Transcript Elimination Disorders - American Academy of Child and

Elimination Disorders
May 3, 2012
Napatia Tronshaw, MD
Child and Adolescent Fellow
University of Illinois at Chicago
Institute of Juvenile Research
Normal Development
 Toddler
 Bowel
Phase (18 months- 3 years)
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
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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
 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
 Star
Alarm
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
 Biofeedback
 Acupuncture
Psychotherapy
Encopresis
 Primary
Encopresis
 Secondary
 Retentive
Encopresis
Encopresis
 Nonretentive
encopresis
Prevalence
 Secondary
 Between
 3:1

encopresis is more common
ages 7-8 prevalence is 1.5%
male to female ratio
Retentive type is 80-95% of cases
Diagnostic Criteria
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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
 Infrequent
 Large
80-95% of cases
Bowel Movements
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
 Biofeedback
 Acupuncture
Psychotherapy
Pharmacological
 Laxatives
 Suppositories
 Enemas
 Mineral
 Stool
Oil
Softeners