Elimination Disorders

May 3, 2012Napatia Tronshaw, MDChild and Adolescent FellowUniversity of Illinois at ChicagoInstitute of Juvenile Research

Normal Development

Toddler Phase (18 months- 3 years)

Bowel Continence

Bladder Continence

Enuresis Nocturnal Enuresis

MonosymptomaticPolysymptomatic

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 CriteriaDiagnostic 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 (occupa tional), 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 OnlyDiurnal OnlyNocturnal and Diurnal

Differential Diagnosis Maturational Anatomical Abnormalities Endocrine Urinary Tract 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