Elimination Disorder in childhood

1. ENURESIS AND ENCOPRESIS
(ELIMINATION DISORDERS)
BY
HANAFI HABEEB
Department of Paediatrics
University of Abuja Teaching Hospital, Abuja
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2. OUTLINE:
Introduction
Epidemiology
Classification
Risk factors/ Aetiology
Pathophysiology
Clinical features
Diagnosis/Investigation
Treatment
Prognosis
conclusion
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3. ENURESIS: Introduction
• Derived from a Greek word enourein – to void
– Enuresis is defined as involuntary (or even intentional)
wetting in children 5 years of age or older after
organic causes have been ruled out (ICD-10 & DSM-IV)
• A form of elimination disorder in childhood (DSM-V)
• A source of emotional and physical distress in
patients and parents
• Achieving continence is the main goal of
treatment
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4. Epidemiology
• Most common urologic condition in childhood
• More common in males than female (1.4:1)
• Prevalence decreases with age
• 23% at age 5; 10% at age 7; 4% at age 10 (Robson,2010)
• 17% among children in SW, Nigeria (Osungade et al)
• 27% among children in Portharcourt, Nigeria (Paul et al)
• No documented racial predisposition
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5. Classification
• Primary and secondary enuresis
• Consider the longest dry period and if lower urinary tract symptoms
are present
• Primary enuresis (~80%): the child has been dry for
less than 6 months (or not at all)
• Secondary enuresis (~20%): a relapse after a dry
period of at least 6 months has occurred
• Further divided into subtypes, based on time of
occurrence
– Nocturnal (ie. during sleep)
– Diurnal (ie. during waking hours)
– Nocturnal and diurnal – nonmonosymptomatic enuresis
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6. Risk factors/ Aetiology
• Risk factors are mainly:
Genetic predisposition – concordance in twins
Family history – 40% with one parent; 70% with
both
Emotional disturbance
Psychosocial stress
Functional or physical abnormalities
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7. Risk factor/ Aetiology cont…
Primary Enuresis
Idiopathic
Overactive bladder
UTI – cystitis/ Urethral
obstruction
Constipation
Neurogenic bladder/
bladder abnormalities
Psychological
Diabetes insipidus
Ectopic ureter
Secondary Enuresis
Idiopathic
Psychological
DM/DI
Seizure disorders
Dysfunctional voiding dx
Obstructive sleep apnea
UTI/ Urethral
obstruction
Constipation
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8. Pathophysiology
– By approximately age 4years, all children with
normal bladder should have achieved continence
– Increased urine volume (polyuria) affects some,
but not all children. This is associated with a
circadian variation (but not lack) of the
antidiuretic hormone (Rittig et al, 1989).
– Impairment of arousal, means that children with
enuresis do not wake up when their bladder is full
(Wolfish et al, 1997)
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9. Pathophysiology…
– Finally, children have an inhibition deficit of the
pontine micturition centre of the brainstem.
When the bladder is full during sleep, they are not
able to sufficiently suppress emptying (Koff, 1996)
– This leads to voiding of urine (bedwetting)
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10. Clinical features
Meticulous History:
– Hydration Hx
– Voiding pattern –
frequency, timing etc
– Toilet training Hx
– Sleep Hx
– Behaviour, personality and
emotional status
– Hx of possible aetiology
– FHx of enuresis
– Nutrition Hx
– Developmental Hx
Physical Examination:
– GPE – clues about child
dev. and parent-child
interaction pattern
– Abdominal exam & DRE –
enlarged kidneys, hard
stool mass, loss of anal
wink
– Neuro Exam – power, tone,
reflexes, sensation
– Spine Exam – spinal defect
& dysraphism
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11. Diagnosis/ Investigation
• Urinalysis – very important test
• Voiding chart
• Others (not routinely done)
– Urine M/C/S
– KUB USS
– MCUG
– Uroflowmetry
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12. Diagnosis/ Investigation
According to DSM-V criteria:
• Repeated voiding of urine into bed or clothes,
whether voluntary or involuntary
• The behaviour either:
– Occurs at least twice a week for at least 3
consecutive months; or
– Results in clinically significant distress or social,
functional, or academic impairment
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13. Diagnosis cont…/ Investigation
• The behaviour occurs in a child who is at least
5 years old (or has reached the equivalent
developmental level)
• The behaviour cannot be attributed to the
physiologic effect of a substance or other
medical condition
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14. Treatment
• Preliminary management – focuses on:
– Counseling
– Educating
– Behavioural modification
• Alarm therapy – more effective
• Pharmacotherapy – low curative potential
– ADH analogue: desmopressin
– TCA: imipramine
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15. Prognosis
• Spontaneous cure, even without treatment
• Relapse is the most common complication
• Mortality attributed directly to enuresis has not
been reported
• Improvement in self-esteem is noted with all
therapies
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16. Encopresis: Introduction
• Bowel control is an important developmental
milestone for children
• Encopresis is defined as both voluntary and involuntary
passage of faeces in inappropriate places in a child
aged four years or older, after organic causes have
been ruled out (ICD-10 & DSM-IV)
• More stigmatized than enuresis and urinary
incontinence
• Associated with high levels of distress for both children
and parents.
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17. Epidemiology
• Common disorder affecting children > 4 years
• Affects 1-3 % of children (Fishman et al, 2003)
• Boys > girls (estimated at 4-6:1) (Levine, 1983)
• Occurs almost always during the day (Bellman, 1966)
• Incidence & prevalence decrease with age (Boon &
Singh, 1991)
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18. Classification
Primary(continuous): child has never
completed toilet training for stool
Secondary (discontinuous): toilet trained child
regresses to incontinence
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19. Classification cont…
Retentive (80-95%): involves
–Constipation
–Stool retention
–Overflow incontinence
Nonretentive or “solitary”(5-20%): involves
–No constipation or overflow incontinence
–Stool toileting refusal/resistance/“phobia”
–Often manifestation of emotional disturbance
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20. Aetiology
• Encopresis is considered a non-organic disorder
• Aetiological factors could be physiological or
psychological
• A typical child with encopresis may show
evidence of:
– Chronic constipation – ~85% of cases
– Avoidance of, or infrequent defecation
– Withholding of bowel movement
– Infective or inefficient sphincter control
– Maternal hostility, harsh and punitive parenting
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21. Pathophysiology
• Chronic constipation due to irregular and
incomplete evacuation results in progressive
rectal distention and stretching of both the
internal and external anal sphincters
• As the child habituates to chronic rectal
distention, he or she no longer senses the normal
urge to defecate
• Soft or liquid stool eventually leaks around the
retained fecal mass, resulting in faecal soiling
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22. Clinical features
Detailed History
– Onset
– Stool character and volume
– Frequency of soiling
– Other GI symptoms
– Nutritional Hx
– Developmental Hx
– Psychiatry Hx – ADHD
– FSHx
Physical examination
• Abdominal examination
and DRE:
– Abdominal distention
– Palpable faecal mass
– Poor perianal hygiene
– Lax and patulous sphincter
– Stool in rectum
• Neurologic examination –
usually normal
• Psychiatry assessment
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23. Investigation
Abdominal X-ray – faecal impaction
Barium enema – dilated rectum
Rectal biopsy R/o Hirschsprung’s disease
Anorectal manometry
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24. Diagnostic criteria
DSM-V criteria for encopresis are as follows:
• Repeated passage of faeces into inappropriate
places, whether intentional or involuntary
• One such event occurs each month for at least 3
months
• Occurs in children at least age 4 years (or of
equivalent developmental level)
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25. • The behaviour is not attributed to the
physiological effects of a substance or another
medical condition except through a
mechanism involving constipation
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26. Treatment
• The standard treatment approach to
encopresis begins with:
– Demystification and education
– Colonic disimpaction – enemas, PEG, Mg. citrate
– Routine laxative therapy – lactulose, bisacodyl
• Concomitant behavioural management is also
indicated
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27. • The focus of behavioural treatment should be
on compliance with:
– Regular post-prandial toilet sitting
– Adoption of high-fiber diet
• Follow-up
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28. Prognosis
• The outcome of encopresis depends on the
cause, chronicity of symptoms, and coexisting
behavioural problems.
• In many cases, encoprsis is self-limiting, and it
rarely continues beyond adolescence.
• Encopresis in children who have contributing
physiological factors , such poor gastric motility
and inability to relax anal sphincter muscles, is
more difficult to treat than in those with
constipation but normal sphincter tone.
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29. Conclusion
• Enuresis and encopresis are a form of elimination disorder
in children
• 15-25% of children with enuresis also have encopresis
(Issenman et al, 1999)
• Both have severe psychosocial effects on children and
parents
• Behavioural training and parental support is essential in
treatment
• Main goal of management is achievement of continence
and bowel control
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Thank you for your attention