ELIMINATION
DISORDERS
The main categories of pediatric elimination disorders include
enuresis and encopresis.
Enuresis is defined as voiding of urine into bed/clothing in children
who are at least five years of age. For the diagnosis to be given, the
voiding must occur at least twice per week for at least three
months. Enuresis can occur during the day or at night or both. It is
believed that daytime (diurnal) enuresis is different from nocturnal
enuresis in biological pathways and medical comorbidity.
Encopresis involves either voluntary or involuntary voiding of the
bowels (fecal incontinence) in inappropriate places in children who
are at least four years of age (symptoms must persist for at least
three months).
ENURESIS
Clinical definition of enuresis must meet the following criteria:
The child repeatedly voids urine into bed or clothes (whether involuntary or intentional).
The behavior must be clinically significant as manifested by either a frequency of twice
a week for at least three consecutive weeks or the presence of clinically significant
distress or impairment in social, academic (occupational), or other important areas of
functioning.
The child’s chronological or developmental age is at least five years of age.
The behavior is not due exclusively to the direct physiological effect of a substance
(such as a diuretic) or a general medical condition (such as diabetes, spina bifida, a
seizure disorder, etc.).
All these criteria must be met in order to diagnose an individual. Generally, healthcare
providers may further investigate for bladder control issues if a child is still enuretic in
the daytime by age four, or if they are still enuretic at nighttime by age five or six.
EPIDEMIOLOGY
Approximately 10% of six- to seven-year-olds around the world
experience enuresis. While 15–20% of five‐year‐old children
experience nocturnal enuresis, which usually goes away as they
grow older, approximately 2%-5% of young adults experience
nocturnal enuresis. About 3% of teenagers and 0.5%-1% of adults
experience enuresis or bedwetting, with the chance of enuresis
resolving being lower if it is considered frequent.
ETIOLOGY
Enuresis can be caused by one or more of the following:
caffeine consumption (which increases urine production), pattern and volume
of fluid intake (which could be remedied by drinking more throughout the day
and less in the evening before bed), less bladder capacity, dysfunctional
voiding (an obstruction of the bladder due to muscles controlling urine flow
that do no completely relax, thus making the person feel that their bladders is
always full and strain to urinate), urinary tract infection, delay in maturation
and development (which can be worsened if a child experiences stress and/or
anxiety), bladder instability, nocturnal polyuria (which involves altered
nighttime secretions of a hormone that controls water retention in the body),
sleep disorders (specifically those that may cause an inability or difficulty
arousing from sleep), and genetics (although several genes are considered of
interest in relation to enuresis, lack of a single gene that may cause enuresis
means that individuals of a family may have differing genetic mechanisms
resulting in the condition).
One particular study examined possible environmental factors
leading to enuresis and concluded that a history of anxiety in the
early years of childhood (as well as a parental history of anxiety
symptoms) predicted the development of this disorder; the greater
the anxiety and depression, the lower the functioning at age three
and more likely a child was to have a longer duration of enuresis.
Children with comorbid ADHD had elevated ADHD and depression
symptoms. Additionally, in line with other studies that have looked
at the underlying causes of enuresis, the researchers found that
humiliation and lowered self-esteem may be associated with this
disorder and become a risk factor for developing symptoms of
depression later on in life
ENCOPRESIS
The DSM clinical diagnosis criteria are
repeated passage of feces into inappropriate places (e.g., underwear
or floor) whether voluntary or unintentional.
at least one such event a month for at least three months.
chronological age of at least four 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.
The DSM-5 recognizes two subtypes: with constipation and overflow
incontinence and without constipation and overflow incontinence.
EPIDEMIOLOGY
Between 1.5% and 7.5% of children suffer from encopresis; 25% of
visits to pediatric gastroenterology clinics and 3% of visits to
general pediatric clinics are due to encopresis.The estimated
prevalence of encopresis in four-year-olds is between 1%-3%. The
disorder is thought to be more common in males than females, by a
factor of six to one.
ETIOLOGY
Encopresis is commonly caused by constipation, reflexive withholding of
stool, due to various physiological, psychological, or neurological
disorders, or from surgery (a somewhat rare occurrence). The colon
normally removes excess water from feces, but if the feces or stool
remains in the colon too long due to conditioned withholding or incidental
constipation, so much water is removed that the stool becomes hard, and
becomes painful for the child to expel in an ordinary bowel movement. A
vicious cycle can develop, where the child may avoid moving his/her
bowels in order to avoid the expected, painful toilet episode. This cycle
can result in deeply conditioning the holding response; thus the rectal anal
inhibitory response or anismus results. The rectal anal inhibitory response
has been shown to occur even under anesthesia and when voluntary
control is lost. The hardened stool continues to build up and stretches the
colon or rectum to the point where the normal sensations associated with
impending bowel movements do not occur.
Eventually, softer stool leaks around the blockage and cannot be withheld
by the anus, resulting in soiling. The child typically has no control over
these leakage accidents, and may not be able to feel that they have
occurred or are about to occur due to the loss of sensation in the rectum
and the rectal anal inhibitory response.
Strong emotional reactions typically result from failed and repeated
attempts to control this highly aversive bodily product. These reactions,
in turn, may complicate conventional treatments using stool softeners,
sitting demands, and behavioral strategies.
Beginning school or preschool is another major environmental trigger
with shared bathrooms. Feuding parents, siblings, moving, and divorce
can also inhibit toileting behaviors and promote constipation. An initiating
cause may become less relevant as chronic stimuli predominate.
