DSM-5 (American Psychiatric Association 2013) placed elimination disorders in their own chapter (formerly grouped, in DSM-IV, under “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”).
Enuresis is defined as repeated voiding of urine into bed or clothes, after a chronological age (or equivalent developmental level) of at least 5 years and occurring at least twice a week for at least 3 consecutive months or causing clinically significant distress or impairment in functioning (American Psychiatric Association 2013). Urinary incontinence in young children, and occasionally in older children after toilet training has been completed, may be a normal developmental phenomenon. Monosymptomatic enuresis (MSE) is nocturnal, does not involve bladder dysfunction, and includes no daytime symptoms. Children with MSE produce more urine at night than children without MSE and may have decreased functional bladder capacity. Children with nonmonosymptomatic enuresis (NMSE) have daytime (and also often nighttime) wetting. They may have urinary urgency, leaking, or frequency and may have bladder dysfunction, including emptying and storage abnormalities.
Nocturnal enuresis typically occurs 30 minutes to 3 hours after sleep onset but may occur at any time during the night. The child may sleep through the episode or be awakened by the moisture. Daytime bladder control usually precedes nocturnal control by 1–2 years. Some clinicians do not diagnose nocturnal enuresis until the child is age 6 or 7 years. If bladder control has not yet been achieved, the enuresis is primary. In secondary enuresis, wetting reappears after a period of established urinary continence.
Enuresis is seen in 10%–15% of 7-year-olds. The male predominance of primary enuresis decreases with age. After age 5 years, the prevalence of enuresis in both boys and girls spontaneously decreases by 15% per year. Between 3% and 9% of school-age girls experience daytime wetting (Mattsson and Gladh 2003). The general prevalence in older adolescents and adults is 1%. Few of the children with nocturnal enuresis also have diurnal enuresis or encopresis. In contrast, 50%–60% of patients with diurnal enuresis are likely to experience nocturnal incontinence. Enuresis is of the primary type in more than 85% of cases, a percentage that gradually decreases with age. Secondary enuresis is equally prevalent in boys and girls.
Approximately 70% of children with enuresis (particularly boys) have a first-degree relative with enuresis. Studies of monozygotic and dizygotic twins show a strong genetic factor, although the mode of transmission is unclear. A “maturational” etiology is suggested in patients with primary enuresis who have small-volume voidings, short stature, low mean bone age, and delayed sexual maturation. Some patients have a relative inability to concentrate urine. Excessive fluid intake may contribute to the problem. Anatomical abnormalities of the urinary tract are not typical causes of enuresis. Constipation with or without encopresis is common in children with enuresis, and should be treated first as this often improves enuresis. Vaginal reflux of urine (incontinence within 10 minutes of voiding in girls) and “giggle incontinence” (solely associated with laughter between ages 10 and 20) are not considered enuresis. Enuresis is more common in patients with obstructive sleep apnea and with attention-deficit/hyperactivity disorder (ADHD). See Table 11-1 for medical causes of enuresis.
Urinary tract infection
Urethritis—bubble bath, sexual abuse
Sickle cell trait
Neurogenic bladder—myelodysplasia, trauma, other neurological disorder
Congenital malformation of the genitourinary tract
Urinary obstruction—stone, pelvic mass
Medication side effect
Psychological factors are not generally thought to be causal of enuresis. Anxious children may experience urinary frequency, resulting in daytime incontinence if toilet facilities are not readily available or if the child is fearful of certain bathrooms. In oppositional defiant disorder, refusal to use the toilet may be part of the child’s battle for control. ADHD is often comorbid with enuresis, and both may represent central nervous system maturational delays (Shreeram et al. 2009). However, children with ADHD may wait until the last minute to urinate and then lose control on the way to the bathroom. Secondary enuresis may be related to stress, trauma, or psychosocial crisis. Enuresis that continues into adolescence is associated with higher rates of psychopathology.
Course and Prognosis
Primary enuresis has a high rate of spontaneous remission. Only about 1% of boys (and a smaller percentage of girls) still have this condition at age 18 years. Secondary enuresis usually begins between ages 5 and 8 years. Onset in adolescence may signify more psychiatric problems and less favorable outcome.
Complications include embarrassment, anger from and punishment by caregivers, teasing by peers, avoidance of overnight visits and camp, social withdrawal, and angry outbursts. The development of psychiatric disorders is higher in enuretic children than in the general population.
Evaluation and Differential Diagnosis
Initial medical evaluation is required to rule out medical causes (see Table 11–1). This includes a medical history (including questions about frequency, urgency, dysuria, and bowel habits), family history, and a physical examination. For MSE, the only laboratory study initially needed is a urinalysis, with appropriate follow-up if the results are abnormal. Evaluation of NMSE includes a urinalysis, urine culture, bladder ultrasound, and uroflow testing. Urodynamic studies are reserved for children who do not respond to treatment or who have physical exam findings suggestive of tethered spinal cord. A family history of enuresis is generally reassuring and implies that it will eventually be outgrown.
Psychiatric evaluation of the child and family includes assessment of associated psychiatric symptoms, recent psychosocial stressors, and family concern about and management of the symptoms. Developmental evaluation can identify the child who is not mature enough to achieve continence.
Treatment of MSE begins with behavior modification. For younger children who wet only at night, the most useful strategy is to minimize symptoms by advising the parents not to punish or ridicule the child while awaiting maturation. Children can be taught to change their own beds to reduce negative parental reactions. Restricting fluids before bedtime, eliminating caffeinated beverages, and voiding at bedtime may be helpful.
For older children who are motivated to stop bed wetting, a monitoring and reward procedure (a chart with stars to be exchanged for rewards) may be effective. Daytime urinary continence may be achieved rapidly with a behavioral program. A program of “bladder training” exercises may be helpful. Practice in delaying bladder emptying may increase bladder capacity. Interruption of the stream while urinating may strengthen sphincter muscles and improve awareness of bladder sensations. Instruction on adapted voiding posture and hygiene may be effective for urethrovaginal reflux (Mattsson and Gladh 2003).
If simple interventions are unsuccessful, a urine alarm is recommended. This device, an improvement on the “bell and pad,” has a high success rate of 75% at 6 months and 56% at 12 months. This rate compares favorably to rates using observation alone of 6% at 6 months and 16% at 12 months. If the alarm is set up to awaken the parents so they awaken the child, the relapse rate is low. A combination of the urine alarm, cleanliness training, retention control, and overlearning can stop bed wetting in two-thirds of children with primary enuresis (see Bennett 2005 in “Additional Reading”).
Although behavioral treatments consistently demonstrate higher success rates than medication, DDAVP (desmopressin) at bedtime can be helpful in the short term in patients who are resistant to behavioral interventions or who need a rapid result (e.g., for camp). The majority of patients relapse when medication is withdrawn (unless maturation has intervened). The oral form of DDAVP is preferred over the intranasal spray because of the risk of hyponatremia associated with the spray. Neither form should be given to a child who has fever, vomiting, diarrhea, or other condition that may result in sodium imbalance.
Psychotherapy is rarely useful in the treatment of enuresis. However, it may be indicated for the treatment of psychosocial sequelae of enuresis. Children who experience enuresis as a consequence of trauma or stress may also benefit from psychotherapeutic interventions. Associated disorders may require psychiatric treatment.
Encopresis is defined as fecal soiling of clothes or excretion into inappropriate places that occurs at least once a month for at least 3 months. The child’s chronological age (or equivalent developmental level) must be at least 4 years, when full bowel control is developmentally expected. Medical evaluation is necessary before labeling the disorder as “functional.”
Encopresis is associated with constipation about 80% of the time. Children may have constipation or voluntary stool withholding with continuous leaking overflow incontinence, a problem that resolves with treatment of the constipation. This problem is classified as “retentive encopresis.” Children with incontinence without constipation, or “functional nonretentive fecal incontinence,” tend to produce formed stools in inappropriate contexts.
Prevalence of encopresis gradually decreases with age and is reported in approximately 3% of 4-year-olds, 2% of 6-year-olds, and 1.6% of 10- to 11-year-olds. The problem is rare in adolescents. Among school-age children, males predominate in ratios from 2.5:1 to 6:1.
Retentive encopresis may initially be triggered by painful defecation, inadequate or punitive toilet training, fear of using the school bathroom, or toilet-related fears. Once retention and constipation are initiated by emotional or medical factors, bowel physiology may maintain them independently. Parents may not recognize that the soiling is related to chronic constipation rather than reluctance to use the toilet. Pathophysiological mechanisms include altered colon motility and contraction patterns, obstruction, stretched and thinned colon walls (megacolon), or decreased sensation or perception secondary to a neurological disorder. Liquid stool leaks around the impaction and the child is unaware and unable to exert control.
The etiology of nonretentive encopresis is less well understood. It is often associated with younger age, positive family history, male gender, and life events such as birth of a sibling, parental discord, or other stressors. It may be a deliberate attempt by the child to effect change or communicate anger. Thirty to 50 percent of these children will have a comorbid emotional or behavioral disorder (Koppen et al. 2016).
Course and Prognosis
The course and prognosis for encopresis are variable. Although the majority of children with encopresis will recover within a year of treatment, some studies indicate persistence of symptoms into adulthood. One study of constipation with encopresis found that among 16-year-olds, one-third were still symptomatic. A 10-year follow-up of children with nonretentive encopresis found that 49% of 12-year-olds were symptomatic, as were 15% of 18-year-olds (Rajindrajith et al. 2013). Psychiatric or medical comorbidity may be the primary determinant of prognosis.
Behavior problems are more common in the psychiatrically referred population than in those seen by pediatricians. In the psychiatric population, 25% of children with encopresis also have enuresis. Encopresis is also more common in children with ADHD.
Evaluation and Differential Diagnosis
A detailed history of bowel function, nature and pattern of soiling, attempts to train or treat, and bathroom habits and environment is needed. Physical examination should include an abdominal examination for evidence of a fecal mass, an anal examination for evidence of fecal material, a rectal digital examination for stool consistency, and a neurological examination with perianal sensation testing. The need for additional laboratory tests is based on the history and physical examination. A barium enema is not necessary in uncomplicated cases of encopresis but may be helpful in diagnosing Hirschsprung’s disease (congenital megacolon). Urinalysis will detect a secondary urinary tract infection, which is common in girls with encopresis. Medical causes of fecal incontinence include thyroid disease, hypercalcemia, lactase deficiency, pseudo-obstruction, myelomeningocele (spina bifida), cerebral palsy with hypotonia, rectal stenosis, anal fissure, Hirschsprung’s disease (which is usually associated, however, with large feces rather than incontinence), and anorectal trauma.
Psychiatric evaluation includes assessment for associated psychiatric disorders. Oppositional children may soil willfully. Children with ADHD do not plan ahead, so they may be caught by an urge to defecate when a bathroom is not available. They also may be prone to constipation (because of spending insufficient time toileting) or fecal soiling of underwear (due to careless hygiene). Anxious children may be intimidated by perceived or real dangers or humiliations in school bathrooms and avoid defecation, only to have an “accident” on the way home.
Most cases of encopresis can be treated by a pediatrician, but more complex cases need psychological intervention. The pediatrician educates the child and parents about bowel function. For encopresis without constipation, a behavior-shaping program gives rewards first for just sitting on the toilet and later for moving the bowels appropriately. Manipulative soiling requires family behavioral treatment and attention to any exacerbating dynamic factors. For children with severe stool retention, impaction, and loss of bowel tone, initial bowel cleaning (most often with oral polyethylene glycol [PEG], or with enemas) followed by “retraining” the bowel (e.g., with stool softener or mineral oil, a high-fiber diet, development of a toileting routine, and use of a mild suppository if necessary) must be used in conjunction with the behavioral program (Rowan-Legg and Canadian Paediatric Society 2011). Repeated administration of enemas by parents is harmful to the parent–child relationship. Individual and family psychiatric interventions are indicated in resistant cases, in which the focus of treatment shifts to the associated psychiatric disorders.
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