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PEDIATRIC ELIMINATION DISORDERS

S O P H I A L . T H O M A S M N , A P R N , F N P - B C , P P C N P - B C , F N A P , F A A N P

I HAVE NO KNOWN CONFLICTS OR DISCLOSURES

Objectives:

1. Define elimination disorders

2. Discuss diagnostic criteria for enuresis and encopresis

3. Differentiate classifications of these disorders

4. Discuss treatments for these disorders

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ELIMINATION DISORDERS

Elimination disorders are disorders that concern the elimination of feces or urine from the body.

The American Psychiatric Association recognizes two elimination disorders:

Enuresis F98.0

Encopresis F98.1

NORMAL DEVELOPMENT

Toddler Phase (18 months- 3 years)

Bowel Continence

Bladder Continence

TOILET TRAINING 101

Readiness for Toilet TrainingMajor milestone in physical and social development that is often

achieved during the day by 36 months although accidents may continue through 5 yearsReadiness CriteriaBladder control (should empty completely and stay dry)Physical readiness (fine- and gross-motor coordination) Instructional readiness (ability to follow directions)

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Enuresis (urinary incontinence) is the persistent inability to control urination that is not consistent with one’s development age.

‘Enuresis’ is derived from the Greek word ‘enourein’, which means ‘to void urine’.

2-10% of children affected

Nocturnal enuresis is more commonly known as bedwetting

ENURESIS CLASSIFICATIONS 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

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PREVALENCE 30% of US children achieve continence by age 2

More common in males. Age 7: 9% boys and 6% girls

Mortality: only due to fatal abuse

At age 4, 25% of kids wet the bed; 5-10% of 7 year olds

15% of enuretic children have spontaneous resolution of symptoms each year

8% of boys/4% girls age12 years meet criteria for nocturnal enuresis

1% of 18 year olds still have enuretic symptoms

Resolution of 15% per year

30% of children with ADHD

Health and Psychological Consequences

Could be marker for medical conditions such as urinary tract infections Psychosocial consequences result from

shaming, blaming and characterological attributions that are directed to incontinent children in addition to increased risk of child abuse secondary to incontinence

Evidence-based Assessment No widely used tools Most research using instruments that

incorporate items into larger constellation of items on psychosocial issues Dysfunctional Voiding Scoring System

assesses enuresis and other co-morbid voiding and/or elimination symptoms Domains of interest include wet or dry

days or nights and size of urine spot

ENURESIS

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ENURESIS DIAGNOSTIC CRITERIADSM-5 Diagnostic Criteria for Enuresis F98.0

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 OnlyDiurnal OnlyNocturnal and Diurnal

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DIFFERENTIAL DIAGNOSIS

MaturationalAnatomical AbnormalitiesEndocrineUrinary Tract DiseaseNeurologicalMedicationsPsychological

DIAGNOSTIC WORKUPChild’s AgeOnset of Symptoms (Primary/Secondary)Timing (Nocturnal/Diurnal/Both)FrequencyFamily HistoryDevelopmental HistoryHydration and nutrition historyDaytime voiding patternToilet training historySleep historyBehavior, personality, and emotional status

PHYSICAL EXAM

Neurological Exam

Throat and Neck Exam

Skin Exam

Abdominal Exam

CMP (but blood tests usually not necessary)

UA

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COMMON UNDERLYING PROBLEMS

• Overactive bladder or dysfunctional voiding

• Cystitis or UTI

• Constipation

• Neurogenic bladder

• Sleep-disordered breathing

• Urethral obstruction

• Major motor seizure

• Ectopic ureter

• Diabetes mellitus or insipidus

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

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NON-PHARMACOLOGICAL INTERVENTIONS

Education

Behavioral Modification

Bell and Pad

NON-PHARMACOLOGICAL INTERVENTIONS Bladder-Volume Alarm

Star Chart System

Nightlifting

Timed Night Awakening

Bladder Training Exercises/Overlearning

Evidence-based Interventions

Bell-and-Pad or Urine-Alarm Training treatment success is higher and relapse rate lower than any other method, especially when combined with Desmopressin

ENURESIS

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Medications Desmopressin AcetateOxybutynin Chloride Imipramine

Other Treatment Approaches Hypnosis Sphincter exercises Restriction of fluids before bed

ENURESIS

PHARMACOLOGICAL INTERVENTIONS

Desmopressin

Oxybutynin

Imipramine

TCAs, SSRIs & Psychostimulants

NSAIDs

PATHYPHYSIOLOGY, CLASSIFICATION, & TREATMENT STRATEGIES

Wright, A. (2016) Childhood enuresis. Paediatrics and Child Health, 26( 8) 353-359

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DESMOPRESSIN (DDAVP)

• For polyuria• A synthetic analogue of ADH• Increases water uptake of the renal distal tubules ===

diminishes urine production• Must restrict fluids 1 hr before and 8 hrs after administration

(risk of hyponatremia)• May use in conjunction with the alarm• 1/3 of children don’t respond – most have small nocturnal

bladder capacity• Dose age 6 and older: tablets 0.2mg q hs, max 0.6mg• *nose spray no longer indicated for primary enuresis due to

hyponatremia risk• Not all children will respond; not all kids with enuresis have

low ADH or overproduce urine

PATHYPHYSIOLOGY, CLASSIFICATION, & TREATMENT STRATEGIES

Wright, A. (2016) Childhood enuresis. Paediatrics and Child Health, 26( 8) 353-359

OXYBUTYNIN

Anticholinergic

Beneficial for children who have small bladder capacity, daytime symptoms of frequency and urgency, or those who wet more than once at night

Does not decrease urine production

For detrusor overactivity: Relaxes bladder smooth muscle: Allows the bladder to hold more urine

Start in ages over 5 years old 5mg BID

Maximum dose is a total of 15 mg per day

Onset 1 hr, t1/2 2‐3 hrs

Extended release for children older than 6 at 5mg po daily

Maximum is 20 mg po daily (increase by 5mg weekly)

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IMIPRAMINE (TOFRANIL)

Tricyclic antidepressant

Facilitates urine storage by decreasing bladder contractility and increasing outlet resistance

Inhibits reuptake of norepinephrine and seratonin at the presynaptic neuron

First prescribed for enuresis when psych causes of enuresis were considered common

Dose 1 hr before bed: 6-12 years 10-25 mg qhs, max 50 mg

12+ years 10-25 mg qhs, max 75 mg

Dose earlier in early night wetters

Black box warning – suicide risk, worsening MDD

Caution in cardiovascular disease, possibility of arrhythmias

Baseline EKG

TREATMENT ALGORHYTHM FOR NOCTURNAL ENURESIS

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ADDITIONAL TREATMENTSCognitive Behavioral Therapy

Psychodynamic Psychotherapy

Biofeedback

Acupuncture

Encopresis is a repeated passage of feces into inappropriate places, such as on clothing or the floor.

Usually involuntary in nature, often related to constipation, impaction and retention with a resultant overflow

May be intentional in some cases

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ENCOPRESISPrimary Encopresis

Secondary Encopresis

Retentive Encopresis

Nonretentive encopresis

ENCOPRESIS PREVALENCESecondary 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

25% of encopretic kids have enuresis

ENCOPRESIS RISK FACTORS

Abuse or neglect;

Diet that is rich in fat and/or sugar;

Inadequate water intake;

Presence of chaos or unpredictability in the patient’s life;

Lack of physical exercise;

Refusal to use the bathroom, especially public restrooms;

Presence of a neurological impairment;

History of constipation or painful defecation;

Cognitive delays, such as autism or mental retardation;

Presence of obsessive/compulsive disorders;

ADHD or difficulty focusing;

Learning disabilities

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ENCOPRESIS ETIOLOGYDelay in Maturation

Underlying Medical Condition

Psychological/Behavioral

Constipation

Etiology Biological Variables Genetics

Developmental Delay?

Hirschsprung’s disease

Emotional Variables Early theories assumed

psychodynamic etiology (e.g., unconsious conflict, personality profiles)

Etiology (Cont) Learning Variables Most useful view considers types Manipulative

Stress-induced

Constipation (80-95% of cases)

Manipulative soiling follows reinforcement model

Chronic diarrhea and loose bowels

Chronic Constipation Diet

Toilet habits/Withholding

School bathroom conditions

ENCOPRESIS

ENCOPRESIS

DSM-V Diagnostic Criteria for Encopresis

A. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional.

B. At least 1 event a month for at least 3 months.

C. Chronological age is at least 4 years (or equivalent developmental level).

D. The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.

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DIAGNOSTIC CRITERIAThe DSM-IV recognizes 2 subtypes:1. constipation and overflow incontinence• Feces poorly formed, leakage continuous, occurs sleeping

and waking hours2. without constipation and overflow incontinence• 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

ENCOPRESIS

SYMPTOMS

• Occasional passage of very large stools;

• Secretive behavior associated with the act of having a bowel movement;

• Inability to retain feces (bowel incontinence);

• The passage of stool in inappropriate places (for example in the child’s clothing);

• Constipation and/or hard stools

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PRIMARY RETENTIVE ENCOPRESIS

Delayed Physical Maturation

Inappropriate Toilet Training

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RETENTIVE ENCOPRESISRepresents 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

Health and Psychological Consequences

Most serious/common involves urinary tract infections from contamination of urinary tract with feces from child’s underwearMost serious social consequence is

teasing and ridicule from peers, classmates, friends, and siblings

Evidence-based AssessmentOne of the available general

parent and teacher rating scales (BASC, CBCL, Connors CBRS) to identify comorbidities such as ODD and ADHD which may interfere with parent’s ability to implement treatment recommendations

ENCOPRESIS

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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

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EDUCATIONDietary Changes (foods high in fiber)

Increase Fluid Intake

Make Toilet Training Non-Threatening

Make Toilet Accessible

Regular Bathroom Times

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Other Treatment ApproachesBiofeedback no better than

Medical-BehavioralFor “Manipulative Soiling”Behavioral and family therapyCoping and communication skills emphasizedReward appropriate behaviors and do not reinforce soiling behavior

Other Treatment Approaches (Cont) For “Chronic Diarrhea or Irritable

Bowel Syndrome” Stress reduction and learning

effective coping skills Systematic desensitization and

hypnosis Relaxation training, stress inoculation

training, assertiveness training, general stress management Supportive psychotherapy and

antidiarrheal medications

ENCOPRESIS

NONPHARMACOLOGICAL

CBT

Psychodynamic Psychotherapy

Biofeedback

Acupuncture

PHARMACOLOGICAL

Laxatives

Suppositories

Enemas

Mineral Oil

Stool SoftenersFiber supplements

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MAINTENANCE MEDICATIONS

Osmotic laxatives

Mechanism of Action: Retain water in stool, which adds bulk and softness, results in distension and promotes peristalsis

Lactulose (concentration: 10 g / 15 mL)• Lactulose is a synthetic, nonabsorbable disaccharide.• Dose: 1 to 3 mL/kg/day divided doses BID• Tastes sweet• Abdominal cramping, flatus

Sorbitol: 1 to 3 mL per kg per day given in divided doses twice dailyLess costly than lactulose

MAINTENANCE MEDICATIONS

Magnesium hydroxide (MOM, Pedia-Lax)• Magnesium is a divalent cationmaximally absorbed at distal small intestine• Dose: 1 to 3 mL/kg/day divided doses BID for > 2 years old• Thick, chalky. May mix with milk/choc milk• May cause cramping (increased Mag levels stimulate GI motility and secretion)• With OD/renal insufficiency: risk of hypermagnesemia, hypophosphatemia, or

secondary hypocalcemia

Polyethylene glycol powder (Miralax)• Long chain of ethylene glycol, poorly absorbed• Dose: 17 g /240 mL water/juice // 6 months and older: 0.5 -1.5 g/kg/day for no

more than 2 weeks• Titrate dosage at three-day intervals to achieve mushy stool consistency.• Benefits: Solution may be prepared in advance for administration over one to two

days.• Better adherance, tasteless and odorless, dissolve in all liquids

MAINTENANCE MEDICATIONS

Mineral Oil Suspension:Lubricant

Nonabsorbable fat

Softens stool, decreases water absorption from GI tract, and eases passage

Dose: age 6-11 10-25 mL/day, >12 15-45 mL/day

tasteless, chill or give with juice

Don’t use > 1 week

Adherence problems: Leakage may occur if dose is too high or impaction is present.

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THANK YOU!