Elimination Disorders

May 3, 2012
Napatia Tronshaw, MD
Child and Adolescent Fellow
University of Illinois at Chicago
Institute of Juvenile Research
 Normal Development
 Toddler Phase (18 months- 3 years)

 Bowel Continence

 Bladder Continence
 Enuresis
 Nocturnal Enuresis
Monosymptomatic
Polysymptomatic

 Diurnal Enuresis

 Primary Enuresis

 Secondary Enuresis
 Types of Enuresis
 Regressive Enuresis

 Monosymptomatic Nocturnal Enuresis

 Polysymptomatic Nocturnal Enuresis

 Functional Enuresis

 Nonfunctional Enuresis

 Revenge Enuresis

 Enuresis due to lack of training

 Detrusor Dependent Enuresis

 Volume-Dependent Enuresis
 Prevalence
 30% of US children achieve continence by age 2

 5-10% of 5 year olds meet criteria for nocturnal

enuresis

 15% of enuretic children have spontaneous

resolution of symptoms each year

 2-3% of 12 year olds meet criteria for nocturnal

enuresis

 1% of 18 year olds still have enuretic symptoms

 Diagnostic Criteria
Diagnostic criteria for 307.6 Enuresis
 A. Repeated voiding of urine into bed or clothes (whether
involuntary or intentional).
 B. The behavior is clinically significant as manifested by either 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 (or equivalent
developmental level).
 D. The behavior is not due exclusively to the direct physiological
effect of a substance (e.g., a diuretic) or a general medical
condition ( e.g., diabetes, spina bifida, a seizure disorder).
 Specify type:
 Nocturnal Only
 Diurnal Only
 Nocturnal and Diurnal
 Differential Diagnosis
 Maturational
 Anatomical Abnormalities
 Endocrine
 UrinaryTract Disease
 Neurological
 Medications
 Psychological
 Diagnostic Workup
 Child’s Age
 Onset of Symptoms (Primary/Secondary)
 Timing (Nocturnal/Diurnal/Both)
 Frequency
 Family History
 Developmental History
 Physical Exam
 Neurological Exam

 Throat and Neck Exam

 Skin Exam

 Abdominal Exam

 Routine Blood Draw

 UA
 Consults
 Pediatric Urology
 Ultrasound of Genitourinary system
 Voiding Cystourethrogram
 Renal Ultrasound
 Pediatric Neurology
 Sleep Study
 Treatment
 Education

 Watchful Waiting

 Non-pharmacological Management

 Pharmacological Management

 Therapeutic Interventions
 Non-Pharmacological
Interventions
 Education

 Advice

 Bell and Pad

 Non-Pharmacological
Interventions
 Bladder-Volume Alarm

 Star Chart System

 Nightlifting

 Timed Night Awakening

 Bladder Training Exercises/Overlearning

 Pharmacological
Interventions
 Desmopressin

 Imipraminine

 Oxybutynin

 TCAs, SSRIs & Psychostimulants

 NSAIDs
 Additional Treatments
 Cognitive Behavioral Therapy

 Psychodynamic Psychotherapy

 Biofeedback

 Acupuncture
 Encopresis
 Primary Encopresis

 Secondary Encopresis

 Retentive Encopresis

 Nonretentive encopresis
 Prevalence
 Secondary encopresis is more common

 Between ages 7-8 prevalence is 1.5%

 3:1 male to female ratio

 Retentive type is 80-95% of cases

 Diagnostic Criteria
 Repeated passage of feces into inappropriate
places (e.g., clothing or floor) whether voluntary or
unintentional
 At least one such event a month for at least 3
months
 Chronological age of at least 4 years (or
equivalent developmental level)
 The behavior is not exclusively due to a
physiological effect of a substance (e.g., laxatives)
or a general medical condition, except through a
mechanism involving constipation.
 Diagnostic Criteria
 The DSM-IV recognizes two subtypes with constipation
and overflow incontinence, and without constipation
and overflow incontinence. In the subtype with
constipation, the feces are usually poorly formed and
leakage is continuous, and occurs both during sleep and
waking hours.

 In the type without constipation, the feces are usually

well-formed, soiling is intermittent, and feces are usually
deposited in a prominent location. This form may be
associated with oppositional defiant disorder or conduct
disorder, or may be the consequence of large anal
insertions, or more likely due to chronic encopresis that
has radically desensitized the colon and anus
 Etiology
 Delay in Maturation

 Underlying Medical Condition

 Psychological/Behavioral

 Constipation
 Primary Retentive
Encopresis
 Delayed Physical Maturation

 Inappropriate Toilet Training

 Retentive Encopresis
 Represents 80-95% of cases

 Infrequent Bowel Movements

 Large Stools

 Painful Defecation
 Secondary Encopresis
 Birth of sibling

 Parental Divorce

 Abuse

 ODD or CD

 MR/Autism/ Psychosis/RAD
 Diagnosis
 Child’s age
 Onset (primary/secondary)
 Timing (day/night)
 Frequency
 Location of soiling
 Bowel Habits (frequency, stool size,
consistency)
 Melena/Hematochezia
 Pain with Defecation/Fluid and Dietary
Habits
 Physical Exam
 Abdominal pain/distention
 Height/Weight
 Neurological Exam
 Skin Exam
 Rectal Exam
 Abdominal XRAY
 Stool Collection
 Blood Testing
 Rectal Biopsy/Barium Enema
 Treatment
 Advice/Education

 Nonpharmacological

 Pharmacological Intervention
 Advice/Education
 Dietary Changes (foods high in fiber)

 Increase Fluid Intake

 Make Toilet Training Non-Threatening

 Make Toilet Accessible

 Regular Bathroom Times

 Nonpharmacological
 CBT

 Psychodynamic Psychotherapy

 Biofeedback

 Acupuncture
 Pharmacological
 Laxatives

 Suppositories

 Enemas

 Mineral Oil

 Stool Softeners