Transcript Eliminative Disorders: Enuresis and Encopresis

Eliminative Disorders: Enuresis and
Encopresis
James H. Johnson, Ph.D.
University of Florida
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Enuresis
• Children are considered as
enuretic if they;
– fail to develop control over
urination by an age at which
it is usually acquired by most
children or
– if they revert to wetting the
bed or clothing after
initially (for at least 6
months) developing control
over micturition.
• Daytime control is typically
accomplished by the age of 3
or 4.
• Nighttime control is
typically present by four of
Some Statistics on Enuresis
• An estimated 5 million to 7 million
children in the United States have
primary nocturnal enuresis (wetting
at night).
• Fifteen to 20 percent of children
will have some degree of nighttime
wetting at five years of age.
• By age 15 only 1 to 2 percent will
still wet the bed.
• Boys wet the bed more frequently than
do girls.
• About 80 percent of children with
enuresis wet the bed only at night.
Enuresis: DSM IV Criteria
• Repeated voiding of urine into bed or clothes.
• The behavior is manifested by;
– a frequency of twice a week for 3 consecutive months
– the frequency can be less given the presence of
clinically significant distress or impairment in social,
academic (occupational), or other important areas of
functioning.
• Chronological age is at least 5 years.
• The behavior is not due to the direct effect of a
substance or a general medical condition.
• Note: Approximately 90 % of cases of
involuntary voiding are considered
examples of "functional enuresis"
with no medical problem
Enuresis: Some Definitions
• The disorder may be of either
the primary or secondary type.
• Primary enuresis refers to cases
where
the
child
has
never
developed control.
• Secondary enuresis refers to
instances where the child has,
at some time, developed control
over wetting (for at least 6
months) but has subsequently
resumed wetting.
Enuresis: Etiology
• Biologically-oriented researchers have
emphasized the importance of delays in the
development of cortical control over
reflexive voiding.
• The higher incidence of enuresis in
children whose parents were enuretic has
also highlighted possible genetic factors.
• In families where both parents have a
history of enuresis, 77 percent of children
will have enuresis.
• In families where one parent has had
enuresis, 44 percent of children will be
affected;
• Only about 15 percent of children will have
enuresis if neither parent was enuretic.
Enuresis: Genetics
• Heredity as a causative factor of primary
nocturnal enuresis has also been strongly suggested
by the identification of a genetic marker associated
with the disorder.
• In one study, Danish researchers evaluated 11
families with primary nocturnal enuresis. The trait
showed nearly complete penetrance in these
families.
• This seems to suggest the existence of a major
dominant gene for primary nocturnal enuresis.
• While this gene appears to be located on
chromosome 13, no specific locus on this
chromosome has yet been identified.
Depth of Sleep and Enuresis
• It has been suggested that enuretic children
are deep sleepers and more difficult to
arouse than non-enuretic children.
• This would make it more difficult for them
to awaken to cues associated with a full
bladder while asleep.
• Some investigators studying sleep EEG’s have
reported a higher incidence of increased
slow brain-wave activity in patients with
nocturnal enuresis.
• Most other studies have not supported this
finding and demonstrate no consistent
correlation between abnormal sleep patterns,
or stage of sleep and bed-wetting.
• Some have documented more difficulty in
waking.
Enuresis and Upper Airway
Obstruction
• Nocturnal enuresis has, in some cases, also been
associated with upper airway obstruction in children.
• In these instances, surgical relief of the obstruction by
tonsillectomy, adenoidectomy or both has been
reported to diminish nocturnal enuresis in up to 76
percent of patients who display this condition.
• Immaturity in motor and language development has
also been implicated although the specific
mechanisms have not been determined.
Enuresis and Anatomic Factors
• In cases of primary enuresis, anatomic abnormalities
are not usually found.
• Findings from some studies, however, have suggested
that functional bladder capacity may be reduced in
patients with nocturnal enuresis.
• These findings have been disputed by other research
which have not found abnormalities in bladder
function or size when only nocturnal enuresis cases
were considered.
• While some parents report a small bladder capacity
in children with enuresis, this condition usually is
accompanied by daytime symptoms.
Secretion of Antidiuretic Hormone
• It has been found that humans show both
diurnal and nocturnal variations in the secretion
of antidiuretic hormone, when assessed over a
24-hour period.
• Normal increases in the secretion of
antidiuretic hormone are typically found in
response to extended periods of sleep.
• During this period, the bladder does not empty
Secretion of Antidiuretic Hormone
• In normal children who sleep between 8 - 12 hours per
night, the increase in the secretion of anti-diuretic
hormone reduces the amount of urine produced by the
kidneys, thus decreasing the amount of urine stored by
the bladder.
• There is some evidence that children with enuresis
excrete significantly higher volumes of urine during
sleep than children without enuresis.
• This suggests that abnormal (e.g., lower) secretion of
antidiuretic hormone at night may be a significant
contributor to nocturnal enuresis in some children.
Other Possible Etiological Factors:
Dynamic and Behavioral Factors
• Dynamically oriented clinicians have argued
that enuresis results from underlying
psychological conflict.
• The available evidence would, however, seem
to suggest that the majority of enuretic
children show no signs of significant
emotional problems
• When psychological problems are present
these may often be secondary to the
enuresis rather than causal.
• Behavioral regression due to stress
(divorce, abuse, school trauma,
hospitalization) does seem to be involved
in many cases of secondary enuresis.
Etiology
• Behaviorally oriented psychologists
have emphasized faulty learning
experiences (perhaps compounded by
stressful approaches to toilet
training) in the development of
enuresis.
• While behavioral approaches to
treatment have been shown to be quite
effective, behavioral causes of
enuresis have not been well
documented.
• Despite research related to a range
of possible etiological factors,
findings have often been conflicting
and have failed to provide clear
Treatment of Enuresis
• The most widely used treatment
methods involve the use of drugs,
conditioning approaches, and
psychodynamic psychotherapy.
• Historically, the drug most commonly
used with enuretics has been
Tofranil (Imipramine) which is a
tricyclic antidepressant.
• This drug has been shown to be
superior to a placebo treatment and
to show 40 to 60 % effectiveness.
• A major problem, however is that the
relapse rate is on the order of 50%
when the drug is discontinued (also
Biological Treatments
• Another drug, desmopressin (DDAVP),
which is a synthetic antidiuretic
hormone - administered in the form of
a nasal spray or tablet - is being
increasingly used to treat enuresis.
• In many clinical settings it seems to
have become the pharmacological
treatment of choice.
• While becoming increasingly popular,
available research suggest effects
not unlike Tofranil.
• Compared to controls, up to 60 % of
children treated with this drug show
significant reductions in bed
wetting, although relapse rates may
Biological Treatments (cont.)
• Despite the high probability
of relapse, it has been
suggested that desmopression
is fast acting and may have
fewer side effects than
Tofranil.
• It may be a useful treatment
for older children who do not
respond well to other
treatments or who simply wish
to decrease the probability
of wetting the bed while
Behavioral Treatments
Conditioning Treatments
• The most common behavioral treatment is the
bell and pad approach.
• This method, originally developed by Mowrer
and Mowrer (l938), involves having the
child sleep on a urine-sensitive pad,
constructed so that when the child wets a
circuit is completed, which activates a
buzzer or bell loud enough to awaken the
child.
• The rationale for this approach is that if
the bell, which results in the child waking
up, can be paired over time with the
sensations associated with a distended
bladder, the child (due to classical
conditioning) will come to awaken and
inhibit urination in response to these
sensations.
Bell and Pad Treatment
• The bell and pad method has been
found to be quite effective in
dealing with bed wetting, with
success rates of from 70 to 90
percent being reported.
• While relapse rates of anywhere
from 20 to 30 % have been found
with this procedure, several
studies suggest that over learning
approaches that involve continued
use of the bell and pad (after
wetting has ceased) combined with
gradual increases in fluid intake
seem to significantly reduce the
likelihood of relapse
Other Behavioral Approaches to
Enuresis
• Other behavioral approaches include
Retention Control Training (Kimmel &
Kimmel, l970).
• Here, the child is reinforced for
inhibiting urination for longer and
longer periods of time.
• Although there is research suggesting
that this approach is less effective
than the bell and pad with bed
wetting, it may be useful with
daytime enuresis (Doleys, 1989).
Other Behavioral Approaches
• An additional behavioral approach,
developed by Azrin, et al (1974), is
Dry Bed Training.
• This is an intense training program
that includes a number of elements;
– nighttime awakening,
– positive practice in appropriate
toileting (e.g., getting up from bed,
going to toilet, pulling pants down,
setting on toilet for several seconds,
pulling pants up and returning to bed),
– retention control training (as described
above),
– positive reinforcement for appropriate
toileting behaviors, and cleanliness
training (e.g., removing wet sheets,
cleaning mattress, making bed, showering
Other Behavioral Approaches
• These procedures are combined in an
intensive treatment package, carried out in
one evening, with maintenance procedures
being employed until the child has 14 dry
nights.
• While there are studies supporting the
effectiveness of dry-bed training, this
approach often elicits strong emotional
responses on the part of the parent and
child, with temper tantrums and parental
upset being common side effects.
• This, along with some findings that
treatment is not successful without the
simultaneous use of an alarm apparatus, has
led some to question whether this approach
is indeed preferable to the bell and pad.
Modeling – A case example
Effectiveness of Traditional
Psychotherapy
• Some attempts have been made to
assess the effectiveness of
traditional psychotherapy in
enuresis.
• Here, it can be noted that an early
study by DeLeon & Mandell (l966)
compared response to treatment in 5
to 14 year-old-children who were
assigned to a bell and pad group, a
psychotherapy condition or a no
treatment control group.
• Improvement rates of 86.3, 18.2 and
11.1 percent were found for these
three
groups,
respectively.
Such
Encopresis
• Encopresis involves
soiling, which occurs
past the age where
control over
defecation is
expected.
• The conditions occurs
in somewhere between
1 and 5% of 5-yearolds.
• Boys are 6 times more
likely to have this
DSM IV Criteria
• Repeated passage of feces into inappropriate
places, whether involuntary or intentional.
• At least one event a month for at least 3
months.
• Chronological age is at least 4 years.
• The behavior is not due exclusively to the
direct physiological effects of a substance or
a general medical condition except through a
mechanism involving constipation.
TWO TYPES
– With Constipation and Overflow Incontinence
– Without Constipation and Overflow Incontinence
Forms of Encopresis
• As with enuresis, encopresis can
take various forms.
• The most common distinctions (in
addition to those in DSM IV), are
– Between the continuous type
(analogous to primary enuresis)
where the child has never become
toilet trained, and
– The discontinuous type (analogous
to secondary enuresis) where the
child has initially been toilet
trained and has subsequently become
Contributors to Encopresis
• First, it must be acknowledged
that we do not know for sure what
“the cause” of encopresis is.
• Historically, it has been
suggested that continuous
encopresis is associated with a
lax approach to toilet training.
• The assumption here, is that the
overly casual approach to
toileting may result in the child
failing to learn appropriate
toileting skills as well as having
Contributors to Encopresis
• The discontinuous type has been seen
as more likely a result of rigid and
stress inducing approaches to
training.
• It has been suggested that coercive
approaches may result in the child
developing excessive anxiety over
toileting, fears of the toilet, and
conflicts with parents over
toileting.
• It is noteworthy that such harsh
approaches may result in a child
attempting to withhold feces (to
avoid punishment), which might lead
The Role of Constipation
• Encopresis is a problem that children can develop
due to chronic constipation.
• With constipation, children have fewer bowel
movements, and the bowel movements they do have
are often hard, dry, difficult to pass and painful.
• Once a child becomes constipated, he/she may
avoid using the bathroom to avoid discomfort that
comes from passing a hard stool or from the pain
that may result from secondary anal fissures.
• At this point the stool can become impacted in the
distended colon and unable to be evacuated .
The Role of Impaction
• As the rectum/intestine become enlarged due to the
impaction (Megacolon), the child may adapt
to the sensations of fullness in the
rectum, and be unaware of the need
to defecate - due to this loss of
“bowel tone”.
• Soiling may occur as the anal
sphincter (the muscle at the end of
the digestive tract) loses its
strength and feces (usually in
liquid form) leaks around the
impacted stool and is gradually
expelled without the child's
awareness.
• Such factors may contribute to
encopresis without any other
Assessment for Encopresis
• In all cases it is necessary for the child to
have a thorough physical work up to rule out
physical factors.
– Assessment for megacolon.
– Assessment for Hirschsprung’s disease
– Assessment for other health problems that may
cause chronic constipation (which often precedes
the soiling.
• diabetes,
• hypothyroidism,
• inflammatory bowel disease.
Encopresis: Assessment
• The assessment may involve not only a
physical examination but also lab tests.
• Abdominal x-rays to evaluate the
amount of stool in the large intestine
• Barium enemas to test for intestinal
obstruction, strictures (narrow areas of
the intestine), and other abnormalities.
Treatment of Encopresis
• In the case of children with impaction, the initial stage
of treatment involves attempts to remove the impacted
stool. This is usually accomplished through the use of
enemas, prescribed by the physician.
• The physician will likely also prescribe medications
that are designed to help the child’s bowel movements
remain soft.
• This is to prevent a recurrence of the impaction.
• The physician may also make recommendations
regarding diet (e.g., fluids, high fiber, low dairy) that
are aimed at increasing the likelihood of large soft
stools.
http://www.keepkidshealthy.com/welcome/conditions/encopre
sis.html
Treatment of Encopresis – Cont.
• While a variety of treatment
approaches have been employed with
encopresis, behavioral methods
appear to have the greatest
success.
• These approaches have typically
been of the operant variety where
the child is positively reinforced
for setting on the commode and for
defecating, for having clean
underpants, and where mild
punishment may be used with
soiling.
• Extinction procedures have also
been employed, whereby there is an
attempt to remove the reinforcers
Behavioral Intervention with
Encopresis
• Most often a combination of operant
procedures is employed.
• In some instances these procedures have
been supplemented by the use of
suppositories to stimulate bowel
movements which can then be rewarded.
• Although there are few examples of well
controlled research in this area, the
research that is available has provided
reasonably strong support for a
behavioral approach to treatment. (Case
Example).
http://www.aafp.org/afp/990415ap/2171.html