A 7-year-old boy soils his underwear several times a week with large, soft stools. Examination reveals a dilated rectum packed with hard stool. He has a 2-year history of painful defecation with withholding behavior. There are no urinary symptoms and growth is normal. What is the most appropriate initial management?

• A Disimpaction followed by daily maintenance laxative therapy and scheduled toilet sitting ✓
• B Behavioral star chart alone with strict punishment for soiling episodes
• C Rectal biopsy to exclude Hirschsprung disease before any treatment
• D Daily imipramine

Explanation

This is functional constipation with retentive encopresis, where overflow of liquid stool around an impacted mass causes soiling. Treatment follows three steps: complete disimpaction, then prolonged maintenance laxatives such as polyethylene glycol, combined with regular post meal toilet sitting and positive reinforcement. Rectal biopsy is indicated only for red flags like delayed meconium passage or failure to thrive, absent here. Imipramine is an enuresis drug and punishment worsens withholding, which kills those distractors.

Reference: Nelson Textbook of Pediatrics, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.