Constipation and soiling

Very common

Less common

Soiling (encopresis) is the most misread sign of all. Parents and teachers often think the child is having diarrhoea, or being lazy, or doing it on purpose. It is neither. Softer poo from higher up seeps around the hard, impacted mass and leaks out — the child usually cannot feel it happening and cannot control it. Soiling is a sign of severe constipation, not of naughtiness.

• Get an accurate assessment first

  Your GP, health visitor or school nurse can feel the tummy and take a history to work out whether the rectum is loaded. Treatment for impaction is very different from a mild, one-off episode.

• Disimpaction: a planned, escalating course of macrogol

  This clears the backlog. Doses start low and increase over several days under GP guidance. Expect it to get messier before it gets better — a big volume of soft poo is the sign it is working, not the sign it has gone wrong.

• Then maintenance: a daily dose, every single day, for months

  This is the part that actually heals it. Keeping stools soft and the rectum empty lets the stretched muscle and nerves recover. NICE guidance is to continue for several months after a regular pattern is established, then reduce slowly — never to stop abruptly.

• Titrate the dose to the poo, not to the packet

  You are aiming for soft, easy, sausage-or-porridge consistency (type 4 on the Bristol chart), most days, without pain. If poos are hard, the dose is too low. If they are watery, it is too high. Your prescriber will expect you to adjust within the range they give you.

• Never stop the moment things improve

  The most common reason children relapse is stopping early. Things looking normal means the medicine is working, not that the rectum has recovered its size and sensation.

• Toilet sits after meals, 5 minutes, three times a day

  The gut naturally pushes after eating (the gastrocolic reflex). Regular, unpressured sits use that reflex and rebuild the habit.

• Feet flat on a step stool, knees above hips

  A squat position relaxes the puborectalis muscle so the poo can come out without straining. Dangling feet make it mechanically harder.

• Reward the sitting, not the pooing

  Your child can control turning up. They cannot control whether a poo arrives. Rewarding the sit removes the pressure and the sense of failure.

• Water, movement and fibre — as support, not as the cure

  Fluid and activity genuinely help keep things moving. But once the rectum is loaded, no amount of pears and prunes will clear it. Diet supports treatment; it does not replace it.

• Take the shame out of soiling entirely

  Explain it in plain words: 'Your poo tube got stretched and can't feel properly yet. This isn't your fault and the medicine is helping it get better.' Keep clean pants in the bag, change without comment, never punish an accident.

• Tell school and agree a quiet plan

  Many children hold on all day because school toilets feel unsafe, dirty or public. A discreet toilet pass and a spare-clothes bag removes the main daytime trigger.

• Keep a simple diary

  A tick chart of dose, poos and accidents shows the real trend across weeks and gives your GP something concrete to adjust the plan on.

• Stopping laxatives as soon as poos look normal

  This is by far the biggest cause of relapse. The rectum needs months of being kept empty to regain tone and sensation.

• Giving a dose only 'when they need it'

  On-and-off dosing lets the cycle re-establish between doses. Maintenance only works when it is daily and boring.

• Worrying that laxatives are addictive

  Macrogol is an osmotic, not a stimulant. It doesn't make the bowel lazy. Under-treating out of this worry keeps children in pain for months longer than necessary.

• Treating soiling as a behaviour problem

  Telling off, shaming or sticker-charting accidents adds distress to something the child cannot feel or control, and often makes them hide poo and hold on more.

• Fibre-only approaches for an impacted child

  Adding bulk on top of a blockage can increase pain and bloating. Clear first, then support with diet.

• Pressure and negotiation at the toilet

  Sitting there being asked 'have you done one yet?' makes the whole area tense — including the pelvic floor.

• Only using suppositories or enemas to 'clear it out'

  They can be part of specialist treatment, but on their own they clear the backlog without changing anything that caused it.

These are gentle observations, not blame. None of us avoid all of them all of the time.

• “Your tummy has been holding on to too much poo, and that's why it hurts. The medicine makes it soft so it doesn't hurt any more.”
• “The accidents in your pants aren't your fault. Your bottom can't feel it yet. It's getting better.”
• “We're going to sit after tea for five minutes. You don't have to do anything. Just sitting is the job.”
• “Feet on the stool, tummy soft, blow the candle out.”
• “I know it looks better now. We keep taking the medicine so the stretchy bit inside can heal properly.”
• To school: “She has a medical bowel condition and is being treated. She needs to be able to use the toilet whenever she asks, no questions.”

• Myth: laxatives are addictive and make the bowel lazy. Osmotic laxatives simply hold water in the stool — the bowel recovers because of them, not despite them.
• Myth: soiling means the child is doing it on purpose. It is overflow around impacted poo, and the child usually cannot feel it.
• Myth: once they're pooing normally you can stop the medicine. Stopping early is the number one cause of relapse.
• Myth: more fruit and water will fix it. Diet helps prevention, but it cannot clear an impacted rectum.
• Myth: a daily poo means they can't be constipated. Small, hard or incomplete poos can coexist with a loaded rectum.