1. Wetting and Soiling Lydia Burland

2. 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

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

4. 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

5. Nocturnal Enuresis

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

7. What are the risk factors? Nocturnal Enuresis

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

9. What else should you ask in the history? Nocturnal Enuresis

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

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

12. Encopresis

13.  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

14.  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

15. 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

16. 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

17.  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

18.  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

19.  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

20. Practice Questions

21. 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

22. 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

23. 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 38.1. 6. 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

24. 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

25. Answers

26. 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

27. 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

28. 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

29. 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 38.1. 6. 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

30. 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 38.1. 6. 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

31. 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

32. 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

33.  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

34.  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

35.  NICE Nocturnal Enuresis Guideline  NICE Constipation in Children and Young People  www.ERIC.org.uk Extra Reading

36. Thanks