Wetting and Soiling Lydia Burland

By the end of the session you should;  Know the usual ages at which children become toilet trained  Be able to define nocturnal enuresis and encopresis  Be able to list the risk factors for both nocturnal enuresis and encopresis  Be able to take a history and explain the initial management strategies  Be able to answer exam-based questions Learning Outcomes

When do children usually gain bowel and bladder control? Toilet Training

4 years Majority have bowel control 4 ½ years 79% dry 5+ nights a week 8% frequently bedwetting 5 yearsMajority have bladder control 9 ½ years 92% dry 5+ nights a week 1.5% frequently bedwetting Toilet Training

Nocturnal Enuresis

 Involuntary wetting during sleep  Without underlying pathophysiology  May be associated with;  Excessive nocturnal urine production  Poor sleep arousal  Reduced bladder capacity Nocturnal Enuresis

What are the risk factors? Nocturnal Enuresis

Risk factors include;  Family history  Daytime wetting and encopresis  Developmental delay  Constipation  Excess methylxanthine-containing drinks  Emotional stressors Nocturnal Enuresis

What else should you ask in the history? Nocturnal Enuresis

Ask about;  The wetting  Daytime urination habits  Drinking habits  Bowel habits  Development  Behaviour or emotional issues  Recent lifestyle changes or stressors Nocturnal Enuresis

 Investigations may include a urine dip and blood sugar  Management;  If <5 years, reassure parents  Lifestyle changes  Star charts and alarms  Desmopressin Nocturnal Enuresis

Encopresis

 Passage of stool into underwear after a child is toilet trained  Often occurs in the afternoon and evening  Children often feels guilty or ashamed, and may try to hide the problem What’s the most common cause of soiling? Encopresis

 Constipation is the most common cause;  Pain on defecation results in reluctance to pass stool  This leads to a build up of stool, which gets stuck and stretches the rectum  The muscles are weakened and watery stools can leak around (overflow)  Parents may confuse overflow for diarrhoea Encopresis

Other causes of encopresis;  Emotional issues  Sexual abuse Cause of constipation;  Dietary  Hypothyroidism  Coeliac disease  Cystic fibrosis  Cow’ milk protein intolerance  Hypocalcaemia  Hirschprung’s disease Encopresis

History;  Frequency of stools  Consistency  Episodes of incontinence  Episodes of soiling  Pain or crying on defecation  Any associated behaviours  When did they first pass meconium Encopresis

 On examination;  Faecal mass on examination  Peri-anal fissures  Rectal examination rarely performed  First line investigations may include TFTs, coeliac screening and AXR for faecal impaction Encopresis

 Conservative measures;  Increased fluids and fibre  Encourage appropriate toilet habits and star charts  Avoid punishment for soiling/accidents  Laxatives;  Lactulose/movicol  Suppositories and enemas;  Used only under specialist advice Encopresis

 Disimpaction;  Daily increasing osmotic laxative for 2 weeks  If not effective addition of stimulant  Addition of suppositories/enemas under specialist  Manual evacuation  Once successful laxatives can be weaned, but not stopped  Long-term treatment allows rectum to return to normal size and sphincter function to be regained Encopresis

Practice Questions

1.Nocturnal enuresis is associated with... a. Increased bladder capacity b. Vesico-ureteric reflux c. Poor sleep arousal d. Abnormal sleep pattern 2.Enuresis alarms are most appropriate above what age? a. 5 yearsb. 6 years c. 7 yearsd. 8 years MCQs

a. Hypothyroidismb. Dietary c. T1 diabetes mellitusd. UTI e. Coeliac disease f. Sexual abuse 3. A 6 year old girl presents with constipation after emigrating from Peru. On examination she is short, has coarse facies and mild hypotonia. 4. A 9 month old presents with constipation since weaning at 6 months. There is a family history of T1DM and thyroid disease. EMQs

a. Hypothyroidismb. Dietary c. T1 diabetes mellitusd. UTI e. Coeliac disease f. Sexual abuse 5. A 5 year old presents with a 4/7 history of day and night time wetting, having been previously toilet trained. Temperature A 11 month old Slovakian boy presents with constipation. He drinks 5x 7oz bottles a day, plus some solids. He is generally tender on palpation. EMQs

5. An 11 year old presents with abdominal pain. He is generally tender on examination. FBC/U+E/CRP are normal. a.List two initial investigations. b.What would be your management plan? Clinical Image

Answers

1.Nocturnal enuresis is associated with... a. Increased bladder capacity b. Vesico-ureteric reflux c. Poor sleep arousal d. Abnormal sleep pattern 2.Enuresis alarms are most appropriate above what age? a. 5 yearsb. 6 years c. 7 yearsd. 8 years Answers: MCQs

a. Hypothyroidismb. Dietary c. T1 diabetes mellitusd. UTI e. Coeliac disease f. Sexual abuse 3. A 6 year old girl presents with constipation after emigrating from Peru. On examination she is short, has coarse facies and mild hypotonia. 4. A 9 month old presents with constipation since weaning at 6 months. There is a family history of T1DM and thyroid disease. Answers: EMQs

a. Hypothyroidismb. Dietary c. T1 diabetes mellitusd. UTI e. Coeliac disease f. Sexual abuse 3. A 6 year old girl presents with constipation after emigrating from Peru. On examination she is short, has coarse facies and mild hypotonia. 4. A 9 month old presents with constipation since weaning at 6 months. There is a family history of T1DM and thyroid disease. Answers: EMQs

a. Hypothyroidismb. Dietary c. T1 diabetes mellitusd. UTI e. Coeliac disease f. Sexual abuse 5. A 5 year old presents with a 4/7 history of day and night time wetting, having been previously toilet trained. Temperature A 11 month old Slovakian boy presents with constipation. He drinks 5x 7oz bottles a day, plus some solids. He is generally tender on palpation. Answers: EMQs

a. Hypothyroidismb. Dietary c. T1 diabetes mellitusd. UTI e. Coeliac disease f. Sexual abuse 5. A 5 year old presents with a 4/7 history of day and night time wetting, having been previously toilet trained. Temperature A 11 month old Slovakian boy presents with constipation. He drinks 5x 7oz bottles a day, plus some solids. He is generally tender. Answers: EMQs

5. An 11 year old presents with abdominal pain. a.List two initial investigations. Coeliac screening (IgA tTG antibodies, EMA) TFTs Calcium Answers: Clinical Image

5. An 11 year old presents with abdominal pain. a.List two initial investigations. b.What would be your management plan? Movicol disimpaction Answers: Clinical Image

 Nocturnal enuresis is common, even in older children and teenagers  Ensure no underlying pathology through history taking, urine dip and BM monitoring  Reassure parents and provide lifestyle advice  Star charts and enuresis alarms are first line Key Learning Points

 Children usual gain bowel control before gaining bladder control  The most common cause of encopresis is constipation, affecting up to 30% of children  Take and good history and perform baseline investigations to rule out other causes  Initial management involves dietary and lifestyle advice, before starting osmotic laxatives Key Learning Points

 NICE Nocturnal Enuresis Guideline  NICE Constipation in Children and Young People  Extra Reading

Thanks