Transcript Eliminative Disorders: Enuresis and Encopresis

James H. Johnson, Ph.D.
University of Florida
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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.
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Daytime control is
typically accomplished by
the age of 3 or 4.
Nighttime control is
typically present by four
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An estimated 5 million to 7 million
children in the United States have
primary nocturnal enuresis (wetting at
night).
Thirteen to 33% of children will have
some degree of nighttime wetting at
five years of age (Brown et al,. 2008).
By age 10 only 3% of males and 2 % of
females will still wet the bed.
By late adolescence this figure will
drop to 1% of males and less than 1% of
females (Mellon & Houts, 2006)
Boys wet the bed more frequently than
do girls.
About 80 percent of children with
enuresis wet the bed only at night.
Only about 3% wet during the day
(Peterson, et al., 2003)
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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
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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.
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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. Concordance rates for identical
and fraternal twins are 68% and 36%
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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.
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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.
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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.
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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.
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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
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In normal children who sleep between 8 - 12
hours per night, the increase in the secretion of
anti-diuretic hormone (ADH) concentrates and
reduces the volume of urine produced by the
kidneys, thus decreasing the amount of urine
stored by the bladder.
There is some evidence that children with
nocturnal enuresis may have a deficiency in ADH
and thus 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.
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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.
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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
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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
concern over side effects).
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Another drug, desmopressin (DDAVP),
which is a synthetic antidiuretic
hormone - administered in the form of
a nasal spray - 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 70 % of
children treated with this drug show
significant reductions in bed
wetting, although relapse rates may
be as high as 80% when the medication
is stopped (Fritz, Rockney, et al.,
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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 sleeping away from home for
the night.
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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.
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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
http://www.bedwettinghandbook.com/buyersguide/enuresisalarm
s.html
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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).
Sometimes use in combination with the
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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
after accidents, dressing self in fresh
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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 sometimes 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.
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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
results
clearly
question
the
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Encopresis involves
soiling, which occurs
past the age where
control over
defecation is
expected.
The conditions occurs
in somewhere between
1.5 and 3% of 4 to 5
-year-olds.
Boys are 6 times more
likely to have this
condition than girls
(Brown, et al., 2008)
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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
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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 incontinent.
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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
little motivation to be trained.
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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
to constipation which often precedes
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
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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
physiological disorder to account
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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.
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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.
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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
/encopresis.html
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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
that typically follow soiling
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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