Karen—Your dilemma is not restricted to Toronto, it is literally world-wide.  The most common onset of encopresis everywhere is associated with toilet training.  It truly is absolute misery for all concerned because we are dealing with a private area of the body and an extremely offensive body waste product which is quite literally a biohazard.  If you keep reading on in this column you will learn that your son has overlearned the prepotent holding response which all of us engage when we get voiding urges or signals.  It is our immediate, top level response!  He has had some promising periods of adequately following up with the voiding reflex to stay clean, but this has never become sufficiently reliable.  Wouldn’t it be terrible if he is erring on the side of holding because of Dad’s not buying into his not being in control?  He could be over trying, and once holding gets started for any reason (and that may not be dad’s fault) he truly does not have control.  Perhaps he is a very busy child and hates to be interrupted to brush his teeth, wash his hands, or go to the bathroom.  We just do not know, the consequences are often way much greater than the often completely innocent initiating cause(s).  Lactulose is simply a sugar-based hypermolar agent which draws fluids from the surrounding tissues into the colon to keep the stools soft.  It was probably the most popular stool softener until Miralax came along.  Virtually 99% of docs are stuck on the top down softening route to assure that the stool moves along and that the child does not get backed up and get a blockage that might require hospitalization and medical evacuation of his colon.  Basically, you are on “maintenance therapy” and assurances of “He will grow out of it.” However this has worn thin for you both and you have been extraordinarily patient and hopeful.  No child or family should go beyond a sixth year without a truly effective bowel retraining protocol.  There are psychological and physical consequences of not being more aggressive when that becomes necessary.  That is why I wrote the Clean Kid Manual some 11 years ago.  It is only available from my website at www.soilingsolutions.com or a few professionals out there who purchase them in discounted lots for use with their patients.  You will have access to the SS Parents’ forum with a purchase from my website store where you will find 300 or so parents from around the world who have already successfully used the manual or are currently using it.  I will attach a copy of my medical journal article on the Soiling Solutions protocol along with editorials concerning it in a separate email.  I will also attach a photo of my toilet trained cat.  Check out www.soilingsolutions.com/megacolon.htm where I forcefully and in great detail address the issue of encopresis or functional fecal retention.