ELIMINATION DISORDER
PRESENTED BY SABA AHMED
INTRODUCATION OF ELIMINATION DISORDER
Elimination disorders are disorders that concern the elimination of feces or urine from the body.
INTRODUCTION….
The elimination disorders that most commonly occur in childhood. The developmental milestones of mastering
control over bowel and bladder function are complex processes that occur over a period of months for the
typical toddler. Between 1 and 3 years of age, cortical inhibitory pathways develop allowing the child to have
voluntary control over reflexes that control the bladder muscles. • The assessment of fecal soiling includes
determining whether the clinical presentation occurs with or without chronic constipation and overflow
soiling.
ELIMINATION DISORDER
1. The normal sequence of developing control over bowel and bladder functions is the development of
2. • nocturnal fecal continence( night stool routine)
3. • diurnal fecal continence, (day stool routine)
4. • diurnal bladder control, (involuntary urination that happens at night)
5. • nocturnal bladder control. (Day urination routine)
.
TOILET TRAINING
Toilet training is affected by many factors, such as a
• child's intellectual capacity
• social maturity,
• cultural determinants,
• the psychological interactions between child and parents.
DEFINITION OF ELIMINATION DISORDER
ENURESIS
BED WETTING
Enuresis is a medical term for a disorder generally known as bed wetting. This is a common
elimination disorder and very familiar worldwide problem of childhood. It is important to know
about the symptoms, types, diagnosis and treatment of enuresis to be able to manage the
condition well.
DIURNAL INCLUDES DAY TIME EPISODES
.NOCTURNAL INCLUDES NIGHT TIME EPISODES.
DIFFERENCE BETWEEN ENURESIS AND ENCOPRESIS
ENURESIS the repeated passing of urine in places
ENCOPRESIS is the repeated passing of feces into
other than the toilet. Enuresis that occurs at night, or
places other than the toilet, such as in underwear or on
bed-wetting, is the most common type of elimination
the floor.
disorder.
PREVALENCE
Studies advocate that about 7% of boys and 5% of girl child in their fifth year of age suffer with
enuresis. As they grow this occurrence reduces to 3 to 2 % in the age of 10 years. Usually enuresis
or bedwetting reduces as children grow. Only few cases have been reported of enuresis after the
age of 18 years.
CON..
It is usually noted that the prevalence of enuresis is high in boys than girls. Studies suggest that
rate of wetting is about 1.5 to 2 times higher in boys. Contrarily, day time wetting is more common
in girls. As the age increases tendency of bed wetting decreases.
SYMPTOMS OF ENURESIS
the main symptoms of enuresis include
• Nocturnal bed wetting
• Wetting of clothes
• Excessive sleepiness also during the daytime
• Frequency of wetting minimum two times a month
• History of wetting for at least three months.
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
TYPES AND DESCRIPTIONS OF ENURESIS
These are additional types and/or descriptions of enuresis that one may come across in the literature and in
research.
A. Regressive enuresis- When a child develops secondary enuresis and it is due to a psychological stressor such as
the birth of a new sibling, divorce, and/or move this may be referred to as regressive enuresis
B. Monosympomatic- Nighttime wetting in children who are dry during the day
C. Polysymptomatic- Nighttime wetting along with daytime indicators of bladder dysfunction but do not meet full
criteria for both nocturnal and diurnal
D. Functional- wetting in the absence of an identifiable organic cause
CONTI…
E. Nonfunctional- due to an identifiable organic cause (e.g. due to a general medical condition)
F. Revenge- method of retention in response to harsh training practices and/or strict parent
G. Lack of toilet training- when a family decides not to train a child
H. Detrusor-Dependent- caused by spontaneous bladder contractions
I. Volume-Dependent- caused by nocturnal polyuria
DIAGNOSTIC CRITERIA
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 (occupa
tional), 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
DIAGNOSTIC WORKUP
You first want to begin your evaluation with the question “why now?”
Other questions that need to follow to obtain more information regarding the clinical picture are
1. Is there any straining?
2. Does the child have a normal urine stream?
3. What is the child’s pattern of fluid intake?
4. What methods of toilet training were used or are being used? (rewards/punishments)?
6. What are the patient’s sleeping habits? What are the sleeping arrangements in the home?
CONT…
7. Does the child snore?
8. Is there any history of any developmental delays?
11. Complete medical history
12. Prior treatment for enuresis
13. Mental health history including concurrent mental health disorder
THERE ARE FIVE MAJOR CATEGORIES OF TREATMENT OPTIONS THAT ARE AVAILABLE TO CHILDREN AND FAMILIES
EDUCATION
WATCHFUL WAITING
NONPHARMACOLOGICAL MANAGEMENT
MEDICATION MANAGEMENT
THERAPEUTIC INTERVENTIONS
. Educational Points are important regardless of which treatment option a family chooses. These are some of the educational points
that a family should be made aware of.
a. 15 % annual spontaneous remission rate
b. Review and correct parental expectation
c. Waiting until the child is ready for toilet training
d. Ensuring there is no teasing/shame given for failures
e. Limiting caffeine and dairy products in evening hours
f. Limiting nighttime and not daytime fluids
g. Remind children that it isn’t their fault
h. Teaching parents patience
i. Educating parents to not punish their child
j. Warning parents about potential relapse
2. WHEN PARENTS DECIDE TO PURSUE WATCHFUL WAITING IT IS
IMPORTANT TO EDUCATE THE FAMILY ABOUT THE NATURAL
HISTORY, AVAILABLE TREATMENTS, AND PROGNOSIS OF
ENURESIS
3. For those families that wish to pursue treatment an analysis of the underlying etiology/etiologies will help
determine the most successful modality
a. If the underlying etiology is Diabetes, sleep apnea, hyperthyroidism- treat the disorder
b. Surgery may be indicated for ectopic ureter, neurogenic bladder, bladder calculus, and possibly T&A for OSA
NON-PHARMACOLOGICAL INTERVENTIONS
Education
Advice
Bell and Pad
Education/Advice
a. Achieving continence takes time
b. Do not limit fluids during the day
c. Involving teachers who may discretely remind a child to take bathroom breaks
d. Limit Nighttime fluid intake- all fluid should be withheld within 1 hour of before bed
e. Dairy products should be stopped 4 hours before bed- potential to cause osmotic diuresis
a. Caffeine should be limited to morning use only provided its long half-life
b. Urinate before bed
c. Hallway night light
d. If bathroom is far place a toilet chair in the child’s room
e. Help the child clean soiled linen
f. Girls- can benefit from being reminded to wipe from front to back to prevent UTIs
g. Overweight females often have daytime post-void incontinence- instructing the child to urinate with knees apart instead of together can prevent
vaginal reflux and be curative if this is the etiology
BELL AND PAD
This is the most common and successful non-pharamcological intervention
-Relies upon classical and operant conditioning
-The child sleeps on the pad or it is affixed to their clothing
-When the child begins to urinate a sensor within the pad triggers an alarm (typically an auditory alarm but it may
be vibratory)
Classical Conditioning
-After repeated use of the bell and pad, the distention of the bladder and the sense to urinate become associated
with the auditory signal. This leads to waking (the conditioned response)
Operant Conditioning
-The child views the alarm as a punishment (which may awaken others in the house as well) and therefore seeks to
avoid triggering the alarm.
Efficacy
-Typically takes months for the bell and pad to work
-One month of dry nights is considered a success
-Success rates of up to 80-90% if families continue to use it however 48% prematurely terminate use
-When success is achieved relapse rates can be up to 40% and in these cases the bell and pad can be reintroduced
Drawbacks
-expensive
-time consuming
-requires motivation
-children may find it embarrassing
NON-PHARMACOLOGICAL INTERVENTIONS
1. Bladder-Volume Alarm-Senses the bladder when it is nearing capacity. This has added advantage of alerting the child before they
wet.
2. Star Chart System- Reward system
3. Nightlifting- Taking child to the toilet to the toilet in a semi-sleep state-does not have good efficacy
4. Timed Night Awakening- every two hours- takes a huge investment on the part of the parents
5. Bladder Training Exercises and Overlearning- Drink a large amount of fluid and hold it for as long as possible- can be effective
yet also unpleasant
ADDITIONAL TREATMENTS
Therapy- This type of intervention can significantly address secondary enuresis which may be triggered by a
psychological stressor. CBT may help a child address cognitive distortions
Biofeedback- This is a form of pelvic floor physical therapy. Kegel exercises may strengthen the pelvic floor
musculature
Acupuncture- May be targeted over the sacral area where innnervation is for the bladder
ENCOPRESIS
Encopresis is less common than enuresis
-This elimination disorder may be more impairing and have more consequences
-When bowel continence is not achieved by age 4 a diagnosis of encopresis can be made
-Etiology may be physiological and/or psychological
TYPES OF ENCOPRESIS
Encopresis- defined as the repeated passage of feces in in appropriate places (usually undergarments). The voiding
is typically regarded as involuntary although it may be volitional. The term is derived from the Greek Word
Kopros meaning dung or feces
Primary Encopresis- soiling in a child who has never gained bowel continence for six months or more
Secondary Encopresis- soiling in a child who has previously acquired bowel control. When secondary encopresis
is due to psychological stress it may be referred to as regressive enuresis
Retentive Encopresis- Encopresis with Constipation and Overflow Incontinence
TYPES ENCOPRESIS CONTI….
Nonretentive Encopresis- Encopresis without Constipation and Overflow Incontinence
Encopresis unlike enuresis rarely occurs during sleep and when this occurs it is a poor prognostic indicator
DIAGNOSTIC CRITERIA ENCOPRESIS
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.
ETIOLOGY ENCOPRESIS
Delay in Maturation
Underlying Medical Condition
Psychological/Behavioral
Constipation
PREVALENCE OF ENCOPRESIS
By the age of 4, 95% of children have achieved bowel continence
-Boys tend to lag behind girls
-Secondary encopresis is slightly more common (50-60%)
-Some children don’t meet full criteria; even still isolated incidents have significant consequences (embarrassment
and anxiety) and may led to teasing.
DIAGNOSTIC CRITERIA
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.
PRIMARY RETENTIVE ENCOPRESIS
Delayed Physical Maturation
Inappropriate Toilet Training
Delayed physical maturation is often a common cause of primary retentive encoporesis
It is also caused often by harsh toilet training
Examples of harsh toilet training include
A. Starting training too early
B. Forcing the child to sit on the toilet for very extended periods of time
C. Physical punishment/ridicule for failures
PRIMARY RETENTIVE ENCOPRESIS CON..
Parents at times feel pressure to rush toilet training for the following reasons:
A. Diapers are expensive
B. Continence may be required for child care
Parents at time feel no need to potty train or neglect to do so. The child may develop toilet phobia in these cases
When a child’s parents train inappropriately this can create a power struggle between the parent and child about
using the bathroom
Parental reactions can determine if the child becomes successful with continence
RETENTIVE ENCOPRESIS
Represents 80-95% of cases
Infrequent Bowel Movements
Large Stools
Painful Defecation
RETENTIVE ENCOPRESIS
with overflow incontinence represents 80-95% of cases with encopresis
Children with constipation have infrequent bowel movements, large stools, and difficult painful bowel movements
When stooling is painful a child may avoid stooling and withhold their feces. This will become a repeated
behavior and lead to more hardening of the stool and retention.
The stool may eventually become too hard to pass through the anus. The bowel may also distend as stool
accumulates. With time this may result in the child losing the ability to sense a full bowel.
As the stool continues to accumulate liquid stool may leak around the blockage and cause soiling (encopresis with
constipation and overflow incontinence).
TREATMENT OF RETENTIVE ENCOPRESIS
Breaking this cycle is key in the treatment of retentive encopresis
Addressing the cause of constipation is essential and there can be different causes
including poor fluid intake, poor nutrition as in insufficient fiber in the diet. A child
may also have anxiety related to using public restrooms. Another cause may include
medications the child is taking
SECONDARY ENCOPRESIS
Secondary encopresis may arise due to new stressors
-Bowel incontinence in response to birth of a sibling or other stressors is regressive
-Children with ODD and CD may use soiling as a form of retaliation and anger against parents and authorities
-Some children find their feces interesting enough to smear it. Older children who engage in this behavior may
suffer from MR/Autism/Psychosis/RAD
DIAGNOSIS SECONDARY ENCOPRESIS
Child’s age
Onset (primary/secondary)
Timing (day/night)
Frequency
Location of soiling
Bowel Habits (frequency, stool size, consistency)
Melena/Hematochezia (passage of fresh blood per anus, usually in or with stool)
Pain with Defecation/Fluid and Dietary Habits
SECONDARY ENCOPRESIS
During history taking the clinician again needs to ask why now?
The history should focus on the above items
Developmental history
Recent Stressors
Mental Health –anxiety,depression,MR,Autism,ODD,CD
Current Meds
Previous Surgeries
Past Medical History
Family History
Previous Treatment for encopresis
TREATMENT
Advice/Education
Nonpharmacological
Pharmacological Intervention
It is essential to treat any underlying disorder that is suspected. When an identifiable organic cause can be
determined this should be treated appropriately
ADVICE/EDUCATION (SE)
Dietary Changes (foods high in fiber)
Increase Fluid Intake
Make Toilet Training Non-Threatening
Make Toilet Accessible
Regular Bathroom Times
ALSO CONSIDER..
Increase fluid intake and fiber
Reduce dairy intake
Older children should be encouraged to exercise more frequently
Fiber supplements
Improve access to the toilet
Star charts/small rewards
Timed sitting
Assist in cleaning soiled clothing
Regular bathroom times/ best times are after meals for up to fifteen minutes
TREATMENT
CBT and psychodynamic therapy can be used to help decrease symptoms of anxiety and depression associated
with encopresis
Biofeedback can be beneficial in the treatment of pelvic floor dysfunction. It can also teach the child sphincter
control
