Elimination Disorders

Enuresis

Definitions Enuresis refers to the involuntary or intentional voiding of urine. Primary enuresis: child never established urinary continence. Secondary enuresis: occurs after a period of urinary continence(roughly six months or more). Diurnal includes daytime episodes. Nocturnal includes nighttime episodes.

Epidemiology Primary Enuresis: Male predominance. decreases with age. The point prevalence figures cited in DSM-IV-TR are 7 percent of boys and 3 percent of girls at 5 years of age, 3 percent of boys and 2 percent of girls by 10 years of age. Only 1 percent of boys still wet at age 18 years of age, and still fewer girls wet at this age. 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

Epidemiology DSM-IV-TR also cites a spontaneous remission rate of between 5 percent and 10 percent per year after 5 years of age. Secondary enuresis may occur at any time but most commonly begins between 5 years of age and 8 years of age Mental disorders are present in 20% of patients. Bed Wetting > daytime incontinence Typical occurs 30 minutes to 3 hours after sleep onset.

Etiology  Familial: 70% of children with Enuresis ( particularly boys) have 1st degree relative functional enuresis. Maturational etiology*. Anatomical abnormalities or UTS Giggle incontinence Medications Epidemiologic studies have shown a correlation between psychological disturbance and enuresis. Link to emotional disturbances. Higher rates of behavioral problems(Anxiety states, Opposionality, ADHD) Secondary Enuresis related to stress, trauma, or psychological crisis or infection … * Small volume voiding, short stature, low mean bone age, and developmental delayed sexual maturation.

Medical Causes UTI Urethritis Diabetes Sickle cell anemia Seizure disorder Neurogenic bladder Anatomy Obstruction

Diagnosis and Clinical Features repeated voiding of urine during the day or at night into bed or clothes whether involuntarily or intentionally the behavior is clinically significant as manifested 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.” 

DSM-IV-TR Diagnostic Criteria for Enuresis A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional). B. The behavior is clinically significant as manifested by a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. C. Chronological age is at least 5 years of age (or equivalent developmental level). D. The behavior is not due to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, or a seizure disorder). Specify type:    Nocturnal only    Diurnal only    Nocturnal and diurnal

Diagnostic Criteria for Nonorganic Enuresis A. The child's chronological and mental age is at least 5 years. B. Involuntary or intentional voiding of urine into bed or clothes occurs at least twice a month in children younger than 7 years of age and at least once a month in children 7 years of age or older. C. The enuresis is not a consequence of epileptic attacks or of neurological incontinence and is not a direct consequence of structural abnormalities of the urinary tract or any other nonpsychiatric medical condition. D. There is no evidence of any other psychiatric disorder that meets the criteria for other ICD-10 categories. E. Duration of the disorder is at least 3 months.

Differential diagnosis Genitourinary pathology such as obstructive uropathy, spina bifida occulta, and cystitis. Diabetes mellitus. Seizures, and side effects of medication, such as antipsychotics or diuretics. Because urinary tract infections can produce enuresis, a urinalysis should be part of every evaluation. Using radiographic procedures with contrast media to detect an anatomical or physiological are invasive and painful, and the diagnostic yield is low.( 3.7%)

Course and prognosis usually self-limited; remissions are frequent between 6 and 8 years and puberty. 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 care givers, teasing by peers, avoidance of overnight visits and socializing, angry outbursts.

Treatment ( Factors to consider) Age of child Medical cause has been ruled out Rate of spontaneous remission 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 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 75%,

Treatment General measures : - Restrict fluid intake 3-4 hours beforebedtime. - Empty bladder before retiring to bed. -Keep a chart of wet and dry nights [ STAR CHART ]. - Reward for dry nights. -Avoid punishment/criticism.

Behavioral therapy such as buzzer that wakes child up when sensor detects wetness.

B. Psychotherapy not an effective treatment alone, but can be useful in dealing with coexisting psychiatric problems and emotional and family difficulties.

Most children respond in the 75- to 125-mg range. C. Pharmacotherapy include antidiuretics (such as desmopressin) or Tricyclic antidepressant (such as imipramine) Imipramine 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 relation to blood level  ?! The standard maximal limit for dosage is 5 mg/kg body weight.

DDVAP DDVAP 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 better.

Encopresis

Definition Encopresis : repeated passage of feces into inappropriate places at least once a month for at least 3 months the mental or chronological age of the child must be at least 4 years

Epidemiology. Prevalence is about 1% of 5-year-old children. Prevalence decreases with age A significant relation between encopresis and enuresis has also been found School age: Male> female: 2.5:1-6:1 Higher rates in MR and Low socioeconomic classes.

Etiology Constipation with overflow incontinence can be caused by nutrition; structural disease of the anus, rectum, or colon; medical side effects; or endocrine disorders. Children without constipation and overflow incontinence often have lack of sphincter control. Inadequate training or Emotional issues. Emotional stress also may trigger encopresis. A child may experience stress from premature toilet training or an important life change — for instance, the divorce of a parent or the birth of a sibling.

DSM-IV-TR Diagnostic Criteria for Encopresis A. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional. B. At least one such event a month for at least 3 months. C. Chronological age is at least 4 years of age (or equivalent developmental level). D. The behavior is not exclusively due to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation. Code as follows:    With constipation and overflow incontinence    Without constipation and overflow incontinence

Diagnostic Criteria for Nonorganic Encopresis A. The child repeatedly passes feces in places that are inappropriate for the purpose (e.g., clothing or floor), involuntary or intentionally. (The disorder may involve overflow incontinence secondary to functional fecal retention.) B. The child's chronological and mental age is at least 4 years of age. C. There is at least one encopretic event per month. D. Duration of the disorder is at least 6 months. E. There is no organic condition that constitutes a sufficient cause for the encopretic events.

Differential diagnosis Hirschprung disease Thyroid diseases Hypocalcaemia Lactase deficiency Pseudo obstruction Myelomeningiocele Cerebral palsy with hypotonia Rectal stenosis Anal fissure Anal trauma Anxiety or Phobia

Course and prognosis Outcome depends on the cause, the chronicity of the symptoms, and coexisting behavioral problems. Many cases are self-limiting, rarely continuing beyond mid-adolescence. 25% co morbid enuresis Psychiatric or medical co-morbidity: major determinant of prognosis.

FACTORS TO CONSIDER for TREATMENT 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 reinforcement

Treatment The most widely accepted first line of treatment is one that encompasses educational, psychological, and behavioral approaches The goal of treatment is to prevent constipation and encourage good bowel habits. Educating the child and family about the disorder is another important part of treatment.

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

Treatment There are several methods for clearing the colon and relieving constipation including: Stool softeners, such as lactulose Colon lubricants, such as mineral oil Rectal suppositories Enemas More oral fluids   Pharmacological treatment with imipramine also has been reported as useful for encopresis.