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Constipation and Enuresis

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Presentation on theme: "Constipation and Enuresis"— Presentation transcript:

1 Constipation and Enuresis
Katie Mallam Paediatric Update for Primary care 9th October 2012

2 Constipation – Why? Common Debilitating Cost
Prevalence 5-30% 1/3 become chronic (>8 weeks) = soiling Debilitating Social, psychological and educational consequences Cost Longer duration = longer, more intensive treatment Varying advice = angry parents

3 Constipation – NICE Standardise approach Early treatment
Reduce consequences and cost No need to remember history and examination:

4 Breast fed babies can go up to a week without opening bowels
Constipation? 2 of …….. * * Breast fed babies can go up to a week without opening bowels

5 Constipation?

6 Breast fed babies can go up to a week without opening bowels
Constipation? 2 of …….. * * Breast fed babies can go up to a week without opening bowels

7 Constipation – Causes Mostly idiopathic Rarely Associations
Hirschsprung’s Neurological NB lumbosacral abnormalities Anorectal malformations Hypothyroid Coeliac Cystic fibrosis (but normally diarrhoea due to fat malabsorption) Cow’s milk protein intolerance Associations Cerebral palsy Autism Down’s syndrome (NB beware hypothyroidism and Hirschsprung’s) Hirschspruung’s: Missing parasympathetic ganglion cells from segment of bowel. Therefore can’t relax or peristalse. Presentation depends on length of effected segment. Beware enterocolitis Associated with Down’s, central hypoventilation, deafness, waardenburg’s Lumbosacral ?sacral agenesis, spina bifida occulta, cord tethering

8 Constipation – History 1

9 Faltering growth = treat and do coeliac and TFT (refer)
Constipation – History 2 Faltering growth = treat and do coeliac and TFT (refer)

10 Constipation – Examination
No PR in primary care NB perianal strep Anal atresia Anal wink = reflex contraction of external anal sphincter = S2-4

11 Perianal streptococcal infection
Swab Treat infection and constipation

12 Constipation – Examination
No PR in primary care NB perianal strep Anal atresia Anal wink = reflex contraction of external anal sphincter = S2-4

13 Constipation – It’s NICE
No need to remember history and examination: < 1 year ≥ 1 year

14 Constipation – Actions
Red (or amber) flags Refer paeds No red flags Reassure Explain constipation and treatment (could just do briefly and give patient information using resources in ‘Explain 2’ slide) Treat

15 Constipation – Explain 1
Normally, stools build up in the lowest part of the bowel. When stools accumulate, they start to pass into the rectum (the last part of the bowel) which stretches. This sends nerve messages to the brain, telling you that you need to empty your bowels. If the stool is not passed out then more stools from higher up also reach the rectum. Eventually, large hard stools may build up in the rectum. The rectum may then stretch and enlarge (dilate) much more than normal, to cope with the excessive amount of stools. A very large stool may develop and get stuck (impacted) in an enlarged rectum. If the rectum remains enlarged then the normal sensation of needing the toilet is reduced. The power to pass out a large stool is also reduced (the rectum becomes 'floppy'). More stools build up in the colon behind the impacted stool in the rectum. The lowest part of an impacted stool lies just above the anus. Some of this stool liquefies (becomes runny) and leaks out of the anus. This soils the child's pants or bedclothes. Also, some softer, more liquid stools from higher up the colon may bypass around the impacted hard stool. This also leaks out and soils the pants or bedclothes and can be mistaken for diarrhoea. The child has no control of this leaking and soiling. When a stool is eventually passed, because the rectum is distended and weakened, it simply fills up fairly quickly again with more hard stool from the backlog behind. Rectum gets used to being full: normal reflexes and power are reduced = ‘baggy’. Reduced sensation and overflow: soiling is not intentional Need to ‘get empty and stay empty’ for rectum to shrink back and recover reflexes and sensation: takes time

16 Constipation – Explain 2
Tameside = comprehensive leaflet = very good, can print pdf leaflet ERIC = lots of info for professionals and parents/patients (age banded) NICE ‘template letter’

17 Constipation – Treat Get empty, stay empty! Faecal impaction?
Soiling Abdominal mass Movicol, movicol, movicol! NB different strengths e.g. Paed Plain = no taste ‘Softeners’ Movicol, Lactulose, Docusate (also squeezes) ‘Squeezers’ Senna, sodium picosulphate, bisacodyl Doses as per BNFc or NICE

18 Constipation – Get empty
Disimpaction Aiming for liquid and no more lumps = messy Review after 1 week Movicol If not tolerated = stimulant laxative +/- lactulose If not worked after 2 weeks = add stimulant laxative and urgently refer to Paeds Enemas and manual evacuation only if all else failed

19 Constipation – Stay empty 1
Maintenance Until rectum no longer stretched and reflexes return Laxatives do not make bowel lazy: may need for several years and should be gradually reduced Movicol If not tolerated = stimulant +/- lactulose, or docusate alone If not effective = add stimulant

20 Constipation – Stay empty 2
Behavioural Non-punitive (I say ‘training the subconscious’) Regular toileting after meals Foot support, sit forward (rock and pop!), bubbles, books Diary and rewards (things under their control) NB school (NB ERIC info) Use school nurses and HV

21 Constipation – Stay empty 3
Fluids Page 15, NICE Quick Reference Guide

22 Constipation – Stay empty 4
Diet High Fibre = fruit, veg, high fibre bread, wholegrain breakfast cereals, baked beans Activity

23 Constipation – Failed treatment
Disimpaction has failed if not responded to Movicol after 2 weeks: Urgent referral to Paeds (or Bladder and Bowel Specialist Nurse) Maintenance has failed: In those aged <1 year, if not responded after 4 weeks Refer paeds In those aged ≥ 1 year, if not responded after 3 months Check no red flags If red flags = refer paeds No red flags = refer to the Bladder and Bowel Specialist Nurse Service

24 Constipation Toolkit RED FLAGS, refer paeds EXPLAIN: Tameside leaflet
History and examination questionnaires Bristol Stool Chart EXPLAIN: Tameside leaflet IMPACTED? GET EMPTY, STAY EMPTY! Medical: usually Movicol Paed Plain as per BNFc Non Medical: see Tameside leaflet and fluid rqmts on page 15 of NICE If fails, add stimulant Disimpaction failure, refer paeds Maintenance failure, refer Bladder and Bowel Specialist Nurse

25 Enuresis - definitions
Incontinence uncontrollable leakage of urine Enuresis Incontinence of urine when sleeping: usually say Nocturnal Bedwetting: ‘involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology’ (NICE) Primary Secondary = previously dry for ≥ 6 months

26 Urinary Incontinence – History 1
Secondary (especially recent): UTI Diabetes (drinking overnight) Constipation Neurological: spine and lower limb exam Emotional/behavioural difficulties: consider psychology Urine dipstick NB same day referral if suspect diabetes

27 Urinary Incontinence – History 2
Pattern of bedwetting Variable volume, >1 per night: could be Overactive Bladder Daytime symptoms Urgency, Frequency >7/day, Infrequent <4/day, straining, pain Consider UTI, Overactive Bladder, Neuro/Uro cause Urine dipstick If significant, refer to consider investigation/treatment of those symptoms first Toileting patterns NB School Fluid intake Check not restricting Diary

28 Urinary Incontinence – History 3
Effect on child/YP/family Social (sleep-over), self-esteem PMHx: UTI Developmental, attention or learning difficulties: consider specific management

29 Urinary Incontinence – Examination
Primary Nocturnal: not required according to NICE Secondary Nocturnal or Daytime Symptoms: Genitalia Abdomen Spine Lower limb neuro

30 Urinary Incontinence – Referral
RED FLAGS = recurrent UTI, Diabetes, examination abnormalities: refer paeds No red flags Nocturnal only: refer HV or school nurse Day only, or Nocturnal with daytime symptoms: refer to Bladder and Bowel Specialist Nurse

31 Enuresis – NICE Principles of Care
Not their fault: non-punitive management Tailor management to child/YP and parent/carer Consider parental support Do not exclude <7y Reassure

32 Enuresis Prevalence Age < 2 per week ≥ 2 per week 4.5y 21% 8% 9.5y

33 Enuresis – NICE Principles of Care
Not their fault: non-punitive management Tailor management to child/YP and parent/carer Consider parental support Do not exclude <7y Reassure Trial of BASICS <5y: encourage toilet training if not done already and trial out of nappies at night

34 Enuresis – Management BASICS!
Fluids: avoid caffeinated (and ?fizzy and blackcurrant) Regular toileting 4-7/day NB double voiding if Overactive Bladder symptoms Trial out of nappies/pull-ups: offer alternatives Reward system: for agreed behaviour (not dryness)

35 Enuresis – Information
NHS choices: concise, for parents concise, for parents ERIC: all ages, parents, professionals

36 Enuresis – Alarm High long-term success rate (weeks)
But need commitment and can disrupt sleep Contraindications: < 1-2 wet nights/week Parental distress or negativity (consider parental support) Need training Hence referral to HV/school nurse Encourage to combine with reward system Get up and go to toilet, help change sheets


38 Enuresis – Desmopressin
Rapid, short-term results (sleep-over) Alarm is inappropriate or undesirable Inform them: many relapse when treatment is withdrawn how desmopressin works fluid restriction from 1 hour before until 8 hours after taking desmopressin that it should be taken at bedtime how to increase the dose if the response to the starting dose is not adequate that treatment should be continued for 3 months that repeated courses can be used Stop during sickle cell crises or D&V


40 Enuresis – Other treatments
Only on advice of specialist Anticholinergic with desmopressin Oxybutinin If: Not responded to desmo+/-alarm Daytime symptoms Imipramine Gradual increase and withdrawal Warn re dangers of OD

41 Urinary Incontinence – Top tips
Secondary: think other causes esp Diabetes Examine if Secondary or Daytime Refer all? Red flags = paeds Others = HV/school nurse/BBSN Basics Give/direct to information

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