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Midnight Laundry Enuresis, Encopresis and Diarrhea

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1 Midnight Laundry Enuresis, Encopresis and Diarrhea
Tory Davis, PA-C

2 Enuresis Urinary incontinence in child who should be continent
5-6 years (or developmental equivalent) or older Not caused by medication or medical condition Peeing in clothes or in the bed Involuntary or intentional

3 Enuresis Primary enuresis Secondary enuresis
has never had a sustained period of dryness. 90% nocturnal Secondary enuresis has had a sustained period of bladder control (6-12 months)‏

4 Primary Enuresis Boys 3x girls
Most become continent by adolescence, even without intervention FHx , esp father Likely maturational delay of: sleep/wake mechanisms development of bladder capacity and urethral sphincter control

5 Primary Enuresis 1 14 2-3 12 3-5 10 7 7-8 8 15 5 Occasional daytime wetting Nocturnal enuresis (%)‏ Age in years

6 Daytime Enuresis More common in : Boys = Girls
Kids with hyperactivity Timid/shy kids Boys = Girls 60-80% also have nocturnal wetting

7 Secondary Enuresis Onset after child has had sustained period of continence Often follows a stressful event Loss, new sibling, family discord, move, new school, abuse

8 Differential UTI *MC Distal urethritis (bubble bath)‏
Neurological disorders- congenital or acquired Congenital anomalies (spina bifida)‏ Seizure disorders Diabetes (mellitus or insipidus)‏ Structural abnormalities of the urinary tract (urethral cyst, urethral duplication, obstruction)‏ 1. Need to r/o

9 Diagnosis Take a good history Do a good physical
Observe child’s urinary stream Straining, dribbling, stress incontinence? Urinalysis and urine culture what’s going on in family; potty training hx; 4. To r/o UTI. May not have dysuria

10 Treatment Emphasize that noc wetting is likely developmental lag
NOT acting out, etc Patient understanding and encouragement Spontaneous cure ~15%/year Avoidance of punitive measures Encourage child participation 5. Get them involved

11 Treatment Counseling Bladder training Potty pager/ alarm
Child has active role: keeps calendar, helps with the midnight laundry, talk to the PA Positive reinforcement, remove guilt/blame Bladder training Hold urine longer during day, limit fluids after dinner, practice start/stop urine flow on toilet, pee just before bed. Helpful ~40% Potty pager/ alarm 3. Can be effective. Insurance covers – usually before drugs

12 Meds DDAVP (desmopressin acetate) intranasal qhs. Complete remission during tx 50%, high relapse on discontinuation. Good for special events (camp, sleepovers) and as “bridge” Imipramine (TCA) qhs Anticholinergic side effects Law #13 – delivery of good med care is to do as much nothing as possible – do no harm.

13 Encopresis Fecal incontinence in child who should be continent.
4 years (or developmental equivalent) or older Not due to medication or medical condition Involuntary (usually) or intentional 1-1.5% of school-aged kiddos, very rare in adolescence Boys 4x girls

14 Functional Encopresis Types
Retentive Continuous Discontinuous Toilet phobia

15 Retentive Encopresis *MC
Psychogenic Megacolon Child withholds BMs  constipation  fecal impaction seepage of liquid feces (Type 7!) around impaction and out onto skivvies. Marked constipation Painful defecation Retention reduced sensory feedback Rectal wall stretch causes  contractile strength Harder stools due to increased water absorption Then what happens…? 1. Bristol stool chart

16 Continuous 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 training Often family social/intellectual disadvantage The encopresis is the least of your worries with this child 3. No one tries potty training. 4. This is usually least of concerns about social upbringing.

17 Discontinuous Encopresis
Hx of normal bowel control for extended period Like secondary enuresis, usually in response to stressful event Sometimes voluntary follow-through (smearing, etc)‏

18 Etiologic considerations
Inefficient motility Medical management for (perceived?) bowel disorder Painful defecation (fissures, etc)‏ Surgical hx (imperforate anus)‏ Unrealistic parental expectation 2. Parents think kids are constipated – wide range of “nl”

19 Consequences Fear Shame Isolation Depression
Can depend on caregiver rxn. Need to attend to these other factors during tx

20 History Bowel pattern since birth Age of onset of problems/symptoms
Management attempt and effects Associations (ie with stressors)‏

21 Physical Exam

22 Management (Levine) Counseling Phase
Demystify: Review colon function Normal and abnormal Draw a picture Show imaging Remove blame Explain treatment plan Emphasize intestinal muscle building Talk about it with them. Make it okay Focused on retentive (the most common)

23 Inpatient Catharsis When? What? Severe retention
Poor outlook for home compliance What? Saline enemas bid 3-7 days Bisacodyl suppositories bid 3-7 days Sit on toilet 15 min pc Sometimes need to get them in and clear everything out. 2.3 – try to reset gastrocolic reflex

24 Outpatient Catharsis Mild: Senna daily x 1-2 weeks
Moderate-Severe: 3 day cycles Day 1: Fleet’s enema bid Day 2: Bisacodyl suppository BID Day 3: Bisacodyl suppository once Follow-up x-ray to confirm catharsis

25 Maintenance Sit on toilet bid x 10 min, after meals
2 T mineral oil po bid x 4-6 months MVI supplement Eat fiber! Oral laxative (senna) q day or qod x 1 month Read Anna Karinina ?? Reward- sticker chart, etc 2.1 – worried about malabsorption 3. Like a dry sponge – needs to have water with it to make it work

26 Follow-Up q 1-2 months Check compliance Monitor for relapse
Document progress

27 Thoughts on Potty Teaching
Teach your parents well… Readiness signals: dry periods, interest in toilet,wants to be changed when wet, can follow directions No power struggles Respect child’s autonomy Applaud child’s success Accidents happen

28 Poop Song OIgXyvzUU&feature=rec-rn

29 Acute Diarrhea Gastroenteritis Infectious Food poisoning
Antibiotic-associated Overfeeding Great Ddx chart in Nelson text Need to get a definition of what that means for them.

30 Acute diarrhea Complete history Physical Exam
Include day care, travel, animal contact, foods, antibiotics Physical Exam Stool- check for WBCs and occult blood If neg, think viral If pos- r/o (or in) bacterial cause, then consider IBD 1.1 – who else has it? 2. Sore belly, rash etc

31 Acute diarrhea management
Cure initiating event Correct dehydration and e-lyte deficits Manage complications from mucosal injury NO Imodium, Lomotil, paragoric, etc 2. Do it slowly. 4. don’t want to stop it. Usually happens for a good reason – need to get it out.

32 Chronic Diarrhea Post-infectious secondary lactase deficiency
Cow’s milk intolerance Toddler’s diarrhea Celiac disease CF IBS IBD Giardiasis Laxative abuse AIDS enteropathy

33 Toddler’s Diarrhea- MC Chronic diarrhea in infants
Nonspecific diarrhea of infancy 6m-3y onset, duration >3 weeks Painless First stool of the day formed, become increasingly liquid thru day Exacerbated by teething, infections, also by fruit juices with unabsorbable sugars that increase diarrhea

34 Toddler’s diarrhea Motility disorder with rapid transit
Positive FHx for IBS Dx: r/o infectious causes Tx: high fat, high fiber, low sugar diet

35 Cow’s Milk Intolerance
Infants <1year old Stools contain WBCs, eosiniphils Even in breast-fed babes whose mom’s drink cow milk Diarrhea, vomiting, mucus in stools FTT Assoc with atopy, rhinitis, eczema Dx: Stool studies, CBC Tx: alimentum, nutramagen (not soy) or nursing mom avoid milk

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