Elimination Disorders Enuresis and Encopresis by nikeborome

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									Elimination Disorders:
Enuresis and

        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.
Clinical Description
  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
   and adults
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.
  Maturational etiology*.
  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
  Giggle incontinence
  Medications
Enuresis        (continued)

  Epidemiologic studies have shown a
   correlation between psychological disturbance
   and enuresis, which is more pronounced in
   older children.
  Link to emotional disturbances.
  Higher rates of behavioral problems
  Anxiety states, Opposionality, ADHD
  Secondary Enuresis related to stress, trauma,
   or psychological crisis.
Medical Causes

    UTI
    Urethritis
    Diabetes
    Sickle cell anemia
    Seizure disorder
    Neurogenic bladder
    Anatomy
    Obstruction
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.
Evaluation        (Medical)

  Initial medical work up is required.
  Medical workup include: careful medical
   history, physical examination, urine Flow
   testing, urine culture and urinalysis.
  Urinary Osmolality test
Evaluation       (Psychiatric)

  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
     acetate (DDAVP)
    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
   pharmacologic intervention.
  The bell and pad method of conditioning is a
   reasonable first approach. success rate of
Behavioral Treatment

  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-
   mg range.
  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%
  remained dry.
 The most common side effects were nasal
  stuffiness, headache, epistaxis, and mild
  abdominal pain.
 Combination with behavioral methods works

  “repeated passage of feces into
   inappropriate places.”
  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
   socioeconomic classes.

  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
   neurological disorder.
Etiology     (continued)

  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.
Differential Diagnosis
    Megacolon: Hirschprung disease
    Thyroid diseases
    Hypocalcaemia
    Lactase deficiency
    Pseudo obstruction
    Myelomeningiocele
    Cerebral palsy with hypotonia
    Rectal stenosis
    Anal fissure
    Anal trauma
    ODD
    Anxiety or Phobia

  The most widely accepted first line of
   treatment is one that encompasses
   educational, psychological, and
   behavioral approaches.
  Pharmacological treatment with
   imipramine also has been reported as
   useful for encopresis.
Behavioral approach
  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
   mineral oil.
  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
 Subtypes of encopresis
     Retentive (most common)
     Nonretentive
     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
Thank you

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