Faisal Ahmed, M.D
Urinary incontinence occurs after the
chorological or developmental age of 5
years either at least twice a week for 3
months or sufficiently often to cause
distress or impairment.
Bed Wetting > daytime incontinence
Typical occurs 30 minutes to 3 hours after sleep onset.
Daytime bladder control usually precedes nocturnal
control by 1-2 years.
Enuresis is sub classified into two subtypes, primary
and secondary. Primary enuresis encompasses
children who have never achieved continence,
whereas secondary enuresis refers to those children
who maintain continence for at least one year, only to
lose it at some point after that.
5%-10% of 5 years-olds and around 3%-5% of
10 years olds.
Primary Enuresis: Male predominance
decreases with age.
Secondary Enuresis: Usually equal in both.
Between 3% and 9% of school age girls
experience daytime urinary incontinence
1% general prevalence in older adolescents
Clinical Description and
“repeated voiding of urine during the day
or at night into bed or clothes, whether
involuntarily or intentionally.” and that
“the behavior is clinically significant as
manifested by either a frequency of at
least twice per week for at least three
consecutive months or impairment in
social, academic (occupational) or other
important areas of functioning.”
Familial: 70% of children with Enuresis ( particularly
boys) have 1st degree relative functional enuresis.
Some have a relative inability to concentrate urine. The
development of desmopressin acetate (DDAVP) as a
treatment for enuresis Excessive fluid intake.
Anatomical abnormalities or UTS
Epidemiologic studies have shown a
correlation between psychological disturbance
and enuresis, which is more pronounced in
Link to emotional disturbances.
Higher rates of behavioral problems
Anxiety states, Opposionality, ADHD
Secondary Enuresis related to stress, trauma,
or psychological crisis.
Sickle cell anemia
Course and Prognosis
Primary: high spontaneous remission
Secondary: Usually begins b/w ages 5-8 years.
Adolescent onset signify more psychiatric
problems and less favorable outcome.
Complication include embarrassment, anger from
and punishment by caregivers, teasing by
peers, avoidance of overnight visits and
socializing, angry outbursts.
Initial medical work up is required.
Medical workup include: careful medical
history, physical examination, urine Flow
testing, urine culture and urinalysis.
Urinary Osmolality test
Psychiatric evaluation include
assessment of associated psychiatric
symptoms, recent psychosocial
stressors, and family concerns about the
problems and management of symptoms.
Treatment ( Factors to consider)
Age of child
Medical cause has been ruled out
Rate of spontaneous remission (approximately 14%–16% per year)
Behavioral conditioning with bell and pad or similar methodology
Equally effective as pharmacological treatment
Lower rate of relapse than with pharmacological treatment
Safer than pharmacological treatment
Most commonly used pharmacological intervention is Desmopressin
Most serious side effect (rare) is hyponatremia, leading to seizures
Imipramine is no longer first-line choice for pharmacological treatment,
but can be used for refractory individuals
Combination of behavioral and pharmacological treatment can be
considered for refractory enuresis
The two primary means of treating children
with enuresis fall into the categories of
behavioral and psychopharmacologic methods
Behavioral treatment should be attempted first
because it is usually more innocuous than
The bell and pad method of conditioning is a
reasonable first approach. success rate of
Bladder capacity alarm: results were
comparable with those obtained with the
traditional bell and pad technique.
Other procedures include reward
systems, such as star charts, nighttime
awakening to urinate, retention-control
training, and fluid restriction.
Imipramine : 1960
Most children respond in the 75- to 125-
A baseline electrocardiogram should be
obtained before instituting treatment with
imipramine, and monitoring is advised
above 3.5 mg/kg
No relation to blood level
The newest research into treatment for
enuresis involves the use of DDAVP
Review Studies: 10%-91% success rate
In general, wetting resumes once the
medication is discontinued as only 5.7%
The most common side effects were nasal
stuffiness, headache, epistaxis, and mild
Combination with behavioral methods works
“repeated passage of feces into
And soiling must occur at least once a
month for at least 3 months and that the
mental or chronological age of the child
must be at least 4 years
Primary VS Secondary
With constipation and overflow
incontinence (Retentive) VS Without ( non
Typically occurs during the day.
50-60% have secondary Encopresis.
Association with conduct disorder
Retentive encopresis is characterized by a cycle of
several days of retention, a painful expulsion, and
another period of retention. While the fecal mass is
growing, there may be leakage around the mass. The
category of nonretentive encopresis applies to those
children who simply do not control the expulsion of
feces on a psychological, physiologic, or combined
Prevalence decreases with age
3% of 4 year-olds, 2% of 6 years old, and
1.6 % of 10-11year olds.
Rare in adolescent
School age: Male> female: 2.5:1-6:1
Higher rates in MR and Low
Retentive: painful defecation, ,
inadequate or punitive toilet training, fear
of school bathroom, or toilet related fears
Mechanisms include altered colon
motility, and contraction factors,
obstruction, stretched and thinned colon
walls, and decreased sensation 2nd to
Non retentive : May be deliberate attempt
to effect change, as a means of avoiding
stressors or communicating anger.
Often complicating and difficult to treat.
Course and Prognosis
Secondary Encopresis often starts by age 8
Onset before 4: 63% recover with treatment
Laxative protocol: 50% recover with no
recurrence after 1 year, another 20% after 2
years. (Loening-Baucke 1989).
Psychiatric or medical co-morbidity: major
determinant of prognosis.
Course and Prognosis
25% co morbid enuresis.
Occasionally: symptoms triad: UTI,
Constipation and Encopresis.
Megacolon: Hirschprung disease
Cerebral palsy with hypotonia
Anxiety or Phobia
The most widely accepted first line of
treatment is one that encompasses
educational, psychological, and
Pharmacological treatment with
imipramine also has been reported as
useful for encopresis.
Initial meeting: designed to educate both the
parents and child about bowel function and to
diffuse the psychological tension that may have
developed in the family around the encopresis.
2nd stage: Initial bowel catharsis, after which
the child receives daily doses of laxatives or
There also is a behavioral component to the
treatment, which consists of daily timed
intervals on the toilet with rewards for success
A 78% success rate
FACTORS TO CONSIDER for
TREATMENT FOR ENCOPRESIS
Subtypes of encopresis
Retentive (most common)
Volitional (least frequent)
A thorough history is essential that documents frequency, nature,
and circumstances of event
First line of treatment for retentive subtype usually includes:
Education about bowel functioning with both parents and child
Physiological treatment with laxatives or mineral oil
Behavioral component with time intervals on toilet and positive
Extensive research into biofeedback
Not proven to be more effective than traditional interventions
May be a consideration in refractory cases
Case reports of imipramine in the treatment of nonretentive
Psychodynamic assessment for those with volitional encopresis