A 6-year-old boy is often teased at school because he has stooled in his underwear almost daily for the last 3 months. He was toilet trained at 2 years of age without difficulty, but over the last 2 years he has developed ongoing constipation. His family is frustrated because they cannot believe him when he says, "I didn't know I had to go." He is otherwise normal; school is going well, and his home life is stable. His only significant finding on examination is stool in the rectal vault. The plain radiograph of his abdomen is shown. Initial management of this problem should include which of the following?

(d) Source: (Hay et al, pp 84-85. Kliegman et al, pp 73-75. McMillan et al, pp 672-674, 1920-1923. Rudolph et al, pp 1386-1389.) Encopresis is defined as the passage of feces in inappropriate locations after bowel control would be expected (usually older than 4 years). Encopresis is seen both with chronic constipation and overflow incontinence (retentive encopresis), and without constipation (nonretentive encopresis). Retentive encopresis is more common, and is the source of this child's problem. There is leakage of liquid stool around a large fecal impaction, resulting in fecal soiling. The radiograph demonstrates a dilated, stool-filled colon consistent with retentive encopresis. Treatment involves clearing the fecal mass, maintaining soft stools for a short period of time with mineral oil or stool softeners (3-6 months), and behavioral modification. Most children will grow out of this condition. Timeout would be ineffective, because these children usually have dysfunctional anal sphincters and little control over the problem; they do not know they are soiling their clothes until it is too late. Daily enemas could potentially be harmful. A rectal biopsy would help diagnose Hirschsprung disease, but the story presented is not consistent with that diagnosis.