Elimination Disorders: Enuresis and Encopresis

Faisal Ahmed, M.D

Enuresis
Urinary incontinence occurs after the chorological or developmental age of 5 years either at least twice a week for 3 months or sufficiently often to cause distress or impairment.

Clinical Description
Bed Wetting > daytime incontinence Typical occurs 30 minutes to 3 hours after sleep onset. Daytime bladder control usually precedes nocturnal control by 1-2 years. Enuresis is sub classified into two subtypes, primary and secondary. Primary enuresis encompasses children who have never achieved continence, whereas secondary enuresis refers to those children who maintain continence for at least one year, only to lose it at some point after that.

Prevalence
5%-10% of 5 years-olds and around 3%-5% of 10 years olds. 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 1% general prevalence in older adolescents and adults

Clinical Description and

DSM
repeated voiding of urine during the day or at night into bed or clothes, whether involuntarily or intentionally. and that the behavior is clinically significant as manifested by either 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.

Etiology
Familial: 70% of children with Enuresis ( particularly boys) have 1st degree relative functional enuresis. Maturational etiology*. Some have a relative inability to concentrate urine. The development of desmopressin acetate (DDAVP) as a treatment for enuresis Excessive fluid intake. Anatomical abnormalities or UTS Giggle incontinence Medications

Enuresis

(continued)

Epidemiologic studies have shown a correlation between psychological disturbance and enuresis, which is more pronounced in older children. Link to emotional disturbances. Higher rates of behavioral problems Anxiety states, Opposionality, ADHD Secondary Enuresis related to stress, trauma, or psychological crisis.

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

Course and Prognosis

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 caregivers, teasing by peers, avoidance of overnight visits and socializing, angry outbursts.

Evaluation

(Medical)

Initial medical work up is required. Medical workup include: careful medical history, physical examination, urine Flow testing, urine culture and urinalysis. Urinary Osmolality test

Evaluation

(Psychiatric)

Psychiatric evaluation include assessment of associated psychiatric symptoms, recent psychosocial stressors, and family concerns about the problems and management of symptoms.

Treatment

( Factors to consider)

Age of child Medical cause has been ruled out Rate of spontaneous remission (approximately 14%16% per year) 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

Treatment
The two primary means of treating children with enuresis fall into the categories of behavioral and psychopharmacologic methods 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%,

Behavioral Treatment
Bladder capacity alarm: results were comparable with those obtained with the traditional bell and pad technique. Other procedures include reward systems, such as star charts, nighttime awakening to urinate, retention-control training, and fluid restriction.

Psychopharmacologic Methods
Imipramine : 1960 Most children respond in the 75- to 125mg range. A baseline electrocardiogram should be obtained before instituting treatment with imipramine, and monitoring is advised above 3.5 mg/kg No relation to blood level

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
repeated passage of feces into inappropriate places. And soiling must occur at least once a month for at least 3 months and that the mental or chronological age of the child must be at least 4 years

Classification
Primary VS Secondary With constipation and overflow incontinence (Retentive) VS Without ( non retentive)

Clinicals..
Typically occurs during the day. 50-60% have secondary Encopresis. Association with conduct disorder Retentive encopresis is characterized by a cycle of several days of retention, a painful expulsion, and another period of retention. While the fecal mass is growing, there may be leakage around the mass. The category of nonretentive encopresis applies to those children who simply do not control the expulsion of feces on a psychological, physiologic, or combined basis.

Epidemiology
Prevalence decreases with age 3% of 4 year-olds, 2% of 6 years old, and 1.6 % of 10-11year olds. Rare in adolescent School age: Male> female: 2.5:1-6:1 Higher rates in MR and Low socioeconomic classes.

Etiology
Retentive: painful defecation, , inadequate or punitive toilet training, fear of school bathroom, or toilet related fears Mechanisms include altered colon motility, and contraction factors, obstruction, stretched and thinned colon walls, and decreased sensation 2nd to neurological disorder.

Etiology

(continued)

Non retentive : May be deliberate attempt to effect change, as a means of avoiding stressors or communicating anger. Often complicating and difficult to treat.

Course and Prognosis

Secondary Encopresis often starts by age 8 years. Onset before 4: 63% recover with treatment Laxative protocol: 50% recover with no recurrence after 1 year, another 20% after 2 years. (Loening-Baucke 1989). Psychiatric or medical co-morbidity: major determinant of prognosis.

Course and Prognosis

25% co morbid enuresis. Occasionally: symptoms triad: UTI, Constipation and Encopresis.

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

Treatment
The most widely accepted first line of treatment is one that encompasses educational, psychological, and behavioral approaches. Pharmacological treatment with imipramine also has been reported as useful for encopresis.

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

FACTORS TO CONSIDER for TREATMENT FOR ENCOPRESIS

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 Extensive research into biofeedback
Not proven to be more effective than traditional interventions May be a consideration in refractory cases

Case reports of imipramine in the treatment of nonretentive encopresis Psychodynamic assessment for those with volitional encopresis

Thank you