Encopresis in Adults: Causes, Diagnosis, and Treatment

Encopresis, the involuntary passage of stool, is a term most clinicians reserve for children, but the underlying problem affects millions of adults under different labels. In adult medicine, the condition is usually called fecal incontinence or, when caused by a mass of hardened stool blocking the rectum, overflow incontinence secondary to fecal impaction. Regardless of what it is called, the experience is the same: uncontrolled soiling that can feel isolating and is often far more treatable than people realize.

How Common Is Adult Fecal Incontinence

National survey data put the prevalence of fecal incontinence among noninstitutionalized U.S. adults at roughly 8 percent, which translates to about 19 million people reporting at least one episode in the past month.¹ The rate climbs steeply with age, from about 3 percent in adults in their twenties to over 16 percent in those 70 and older.² Women are slightly more affected than men, but the gap is modest, and the condition crosses all racial, ethnic, and income groups without strong demographic skew after adjusting for age.¹ Those numbers almost certainly undercount the true burden, because shame keeps many people from mentioning symptoms to a doctor. Most leakage involves liquid stool, though solid-stool incontinence and mucus leakage each account for a meaningful share of cases.

Why Adults Develop Encopresis-Like Symptoms

In children, encopresis nearly always traces back to chronic constipation: the rectum fills with hard stool, the child withholds further, and eventually looser stool leaks around the blockage. The same overflow mechanism happens in adults, but the list of contributing causes is longer and often overlapping. Understanding the category of cause matters because treatment depends on it.

Overflow From Fecal Impaction

When a large, hardened mass of stool lodges in the rectum, liquid stool from higher in the colon seeps around the obstruction and leaks out. The person may feel like they have diarrhea when the real problem is severe constipation. Chronic constipation is a factor in nearly half of documented fecal impaction cases, and about 15 percent of affected individuals are hospitalized or institutionalized at the time of diagnosis.³ Immobility, dehydration, opioid use, and low-fiber diets are frequent contributors. Left untreated, impaction can lead to serious complications involving the intestinal wall, the bowel lumen, or surrounding structures.

Pelvic Floor Dysfunction

Dyssynergic defecation is an acquired coordination problem in which the muscles of the abdomen and pelvic floor fail to work together during a bowel movement. It affects up to half of people with chronic constipation and can set up the same overflow scenario described above.⁴ Rather than relaxing during a push, the pelvic floor muscles paradoxically tighten, trapping stool in the rectum. Over time, the rectum stretches and sensation dulls, making it harder to feel the urge to go and easier for overflow soiling to happen unnoticed.

Neurological Conditions

Any disease that disrupts the nerve pathways controlling the colon, rectum, or anal sphincters can cause fecal incontinence. Spinal cord injury is one of the most studied examples: chronic bowel problems develop in roughly 27 to 62 percent of people with spinal cord injuries, mainly because the brain’s control over the sacral nerves that coordinate defecation gets interrupted.⁵ Pudendal nerve damage, which can occur after prolonged straining, childbirth, or pelvic surgery, diminishes rectal sensation and allows stool to accumulate into an impaction that eventually produces overflow leakage.⁶ Multiple sclerosis, Parkinson’s disease, stroke, and diabetic neuropathy are other common neurological contributors.

Cognitive Decline and Immobility

Not all fecal incontinence stems from a physical problem with the bowel or its nerves. Functional incontinence occurs when someone’s cognition or mobility prevents them from getting to the toilet in time, even though their bowel and sphincter are structurally intact. Dementia is a major driver in older adults, and the two mechanisms, neurogenic and functional, frequently coexist in the same person.⁷ In institutional settings, immobility compounds the risk because inactivity slows colonic transit, promotes impaction, and limits the person’s ability to respond promptly to the urge to defecate.

How the Problem Is Diagnosed

Diagnosing the adult equivalent of encopresis involves figuring out both the type of incontinence and the underlying cause. A careful history is the first step: how often soiling occurs, whether it involves liquid or solid stool, whether the person senses the leakage or discovers it afterward, and whether constipation has been longstanding. A digital rectal examination remains an important initial assessment, because it can reveal a fecal impaction, assess sphincter tone and squeeze strength, and detect masses or structural abnormalities.

When the history and physical exam do not tell the full story, specialized testing helps clarify what is going wrong. The most informative studies are anorectal manometry, balloon expulsion testing, and defecography, ideally used together.

• Anorectal manometry: A pressure-sensing catheter placed in the rectum measures how well the sphincters contract and relax and how sensitive the rectum is to filling. High-resolution manometry can identify problems like paradoxical pelvic floor contraction that standard methods may miss.⁸
• Balloon expulsion test: A small balloon is inflated in the rectum, and you are asked to push it out. The test is highly specific for evacuation disorders, meaning a normal result reliably rules out the problem, though it can miss some cases because its sensitivity is lower.⁹
• Defecography: An imaging study (often MRI-based) that shows what happens inside the pelvis during an actual attempt to evacuate. It can reveal rectoceles, intussusceptions, excessive pelvic floor descent, and other structural issues that contribute to incomplete emptying.¹⁰

When manometry shows normal anal relaxation, about two-thirds of patients also evacuate normally on defecography, and those who show paradoxical contraction are significantly more likely to fail evacuation.⁹ Anorectal manometry can also help differentiate between sphincter weakness, rectal hyposensitivity, and pelvic floor dyssynergia in people with neurological disease, all of which can cause soiling but require different treatment approaches.⁵

Treatment Starts With Clearing the Blockage

If fecal impaction is present, no other treatment will work until the mass is removed. The approach depends on how far up the blockage extends and how hard the stool has become. Options include manual disimpaction (physically breaking up and extracting the stool), enemas and suppositories to soften or wash out the impacted material from below, and oral or tube-delivered polyethylene glycol solutions to flush stool from above.¹¹ Sometimes a combination of these approaches is needed.¹² Disimpaction is not pleasant, but it is usually necessary before any maintenance plan can take hold. Skipping this step is one of the most common reasons treatment stalls.

Medications for Maintenance

Once any impaction has been cleared, the goal shifts to keeping stools soft, regular, and easy to pass so that the cycle of retention and overflow does not restart. This usually begins with increased fluid and fiber intake, improved mobility, and a review of medications that might be contributing to constipation, with opioids, certain antidepressants, and iron supplements among the most frequent culprits.

When lifestyle changes are not enough, laxatives become part of the plan. A systematic review of trials in older adults found that bulk laxatives, osmotic laxatives, stimulant laxatives, and newer agents like prucalopride and lubiprostone all outperformed placebo in the short term.¹³ Of these, polyethylene glycol (PEG, commonly sold as MiraLAX) appears safest and most effective for longer-term use of around six months. Laxatives do require some caution in people who already have weakened sphincters: loosening the stool too aggressively can tip the balance from constipation into liquid-stool leakage. The aim is a soft, formed stool that is easy to pass completely, not watery output that overwhelms a compromised sphincter.

Biofeedback and Pelvic Floor Rehabilitation

For adults whose soiling traces back to pelvic floor dysfunction, biofeedback therapy is one of the most effective treatments available, and it carries essentially no side effects. In a biofeedback session, sensors placed in or near the anal canal display real-time information about muscle activity on a screen, so you can learn to relax the pelvic floor during a push instead of paradoxically clenching it. Multiple randomized trials have shown biofeedback to be more effective than laxatives alone for dyssynergic defecation.⁴

Biofeedback has also demonstrated efficacy for fecal incontinence itself, helping people strengthen the external sphincter and improve the coordination between sensing rectal filling and squeezing in time.¹⁴ The treatment works for both defecatory disorders and incontinence, though the training techniques differ: in one case you are learning to relax, in the other to tighten and hold.¹⁵ When structural problems like a rectocele or solitary rectal ulcer coexist with dyssynergia, trying biofeedback before considering surgery is strongly recommended, because the coordination problem may be the real driver of symptoms.¹⁶

Transanal Irrigation

Transanal irrigation, sometimes called rectal irrigation, involves using a device to instill water into the rectum and lower colon on a scheduled basis to flush out stool before it has a chance to accumulate and leak. The technique is especially useful for people with neurogenic bowel dysfunction. In a large study of 348 patients with various underlying causes, about 47 percent achieved a successful outcome over a mean follow-up of nearly two years. Success rates were highest in people with neurogenic bowel dysfunction, where about 63 percent benefited, and in those with anal sphincter weakness, where about 51 percent improved.¹⁷ Patients who stuck with the regimen reported significantly lower bowel symptom bother scores, and serious complications like perforation were exceedingly rare, occurring roughly twice in 110,000 irrigation procedures.¹⁸

Irrigation is not a first-line treatment for most people, but it fills an important gap between oral medications that do not fully control symptoms and surgical options that carry greater risk. It does require commitment and comfort with the procedure, and dropout rates are not trivial, particularly among people with idiopathic constipation, who benefited least in the study above.

Sacral Nerve Stimulation

When conservative treatments have failed, sacral nerve stimulation (also called sacral neuromodulation) offers a surgically implanted option. A small electrode placed near the sacral nerves delivers mild electrical pulses that improve both sphincter function and rectal sensation. The procedure is typically staged: a temporary lead is tested for a few weeks, and permanent implantation goes forward only if symptoms improve during the trial period.¹⁹

Evidence from a Cochrane review suggests that sacral nerve stimulation can improve continence in a proportion of patients with fecal incontinence, though it did not improve symptoms in patients whose primary problem was constipation. Adverse events occurred in some patients.²⁰ The therapy has expanded beyond straightforward sphincter weakness to include more complex presentations such as combined fecal and urinary dysfunction.²¹ The exact mechanism is still not fully understood. Current evidence points toward both a direct strengthening effect on the sphincter muscles and a broader neuromodulation of reflexes that govern rectal sensitivity and contractility.¹⁹

When Childhood Constipation Follows You Into Adulthood

A surprisingly common pathway to adult encopresis starts in childhood. About a third of children with chronic constipation still have symptoms as adults.²² Some of these individuals never fully resolved the problem; others improved during adolescence only to have symptoms return. The bowel habits formed (or disrupted) in childhood, including stool withholding, fear of painful defecation, and chronic rectal distension, can persist as deeply ingrained patterns. Adults in this category sometimes do not recognize their symptoms as abnormal because they have never known anything different.

Young adults whose childhood constipation persisted with ongoing fecal incontinence reported significantly lower quality of life, particularly in areas of bodily pain and general health perception. About 20 percent described difficulties with social contact, and roughly 13 percent reported challenges with intimacy related to their bowel symptoms.²² This group tends to respond to the same treatments used for adult-onset cases, but the behavioral component, years of learned avoidance and altered defecation patterns, often makes biofeedback and structured toilet training an especially important part of the plan.

The Psychosocial Weight of the Problem

The physical symptoms of fecal incontinence are only part of the burden. The condition is physically and psychosocially debilitating, affecting not just the person experiencing it but also their families and caregivers.²³ Embarrassment leads many people to avoid social outings, exercise, travel, and sexual intimacy. Some structure their entire lives around bathroom access. The reluctance to discuss the problem with a doctor means that many suffer for years before seeking help, and clinicians themselves do not always ask about bowel symptoms during routine visits.

Addressing the psychological dimension matters for practical reasons, too. Anxiety about accidents can tighten the pelvic floor, worsening dyssynergia. Depression can reduce motivation to follow through with dietary changes, scheduled toileting, or biofeedback sessions. For people with cognitive decline, caregiver education and environmental modifications, like clear bathroom signage and easy-to-remove clothing, can reduce episodes even when the underlying condition cannot be reversed. Treatment that accounts for the emotional and social impact alongside the physical cause tends to produce better outcomes and higher follow-through than treatment that focuses on the bowel alone.

Why Adults Often Go Undiagnosed

One of the most frustrating aspects of adult encopresis is how long people live with it before getting a diagnosis. Several factors converge to create this delay. The term “encopresis” itself is part of the problem: because it is classified as a pediatric diagnosis, adults who search for their symptoms using that word may come away thinking their condition does not exist in their age group or that no treatment is available. The medical system reinforces this gap. Pediatric gastroenterologists routinely screen for fecal soiling; adult gastroenterologists focus more on inflammatory bowel disease, cancer screening, and liver disease. Fecal incontinence falls into a space between gastroenterology, urology, colorectal surgery, and neurology, and no single specialty consistently owns it.

Medications can obscure the picture further. Opioids, anticholinergics, and calcium channel blockers all slow the gut, promote impaction, and set the stage for overflow, yet the prescribing provider may not connect a patient’s soiling complaint to the medication list. Elderly patients in particular may have multiple constipation-promoting drugs prescribed by different specialists, none of whom realize the cumulative effect. If you or someone you care for is dealing with fecal soiling, bringing a complete medication list to the appointment and explicitly asking about constipation as a side effect is one of the highest-yield steps you can take.

The evidence is clear that effective treatments exist at every level of severity, from simple laxative regimens for overflow, to biofeedback for pelvic floor coordination, to irrigation for neurogenic bowel, to nerve stimulation for refractory cases. The first barrier to getting help is almost always the conversation that has not happened yet.