm

ACUTE

with constipation and fecal impaction

without constipation

ONGOING

fecal impaction resolved

Contributors

Authors

Brian D. Riedel, MD

Clinical Associate Professor of Pediatrics Emeritus

Pediatric Gastroenterology, Hepatology and Nutrition

West Virginia University School of Medicine

Morgantown

Disclosures

BDR declares that he has no competing interests.

Acknowledgements

Dr Brian D. Riedel would like to gratefully acknowledge Dr Linda S. Nield and Dr Uwe Blecker, previous contributors to this topic.

Disclosures

UB declares that he has no competing interests. LSN is an author of a reference cited in this topic.

Peer reviewers

John C. Thomas, MD

Assistant Professor

Division of Pediatric Urology

Monroe Carell Jr. Children's Hospital at Vanderbilt

Nashville

Disclosures

JCT declares that he has no competing interests.

David C. A. Candy, MBBS, MSc, MD, FRCP, FRCPCH, FCU

Consultant Paediatrics Gastroenterologist

Western Sussex Hospitals NHS Trust

Chichester

Honorary Consultant Paediatric Gastroenterologist

Royal Alexandra Children's Hospital

Brighton and Sussex University Hospitals

Brighton

Disclosures

DCAC has received research grants, consultancy fees, and reimbursement of conference expenses from Norgine UK, the manufacturer of Movicol. He is the author of a systematic review of polyethylene glycol-based laxatives; convenor of the Paris Consensus on Constipation Terminology Group; and external advisor of the National Institute for Health and Care Excellence pediatric constipation guideline development group.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Hyams JS, Di Lorenzo C, Saps M, et al. Functional disorders: children and adolescents. Gastroenterology. 2016 May;150(6):1456-68. Abstract

Levitt MA, Pena A. Anorectal malformations. Orphanet J Rare Dis. 2007 Jul 26;2:33.Full text Abstract

Bongers ME, Tabbers MM, Benninga MA. Functional nonretentive fecal incontinence in children. J Pediatr Gastroenterol Nutr. 2007 Jan;44(1):5-13.Full text Abstract

Abrams P, Andersson KE, Apostolidis A, et al. 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. Neurourol Urodyn. 2018 Sep;37(7):2271-2.Full text Abstract

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Nonspecific toddler's diarrhea
- Irritable bowel syndrome (IBS) with alternating constipation and diarrhea
- Infectious diarrhea
More Differentials
Guidelines
- Constipation
- Sixth International Consultation on Incontinence recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence
More Guidelines
Patient information
Constipation in children
More Patient information
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Fecal incontinence in children

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

with constipation and fecal impaction

without constipation

fecal impaction resolved

Contributors

Authors

Brian D. Riedel, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

John C. Thomas, MD

Disclosures

David C. A. Candy, MBBS, MSc, MD, FRCP, FRCPCH, FCU

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice