Presentation on theme: "Midnight Laundry Enuresis, Encopresis and Diarrhea"— Presentation transcript:
1Midnight Laundry Enuresis, Encopresis and Diarrhea Tory Davis, PA-C
2Enuresis Urinary incontinence in child who should be continent 5-6 years (or developmental equivalent) or olderNot caused by medication or medical conditionPeeing in clothes or in the bedInvoluntary or intentional
3Enuresis Primary enuresis Secondary enuresis has never had a sustained period of dryness.90% nocturnalSecondary enuresishas had a sustained period of bladder control (6-12 months)
4Primary Enuresis Boys 3x girls Most become continent by adolescence, even without interventionFHx , esp fatherLikely maturational delay of:sleep/wake mechanismsdevelopment of bladder capacity and urethral sphincter control
5Primary Enuresis1142-3123-51077-88155Occasional daytime wettingNocturnal enuresis (%)Age in years
6Daytime Enuresis More common in : Boys = Girls Kids with hyperactivityTimid/shy kidsBoys = Girls60-80% also have nocturnal wetting
7Secondary EnuresisOnset after child has had sustained period of continenceOften follows a stressful eventLoss, new sibling, family discord, move, new school, abuse
8Differential UTI *MC Distal urethritis (bubble bath) Neurological disorders- congenital or acquiredCongenital anomalies (spina bifida)Seizure disordersDiabetes (mellitus or insipidus)Structural abnormalities of the urinary tract (urethral cyst, urethral duplication, obstruction)1. Need to r/o
9Diagnosis Take a good history Do a good physical Observe child’s urinary streamStraining, dribbling, stress incontinence?Urinalysis and urine culturewhat’s going on in family; potty training hx;4. To r/o UTI. May not have dysuria
10Treatment Emphasize that noc wetting is likely developmental lag NOT acting out, etcPatient understanding and encouragementSpontaneous cure ~15%/yearAvoidance of punitive measuresEncourage child participation5. Get them involved
11Treatment Counseling Bladder training Potty pager/ alarm Child has active role: keeps calendar, helps with the midnight laundry, talk to the PAPositive reinforcement, remove guilt/blameBladder trainingHold urine longer during day, limit fluids after dinner, practice start/stop urine flow on toilet, pee just before bed. Helpful ~40%Potty pager/ alarm3. Can be effective. Insurance covers – usually before drugs
12MedsDDAVP (desmopressin acetate) intranasal qhs. Complete remission during tx 50%, high relapse on discontinuation. Good for special events (camp, sleepovers) and as “bridge”Imipramine (TCA) qhsAnticholinergic side effectsLaw #13 – delivery of good med care is to do as much nothing as possible – do no harm.
13Encopresis Fecal incontinence in child who should be continent. 4 years (or developmental equivalent) or olderNot due to medication or medical conditionInvoluntary (usually) or intentional1-1.5% of school-aged kiddos, very rare in adolescenceBoys 4x girls
15Retentive Encopresis *MC Psychogenic MegacolonChild withholds BMs constipation fecal impaction seepage of liquid feces (Type 7!) around impaction and out onto skivvies.Marked constipationPainful defecationRetention reduced sensory feedbackRectal wall stretch causes contractile strengthHarder stools due to increased water absorptionThen what happens…?1. Bristol stool chart
16Continuous Encopresis Children who have never gained primary control of bowel function.Poop in underwear. Doesn’t care. No regard for social norms.Typically lacks bowel/potty trainingOften family social/intellectual disadvantageThe encopresis is the least of your worries with this child3. No one tries potty training.4. This is usually least of concerns about social upbringing.
17Discontinuous Encopresis Hx of normal bowel control for extended periodLike secondary enuresis, usually in response to stressful eventSometimes voluntary follow-through (smearing, etc)
18Etiologic considerations Inefficient motilityMedical management for (perceived?) bowel disorderPainful defecation (fissures, etc)Surgical hx (imperforate anus)Unrealistic parental expectation2. Parents think kids are constipated – wide range of “nl”
19Consequences Fear Shame Isolation Depression Can depend on caregiver rxn.Need to attend to these other factors during tx
20History Bowel pattern since birth Age of onset of problems/symptoms Management attempt and effectsAssociations (ie with stressors)
22Management (Levine) Counseling Phase Demystify:Review colon functionNormal and abnormalDraw a pictureShow imagingRemove blameExplain treatment planEmphasize intestinal muscle buildingTalk about it with them.Make it okayFocused on retentive (the most common)
23Inpatient Catharsis When? What? Severe retention Poor outlook for home complianceWhat?Saline enemas bid 3-7 daysBisacodyl suppositories bid 3-7 daysSit on toilet 15 min pcSometimes need to get them in and clear everything out.2.3 – try to reset gastrocolic reflex
24Outpatient Catharsis Mild: Senna daily x 1-2 weeks Moderate-Severe: 3 day cyclesDay 1: Fleet’s enema bidDay 2: Bisacodyl suppository BIDDay 3: Bisacodyl suppository onceFollow-up x-ray to confirm catharsis
25Maintenance Sit on toilet bid x 10 min, after meals 2 T mineral oil po bid x 4-6 monthsMVI supplementEat fiber!Oral laxative (senna) q dayor qod x 1 monthRead Anna Karinina ??Reward- sticker chart, etc2.1 – worried about malabsorption3. Like a dry sponge – needs to have water with it to make it work
27Thoughts on Potty Teaching Teach your parents well…Readiness signals: dry periods, interest in toilet,wants to be changed when wet, can follow directionsNo power strugglesRespect child’s autonomyApplaud child’s successAccidents happen
29Acute Diarrhea Gastroenteritis Infectious Food poisoning Antibiotic-associatedOverfeedingGreat Ddx chart in Nelson textNeed to get a definition of what that means for them.
30Acute diarrhea Complete history Physical Exam Include day care, travel, animal contact, foods, antibioticsPhysical ExamStool- check for WBCs and occult bloodIf neg, think viralIf pos- r/o (or in) bacterial cause, then consider IBD1.1 – who else has it?2. Sore belly, rash etc
31Acute diarrhea management Cure initiating eventCorrect dehydration and e-lyte deficitsManage complications from mucosal injuryNO Imodium, Lomotil, paragoric, etc2. Do it slowly.4. don’t want to stop it. Usually happens for a good reason – need to get it out.
33Toddler’s Diarrhea- MC Chronic diarrhea in infants Nonspecific diarrhea of infancy6m-3y onset, duration >3 weeksPainlessFirst stool of the day formed, become increasingly liquid thru dayExacerbated by teething, infections, also by fruit juices with unabsorbable sugars that increase diarrhea
34Toddler’s diarrhea Motility disorder with rapid transit Positive FHx for IBSDx: r/o infectious causesTx: high fat, high fiber, low sugar diet
35Cow’s Milk Intolerance Infants <1year oldStools contain WBCs, eosiniphilsEven in breast-fed babes whose mom’s drink cow milkDiarrhea, vomiting, mucus in stoolsFTTAssoc with atopy, rhinitis, eczemaDx: Stool studies, CBCTx: alimentum, nutramagen (not soy) or nursing mom avoid milk