Elimination Disorders

Elimination disorders refer to conditions where children have difficulty in controlling bowel

or bladder function beyond the typical age of developmental maturity. Normal development

of bowel and bladder control is a complex neurodevelopmental process involving motor and

sensory functions coordinated by the frontal lobe and regulated by neurons in the pons and

midbrain. In infancy, urination is frequent (about every hour), often triggered by feeding, and

the bladder may not empty completely. As the child matures into a toddler, bladder capacity

increases, and between the ages of 1 to 3 years, cortical inhibitory pathways develop. These

allow voluntary control over reflexes responsible for bladder function.

Typically, bowel control develops earlier than bladder control. The usual developmental

sequence includes nocturnal faecal continence first, followed by diurnal faecal continence,

then diurnal bladder control, and finally, nocturnal bladder control. Many factors influence

the timing of toilet training, including the child’s intellectual and social maturity, cultural

expectations, and the nature of interactions between the child and caregivers. In children with

developmental delays, the acquisition of continence may also be delayed due to immature

neurobiological systems.

Incontinence, whether of urine or faeces, can be distressing for both the child and the family

and is often mistakenly seen as intentional misbehaviour. When such issues persist beyond

the expected age range, they may be diagnosed as elimination disorders. According to DSM-

5, the two main elimination disorders are encopresis, defined as repeated passage of faeces in

inappropriate places, and enuresis, defined as repeated urination into bed or clothes. The

diagnosis of encopresis is not made before the age of 4 years, and that of enuresis not before

the age of 5, as these are the ages by which most typically developing children achieve

continence.

In the ICD-10 classification, these disorders are termed nonorganic encopresis and

nonorganic enuresis and are included under the category of other behavioural and emotional

disorders usually beginning in childhood or adolescence. It is important to consider

understand that healthy development involves a wide range of normal variation in when

children become continent.

ENCORPESIS

 Clinical and Diagnostic Features

According to both DSM-5 and ICD-10, encopresis is defined as the repeated passage of

faeces in inappropriate places, such as clothing or on the floor. It can occur in children who

have already achieved bowel control but deliberately soil themselves, often for emotional

reasons. Some children may engage in intentional faecal soiling as a behavioural expression

of anger, defiance, or hostility, particularly in response to punitive parenting. In such cases,

the child may receive negative attention, which unintentionally reinforces the behaviour and

makes it harder to stop. Transient cases of encopresis may also occur during stressful life

events, such as the birth of a sibling, but these usually do not meet the criteria for a formal

diagnosis, as the behaviour is short-lived.

Encopresis can also be involuntary. In these cases, the child may lack proper awareness or

control of the anal sphincter muscles, often due to being distracted or not recognizing the

need to defecate. The stool may be normal, soft, or even liquid. A common cause of

involuntary encopresis is chronic stool retention, leading to overflow incontinence where soft

or liquid stool leaks around impacted faeces. In rare instances, psychological factors such as

anxiety can lead to involuntary diarrhoea or soiling. DSM-5 allows the use of specifiers to

indicate whether encopresis is associated with constipation and overflow incontinence.

Research shows that many children with encopresis, especially those with constipation, have

abnormal contraction patterns of the anal sphincter. These children often find it difficult to

relax the sphincter muscles when trying to defecate, which can hinder treatment. Such

children usually do not respond well to laxatives alone. On the other hand, children without
abnormal sphincter tone generally respond better to treatment and may show rapid

improvement.

 Pathology and Laboratory Examination

Although there is no specific test that confirms a diagnosis of encopresis, it is crucial to rule

out underlying medical conditions, especially Hirschsprung disease. A thorough abdominal

examination should be conducted to assess for fecal retention, particularly in cases involving

constipation with overflow incontinence. If necessary, an abdominal X-ray may be used to

evaluate the extent of constipation. Specialized tests to evaluate anal sphincter tone are

generally reserved for complicated or resistant cases and are not commonly done in typical

presentations.

 Differential Diagnosis

Constipation leading to encopresis often starts in infancy or early toddlerhood and typically

becomes more evident between ages 2 and 4, with soiling usually starting by age 4. Clinical

features include frequent liquid stools, presence of hard fecal masses in the colon or rectum,

and complications such as impaction, megacolon, or anal fissures. The most important

differential diagnosis is Hirschsprung disease (aganglionic megacolon), which is

characterized by an empty rectum and absence of the urge to defecate, despite overflow

soiling. This condition typically presents soon after birth. Other less common causes include

structural abnormalities, adverse drug effects, or systemic disorders like endocrine or

neurologic diseases. Poor nutrition is rarely a contributing factor.

 Course and Prognosis

The prognosis of encopresis depends on the underlying cause, duration, and presence of

coexisting behavioral issues. While some cases are self-limiting, others persist and may

continue into middle adolescence, though this is rare. Children with physiological issues such

as impaired gastric motility or sphincter dysfunction tend to have a more difficult treatment

course compared to those with functional constipation. Socially and psychologically,

encopresis is highly distressing. Families often misinterpret the condition as laziness, which
can lead to high family tension. Peer rejection and teasing are common, contributing to low

self-esteem and social isolation in affected children. Some children may become emotionally

blunted, while others may use encopresis as a means of expressing anger. The success of

treatment largely depends on the family's approach, including a non-punitive attitude and

willingness to participate in therapy, along with the child’s motivation and cooperation.

 Treatment

Treatment of encopresis typically includes a combination of medical, behavioral, and

psychosocial strategies. For children with constipation, initial management may require

surgical disimpassion under anesthesia, followed by daily use of laxatives such as

polyethylene glycol (PEG) at 1 g/kg/day. Cognitive-behavioral therapy (CBT) helps the child

establish regular toileting habits, reduce anxiety around defecation, and increase confidence

in their ability to control bowel movements.

Addressing family distress is essential, as most families present with high levels of conflict

and frustration. Interventions should aim to create a supportive, non-judgmental atmosphere,

both at home and at school. Practical steps, such as providing spare underwear at school and

reducing the child’s embarrassment, are often necessary. Family education is critical to dispel

myths about laziness or misbehavior and to promote cooperation in treatment.

In children without constipation, laxatives may not be needed. Instead, establishing regular

toilet schedules can be effective. Interactive parent–child family guidance, especially in

children under 9 years, has shown success in modifying behavior. Additional therapies like

supportive psychotherapy and relaxation techniques can help address low self-esteem,

anxiety, and social challenges. For children who intentionally soil despite having bowel

control, family therapy and behavioral approaches are essential. The ultimate goal of

treatment is to help the child regain a sense of control over their bowel function, thereby

improving overall psychosocial well-being.

Encopresis affects approximately 3% of 4-year-olds and 1.6% of 10-year-olds, with the

incidence dropping sharply as age increases. Among typically developing children aged 10 to

12 years, the prevalence falls to 0.75%, and the condition is virtually absent by age 16 in

those with normal intellectual functioning. Globally, the community prevalence ranges from

0.8% to 7.8%. In Western cultures, over 95% of children gain bowel control by age 4, and

99% by age 5. The condition is more common in boys, with a male-to-female ratio of 3:1 to

6:1. Encopresis is also significantly associated with enuresis, with many children

experiencing both disorders concurrently.

 Etiology

Around 90% of chronic childhood encopresis is functional in nature, not caused by structural

or medical issues. A common pattern involves children withholding feces, often due to fear of

pain from previous hard or painful bowel movements. This withholding behavior becomes

entrenched, leading to chronic constipation, fecal impaction, and eventually overflow

soiling—a pattern seen in over 75% of encopretic cases. This supports the use of behavioral

interventions aimed at relieving constipation and promoting regular toileting habits. In some

cases, inadequate toilet training may also delay bowel control.

Some children may have lifelong poor sphincter control, while others experience involuntary

soiling due to overflow from retained stool. About 5–10% of cases are due to medical

conditions, such as Hirschsprung disease, neuronal intestinal dysplasia, anorectal

malformations, or spinal cord lesions. Psychological factors also play a role. Some children

with encopresis have a history of sexual abuse or other psychiatric disorders, although

encopresis is not a specific indicator of abuse.

Fear and resistance can become deeply rooted once defecation becomes painful. Parental

pressuring or punitive attitudes can worsen the condition and lead to secondary behavioral

problems. Without treatment, affected children often face social rejection, low self-esteem,
and emotional difficulties. In some children with normal bowel control, intentional soiling

may be related to neurodevelopmental disorders or behavioral issues. Rarely, children may

have toilet phobia, which can trigger withholding behaviors.

Encopresis can also be secondary, occurring after a period of normal bowel habits due to

stressful life events, such as the birth of a sibling, relocation, parental separation, or academic

difficulties. In such cases, the behavior may be regressive, driven by emotional distress.

One of the most common physiological consequences is the development of megacolon,

resulting from chronic fecal retention. This causes rectal distention, loss of muscle tone, and

desensitization to rectal pressure, making the child less aware of the need to defecate. As a

result, overflow encopresis occurs, usually with small amounts of liquid or soft stool leaking

out involuntarily.

ENURESIS

 Clinical and Diagnostic Features of Enuresis

Enuresis is defined as the repeated voiding of urine into the bed or clothes, which can be

either involuntary or intentional. To meet the diagnostic criteria, the child must have a

chronologic or developmental age of at least 5 years. Enuresis can occur during the day

(diurnal), night (nocturnal), or both, and it must occur at least twice per week for a minimum

duration of three months.

Children with enuresis are at increased risk for ADHD, and many also present with comorbid

encopresis. The DSM-5 and ICD-10 both categorize enuresis into three subtypes:

1. Nocturnal only

2. Diurnal only

3. Combined nocturnal and diurnal

“Nonorganic Enuresis”. Both classifications emphasize that the condition must not be due to

other causes such as:

 A medical condition (e.g., epilepsy, urinary tract anomalies, or neurologic disorders)

 Substance use

 Age under 5 years

 Pathology and Laboratory Examination

There is no specific lab test that confirms enuresis. However, it is essential to rule out organic

causes, especially urinary tract infections, which may contribute to or mimic enuresis. In

about 3% of children with symptoms of enuresis, structural obstructive abnormalities of the

urinary tract may be identified.

In uncomplicated cases (i.e., no recurrent infections or red flag symptoms), clinicians

typically avoid advanced investigations like radiographic imaging or urodynamic studies. The

initial approach focuses on clinical assessment, including history, physical examination, and

urine analysis to rule out infection or other pathology.

 Differential Diagnosis

When evaluating enuresis, it is essential to rule out medical causes of bladder dysfunction.

Children who experience both nocturnal and diurnal enuresis accompanied by symptoms

such as frequency and urgency may have underlying genitourinary pathology. Common

medical conditions to consider include urinary tract infections, structural abnormalities,

obstructive uropathy, spina bifida occulta, and cystitis. Other systemic conditions like

diabetes mellitus and diabetes insipidus may present with polyuria and enuresis. Additionally,

disturbances in consciousness or sleep—such as seizures, intoxication, or sleepwalking

medication effects that may affect bladder control.

 Course and Prognosis

Enuresis is often self-limiting, with many children achieving spontaneous remission over

time. Achieving continence is usually associated with improved self-esteem and social

confidence. However, around 80% of affected children have never achieved a full year of

dryness. When enuresis occurs after at least one dry year, especially between ages 5 and 8, it

is typically seen as secondary enuresis. If it starts later in childhood or adolescence, further

evaluation for underlying medical or psychiatric causes is warranted. Children with late-onset

enuresis are more likely to have associated psychiatric disorders. Relapses can occur in both

children undergoing treatment and those improving spontaneously. Emotional and social

challenges—such as low self-image, social embarrassment, and family conflict—are

common. The course and recovery are also influenced by the presence of comorbid

conditions like ADHD and whether they are appropriately treated.

 Treatment

While many children experience natural improvement, treatment is often necessary when

enuresis leads to functional impairment. The first step is to review the child’s toilet training

history. If training has not been attempted, parents should be guided through a structured

approach. Keeping a voiding diary or star chart can help establish a baseline and serve as a

motivational tool. Behavioral techniques such as fluid restriction before bedtime, nighttime

waking (lifting) to use the toilet, and alarm therapy are commonly used. Alarm therapy,

which uses a sensor to detect wetting and sounds a buzzer to wake the child, is particularly

effective in children aged 6–7 years or older who can respond to the alarm.
For children with chronic constipation, assessing and treating the bowel issue—such as by

increasing dietary fibre—may also help improve bladder control. Behavioral therapies,

particularly classical conditioning using the bell-and-pad technique, have the highest success

rates, with over 50% achieving dryness. Bladder training, which involves rewarding children

for delaying urination during the day, can also help, though it is less effective than alarm

therapy.

Pharmacological treatment is considered when behavioral methods fail or when the child

experiences significant distress or functional impairment. Desmopressin, an antidiuretic

hormone analogue, can be used to reduce nighttime urine production and has a success rate

ranging from 10% to 90%, although relapse is common once the medication is stopped. Side

effects may include headache, nasal symptoms, abdominal pain, and in rare cases,

hyponatraemic seizures. Antidepressants like imipramine (used for its anticholinergic effects)

may be effective but carry a higher risk of side effects. A safer alternative, reboxetine, is used

in some countries but is not available in the U.S.

Lastly, psychotherapy may be useful in children with coexisting psychiatric problems, family

conflict, or emotional distress related to chronic enuresis. However, behavioral interventions

remain the first-line treatment.

 Epidemiology

The prevalence of enuresis decreases with age. It affects about 5–10% of 5-year-olds, 1.5–5%

of 9–10-year-olds, and around 1% of adolescents aged 15 years and older. Among toddlers,

enuretic behavior is considered developmentally normal and thus not diagnosed as a disorder.

It occurs in about 82% of 2-year-olds, 49% of 3-year-olds, and 26% of 4-year-olds. Although

most children with enuresis do not have a comorbid psychiatric condition, they are at

increased risk of developing psychiatric disorders, particularly ADHD. Nocturnal enuresis is

more common, accounting for about 80% of all cases, and is 50% more common in boys.

Diurnal enuresis is also more frequent in boys, often due to delayed voiding habits. The
spontaneous resolution rate for nocturnal enuresis is about 15% per year. Children who void

small amounts of urine at night, rather than full bladder volumes, may require evaluation for

other medical causes.

 Etiology

Enuresis results from a complex interaction of neurobiological, physiological, behavioral, and

genetic factors. The control of urination is regulated by centers in the pons and midbrain,

involving motor and sensory functions, as well as both autonomic and voluntary nervous

systems. In some children, bladder detrusor muscle contractions may occur during sleep once

the bladder is full, leading to nocturnal enuresis even without any structural abnormality.

Daytime enuresis is often related to behavioral patterns, such as habitual voluntary tightening

of the external sphincter to avoid urination. This may cause a child to lose awareness of

bladder fullness and result in incomplete emptying, which can later lead to nighttime

bedwetting when the bladder relaxes during sleep.

Most children are unaware or not fully conscious of the act of wetting, and do not do it

intentionally. Neuromuscular development, cognitive maturity, toilet training practices, social

and emotional influences, and genetic predisposition all contribute to normal bladder control.

Delays or disruptions in any of these can lead to enuresis. Genetics play a major role—about

75% of children with enuresis have a first-degree relative with the same history. If the father

had enuresis, the child’s risk increases more than sevenfold. The concordance rate is higher in

monozygotic twins compared to dizygotic twins, supporting the genetic influence.

Physiologically, some children with enuresis have a normal bladder capacity but experience

an urge to void at lower volumes. Others may have reduced nighttime secretion of

antidiuretic hormone (ADH), leading to increased urine production at night. Enuresis does

not correlate with a specific sleep stage, and children with enuresis do not sleep more deeply

than their peers.

(after a period of dryness). Common stressors include the birth of a sibling, hospitalization,

starting school, parental separation, or moving homes.