Elimination Disorders in Children

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Moderator : Presenter :
Dr Srishti Detha Dr Avinash Choudhary
Assistant professor Junior Resident
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INDEX
• Introduction
• Enuresis
• Definition
• Epidemiology
• Etiology
• Clinical features and diagnosis
• Management
• Encopresis
• Definition
• Epidemiology
• Etiology
• Clinical features and diagnosis
• Management
• Conclusion
• References
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Introduction
• Disorders that concern elimination of faeces or urine
from the body.
• EDs comprise the two broad categories-
• 1.Encopresis 2. Enuresis
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• They are very common and distressing disorders in

children.
• Developing children upto 7 years of age-1-3% are
affected by FI, 2-3% by DE and upto 10% by NE.
• These rates are even higher in children with special
needs. eg-intellectual disability.
• Rate of comorbid psychiatric disturbances is
markedly increased in children with EDs.
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• Control over bowel and bladder function are complex

processes that involve motor and sensory functions.
• These functions are coordinated by frontal lobe &
regulated by neurons in pons and midbrain area.
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• Infant to Toddler Bladder capacity

increases
• 1-3years
through Cortical inhibitory pathways

Voluntary control over reflexes

Control over bladder muscles achieved

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Normal sequence of development

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1. ENURESIS
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ENURESIS
• Defined as the involuntary or intentional voiding of urine.
• Derived from Greek word Enourein-”to void urine”.
• Types:-
a. Nocturnal, diurnal or Mixed(according to ICD-11)
b. Primary or secondary( used in clinical practice)
c. Mono symptomatic or Non Mono
symptomatic(based on lower urinary tracts
symptoms)
d. Functional or non functional
e. Daytime urinary incontinence and nocturnal enuresis
(according to ICCS)
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• The severity of enuresis is determined by – frequency

• Quantity of urine used in decision of treatment
• The length of time before continence is considered
established varies in the different literature between 6
months and 1 year.
• DSM-5 requires a chronological age of 5 years, or
alternately, a developmental level equivalent to that age.
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o Nocturnal enuresis(NE)- any wetting during sleep

o Diurnal enuresis/DUI- wetting during day(wake state)

o Primary enuresis- child has been dry for < 6 months

o Secondary enuresis- relapse after a dry period of at least 6 months has
occurred.

 Children with secondary enuresis have experienced stressful life events

and have higher rates of comorbid psychiatric disorders.
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Epidemiology

A. Diurnal enuresis/DUI

• Prevalence is 2-3% up to 7 years of children.

• <1% among adolescents.

• DUI is more common in females(1.5:1).

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B. Nocturnal enuresis(NE)

• NE is 2-3 times more common than DUI.

• Prevalence is 10% among 7 year old children.
• 1-2% among adolescents.
• 0.3-1.7% among adults.
• Mean spontaneous remission rate is 15% per year.
• NE is more common in boys than girls(1.5-2:1).
• Primary enuresis is more common than secondary enuresis.
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Aetiology
• Maturational disorder of the CNS
• Genetic predisposition- 70-80% children with
enuresis have affected relatives.
• Anatomical
• Endocrinological
• UTI
• Neurological
• Medications
• Psychological
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 Pathophysiology of NE

1. Increased urine volumes(polyuria) Circadian

variation of ADH (but not lack of ADH)
2. Impaired arousal during sleep
3. Inhibition deficit of the brainstem do not adequately
suppress the emptying reflexes of the bladder while
sleeping.
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Clinical Features
1) Diurnal enuresis
I. Urge incontinence
• characterized by frequency of >7 times per day, with
short intervals in between.
• sudden, intensive urge
• wet small volumes
• Tiredness
• Holding manoeuvres- ‘curtsey sign’.
• Vulvovaginitis, peri-genital dermatitis, and urinary tract
infections are common.
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II. Voiding postponement

• low micturition frequency(<5 times per day)hoa!
• habitual postponement of micturition in certain situations (school,
play, reading, television).Th
• Holding manoeuvres
• Constipation and encopresis are common.
• Children have a high rate of psychological disorders such as ODD
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III. Dysfunctional voiding

• Repeated straining
• Intermittent and fractioned urine flow
• Incomplete bladder emptying with residual urine
• Urinary tract infections, stool retention, constipation are
common.
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2) Nocturnal enuresis
• Deep sleep and difficult arousal
• Increased urine volumes at night (polyuria) with large
wetted volumes.
• Bladder function during the day is completely normal.
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• ADHD is the most common comorbid disorder in

enuresis.
• The comorbidity rate of psychological symptoms and
disorders among children with Diurnal (30– 40%) is
higher, compared to children with nocturnal enuresis (20–
40%).
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Diagnosis- according to ICD-11

6C00 Enuresis
• Repeated voiding of urine into clothes or bed, during the day or at night.
• Age- 5 years.
• The urinary incontinence may have been present from birth or may have arisen
following a period of acquired bladder control.
• The behaviour is involuntary but in some cases it appears intentional.
• Enuresis should not be diagnosed if unintentional voiding of urine is due to a health
condition that interferes with continence.
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• 6C00.0 Nocturnal enuresis

• 6C00.1 Diurnal enuresis
• 6C00.2 Nocturnal and diurnal enuresis
• 6C00.Z Enuresis, unspecified
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DSM-5
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Pathology And Laboratory

Examination
• No single laboratory finding is pathognomonic of
enuresis
• Rule out organic factors
• Urinalysis
• Radiographic studies
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Differential diagnosis
• urinary tract infections, obstructions, or anatomical
conditions
• diabetes mellitus and diabetes insipidus
• seizures, intoxication, and sleepwalking disorder
• drugs
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Course and Prognosis

• Self-limiting and may have a spontaneous remission.
• late onset of enuresis is associated with a concomitant
psychiatric difficulty and poor outcome.
• Relapses do occur.
• CONSEQUENCES
poor self-image, decreased self esteem, social embarrassment and
avoidance, anxiety and intrafamilial conflict.
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Management

• Detail history
• Medical examination
EVALUATION • Psychiatric evaluation
• Asses child’s
perception of enuresis
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TREATMENT

1. Only 38% seek help and there is high rate of

spontaneous remission
2. Intervention is required when it causes functional
impairment.
3. The first step in any treatment plan is to review
appropriate toilet training.
4. Treatment is always symptom- oriented, with the aim
of achieving complete dryness.
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• Record keeping- determining baseline and

following child’s progress, and itself can be a
reinforcer.
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• Restriction of fluids before bedtime.

• Control of the urge without the use of the pelvic floor
muscles.
• Alarm therapy-1st line treatment
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Behaviour Therapy:

• The primary behavioural intervention is the bell-and-pad method

of conditioning.
• coupled with the use of DDAVP for refractory cases
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• biofeedback— either with uroflowmetry or pelvic

floor electromyography (EMG).
• newest advance-external ultrasonic monitor that is
attached to a waistband.
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Pharmacotherapy:
Indications for medication:
• therapy resistance towards alarm treatment,
• lack of motivation in the children,
• stress in the family,
• lack of co- operation, and
• requirement of short- term dryness, that is, for school outings.
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Desmopressin:
1. antidiuretic compound,2nd line treatment
2. given 30– 60 minutes before going to sleep.
3. Oral dosage is 0.2– 0.4 mg or 120– 240 μg as a melt tablet.
4. does not respond within 4 weeks-non responders
5. A/E- headache, nasal congestion, epistaxis, decreased
appetite and stomach ache.
6. Serious A/E- hyponatremic seizures and water intoxication
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Oxybutinin:
1. 0.3-0.6 mg per kg body weight/ day in three doses(max
15mg/day)
2. Given in diurnal urinary incontinence
3. A/E-flushing, accommodation problems, tachycardia,
hyperactivity, dryness in the mouth, residual urine, and
constipation.
Propiverin:
4. max of 0.8 mg per kg body weight/ day in two doses
5. Lesser A/E
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Imipramine:
1. TCA-antienuretic effect
2. third- line treatment in therapy- resistant cases.
3. A/E-cardiac arrhythmias and intoxication in high doses
4. 5 mg/kg body weight(max)
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ENCOPRESIS
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ENCOPRESIS
• Defined by defecation in inappropriate places either
voluntarily or involuntarily.
• Show a heterogeneous pattern of both internalizing and
externalizing disorders.
• FI is a common disorder, which is a/w stigmatisation,
distress and associated comorbid disorders despite
good treatment approaches.
Epidemiology
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 Prevalence:
• It’s common disorder affecting 1-3% of children from 4
years of age(the definitional age) throughout school
years and can persist into adolescence & even
adulthood.
• 5.4% of children affected by FI in total upto 7years of
age.
• 1.4% are having 1 or more than 1 episode per week.
• Boys are more commonly affected than girls( ratio is 3-
4:1).
• Encopresis occurs almost exclusive during the day.
• The rare occurrence of nocturnal encopresis is often
a/w organic cause.
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Etiology
• 90% functional
• Maturational
• Anatomical
• lack of appropriate toilet training
• sexual abuse.
• Neurological
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 Pathophysiology of FI with constipation:-

chronic stool retention in bowel movements

impaction of large and hard faeces

fresh stool bypassing these faecal masses

overflow soiling
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Types
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Clinical features
1. Functional constipation with FI
• Reduced number of bowel movements with large stools
of altered consistency
• Painful defecation.
• Abdominal pains and reduced appetite
• Colon transit time is increased, and abdominal and
rectal masses are palpable.
• Rectal diameter is increased on USG(>30mm).
• Laxative therapy is useful.
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1. Non- retentive FI
• Daily bowel movements of normal size and
consistency.
• Colon transit time is normal, and no stool masses
can be palpated.
• Enuresis is less common
• Appetite is good.
• Laxatives have no effect , and can worsen the
soiling.
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Megacolon :

Constipation

Painful defecation

Avoidance of defecation

Contraction of the external anal sphincter

Faeces are accumulated in the colon and rectum

Colon transit times increase

Peristalsis and sensation decrease

Fluid withdrawal

Large & hard faecal masses accumulated in colon causes megacolon.

  DIAGNOSIS: according to ICD-11 50

• 6C01- Encopresis
• Repeated passage of feces in inappropriate places.
• Frequency-at least once per month over a period of several months.
• Age- when fecal continence is ordinarily expected =4 years.
• The fecal incontinence may have been present from birth or may have arisen
following a period of acquired bowel control.
• Encopresis should not be diagnosed if fecal soiling is fully attributable to
another health condition (e.g., aganglionic megacolon, spina bifida, dementia),
congenital or acquired abnormalities of the bowel, gastrointestinal infection, or
excessive use of laxatives.
1. 6C01.0 Encopresis with constipation or overflow incontinence
2. 6C01.1 Encopresis without constipation or overflow incontinence
Diagnosis- according to 51

DSM-5

DSM V
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Pathology And Laboratory

Examination
physical examination of the
abdomen

rectal examination

Ultrasound and abdominal X-

ray

Bristol Stool Form

Stool examination
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Differential Diagnosis
• Aganglionic megacolon or Hirschsprung's disease,
coeliac disease, cow milk intolerance/ allergy
• medicinal adverse effects
• endocrine or neurological disorders
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Course And Prognosis

• self-limiting, and it rarely continues beyond middle adolescence.
• Peers are intolerant, taunt and reject a child with encopresis.
• low self-esteem are plagued by constant social rejection.
• The outcome of encopresis is influenced by a family's willingness
and ability to participate in treatment without being overly
punitive and by the child's ability and motivation to engage in
treatment.
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Treatment
1. The first step comprises counselling, provision of
information, and psychoeducation.
2. Enhancing motivation and lighten the guilt feelings.
3. Increase fluid intake and high fibre diet.
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Toilet training
• Basic treatment approach.
• Children are asked to go to the bathroom three times a day
after mealtimes
• Ask them to sit on the toilet seat 5– 10 minutes in a
relaxed way
• These toilet sessions are documented in charts.
• The toiling training procedures have the effect of
regulating defecation habits over the day, as the
postprandial defecation reflexes are most active after
mealtimes.
• Toilet training is the main treatment in non-retentive FI.
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PHARMACOTHERAPY
• In children with constipation, toilet training is
combined with laxative treatment.

• Disimpaction first and then maintenance treatment.

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1.Disimpaction

1. Polyethyleneglycol (PEG— macrogol)

• 1-1.5 g/ kg body weight per day
2. Rectal dis-impaction with enemas are a good alternative-
• 30 mL per 10 kg body weight or
• half an enema for preschool children,
• 3/ 4 to one enema in schoolchildren.
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2.Maintenance treatment

1. Minimum of 6– 24 months
2. In addition to toilet training-oral laxatives are given
3. most effective laxative is PEG (macrogol)-initial dose is
0.4 g/ kg body weight per day in two doses.
• Therapeutic range varies from 0.2 to 1.4 g/ kg body
weight per day.
• A/E-abdominal pain
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4.Lactulose, is less effective

• has more side effects.
• dosage of liquid lactulose ranges from 1 to 3 mL/ kg body
weight per day in 1– 3 doses.
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PSYCHOTHERAPY
• Interactive parent-
child family guidance
intervention
• Supportive
psychotherapy and
relaxation techniques
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CONCLUSION
• Most of elimination disorders are functional.
• It is important to identify and treat at the earliest as it
can cause significant distress and functional
impairment.
• Negative consequences on the child- low self esteem,
negative self image, anxiety and neglect.
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REFERENCES
• Kaplan and Sadock’s comprehensive textbook of
psychiatry, 10th edition, 9295-93
• New Oxford Textbook of Psychiatry, 3rd edition, 1103-
1112
• Lewis child and adolescent psychiatry
• ICD-11, 61-62
• DSM-5, 355-360
• Relevant articles
THANK YOU

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