The developmental milestones of mastering control over bowel and bladder function are complex processes that occur over a period of months for typical toddlers. Infants generally void small volumes of urine approximately every hour, commonly stimulated by feeding, and may have incomplete emptying of the bladder. As an infant matures to be a toddler, bladder capacity increases, and 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 ability to have muscular control over the bowel occurs even before bladder control for most toddlers, and the assessment of fecal soiling includes determining whether the clinical presentation occurs with or without chronic constipation and overflow soiling. The normal sequence of developing control over bowel and bladder functions is the development of nocturnal fecal continence, diurnal fecal continence, diurnal bladder control, and nocturnal bladder control. Bowel and bladder control develops gradually over time. Toilet training is affected by many factors, such as a child’s intellectual capacity and social maturity, cultural determinants, and the psychological interactions between the child and parents.

Enuresis and encopresis are the two elimination disorders described in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). These disorders are considered after age 4 years for encopresis and after age 5 years for enuresis, when a child is chronologically, developmentally, and physiologically expected to be able to master these skills. Normal development encompasses a range of time in which a given child is able to devote the attention, motivation, and physiological skills to exhibit competency in elimination processes. Encopresis is defined as a pattern of passing feces in inappropriate places, such as in clothing or other places, at least once per month for 3 consecutive months, whether the passage is involuntary or intentional. Children with encopresis typically exhibit dysregulated bowel function, for example, with infrequent bowel movements, constipation, or recurrent abdominal pain and sometimes pain on defecations. Encopresis is a nonorganic condition in children who are chronologically at least 4 years old. Enuresis is the repeated voiding of urine into clothes or bed, whether the voiding is involuntary or intentional. The behavior must occur twice weekly for at least 3 months or must cause clinically significant distress or impairment socially or academically. The child’s chronological or developmental age must be at least 5 years.

Students should study the questions and answers below for a useful review of these disorders.