1. Elimination Disorders

2. Enuresis

3. 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.

4. 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

5. 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.

6. 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.

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

9. 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.” 

10. 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

11. 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.

12. 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%)

13. 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.

14. 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%,

15. 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.

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

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

18. 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.

19. 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.

20. Encopresis

21. 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

22. 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.

23. 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.

24. 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

25. 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.

26. 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

27. 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.

28. 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

29. 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.

30. 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

31. 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.