Elimination Disorders
Dr Nemache Mawere
Psychiatrist
MBBS IV Feb 2020
Introduction
• Elimination disorders involve the
inappropriate elimination of urine or faeces
and are usually first diagnosed in childhood or
adolescence
Enuresis
• The involuntary passage of urine in the absence of physical
abnormalities after the age of 5 years old.
• There is repeated voiding of urine into bed or clothes,
whether involuntary or intentional
• The voiding occurs at least 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.
• Exclude physiological effects of a substance (e.g., a
diuretic, an antipsychotic medication) or another medical
condition (e.g., diabetes, spina bifida, a seizure disorder)
Enuresis
Types
• Nocturnal – Bedwetting
• Diurnal - Daytime incontinence.
Enuresis
Primary Enuresis –
-Bedwetting continuous since birth
-Usually every night.
Secondary Enuresis –
-Since birth there has been at least 6 months in
which the patient was dry.
Epidemiology
• 5 Years old – 10%
• 10 Years old – 5%
• 15 Years old – 1%
Aetiology
• Positive Family History
• Small bladder capacity
• Low intelligence
• Environmental factors
- Recent stressful life events
- Large family size
- Social disadvantage.
Management
1. Rule out an organic cause through:
a) History
b) Physical examination
c) Urinary Tract Investigations
2. Reassurance of patient and caregiver:
a) Avoid blame
b) Reduce anxiety
3) Diary: a)Record of dry periods and enuresis.
b) Positive Reinforcement.
4) Buzzer or Bell and Pad. (Older children).
Bed Time 10 pm & Wake-up 6 am- 1st Alarm 2 am ( Mid-point
between Bed-time & Wake-up)-on Day 4 moved forward to 3am and
moved back to 1am on day 5. 2nd alarm is always 2 hours later
DATE 1st ALARM 2nd ALARM
Mon 3 Feb Dry Wet
Tues 4 Feb Dry Wet
Wed 5 Feb Dry Wet
Thurs 6 Feb Wet Wet
Friday 7 Feb Dry Wet
Sat 8 Feb Dry Dry
Sun 9 Feb Dry Dry
Enuresis Management
5) Tricycles Antidepressants:
-Imipramine or Amitriptyline 25-50mg po
Nocte (problem rebound enuresis)
Encopresis
• The repeated passage of faeces into
inappropriate places (e.g., clothing, floor),
whether involuntary or intentional.
• At least one such event occurs each month for
at least 3 months,in the absence of physical
pathology after 4 years of age.
• Exclude laxatives or another medical condition
or through a mechanism involving constipation
Epidemiology
Encopresis uncommon:
• 8 year olds - 1.8% for boys
- 0.7% for girls
Aetiology
• Coercive and obsessed toilet training.
• Disorganized/dysfunctional families.
• In response to stressful situations.
• Emotional (i.e. aggressive)
• Abnormal sphincters that may contribute.
• Fear using the toilet.
• Encopresis may be precipitated by birth of a sibling
or separation of parents
• It usually brings embarrassment and ostracism
CLINICAL FEATURES
Symptoms variable
• Slight staining
• to smearing of faeces onto the wall.
• Psychotic disturbance is common.
• Retentive type
• Non retentive type -Continuous(primary)
-Discontinuous (secondary)
Treatment
-Exclude organic:
• Hirshsprung’s disease-(aganglionic megacolon):
1 in 5000 children overflow of feces
Treatment
• Assess attitude of parents and child problem.
• Objective of treatment:
- Acquire normal bowel habit.
- Improvement of parent-child relationship.
Treatment
Initially bowel washouts or enemas to
clear bowels
-Bowel smooth muscle stimulants
-Stool softener
-Bulk agents (lactulose)
-Suppositories
Treatment
Dietary education – parent and child
Psychological components
-behavioral e.g. Keeping Diaries.
- Individual psychotherapy
Prognosis
• 25% of the patients have enuresis as well
• The condition has good prognosis if underlying
issues are addressed.
