Elimination Disorders

1. Elimination Disorders May 3, 2012 NapatiaTronshaw, MD Child and Adolescent Fellow University of Illinois at Chicago Institute of Juvenile Research

2. Normal Development • Toddler Phase (18 months- 3 years) • Bowel Continence • Bladder Continence

3. Enuresis • Nocturnal Enuresis Monosymptomatic Polysymptomatic • Diurnal Enuresis • Primary Enuresis • Secondary Enuresis

4. 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

5. Prevalence • 30% of US children achieve continence by age 2 • 5-10% of 5 year olds meet criteria for nocturnal enuresis • 15% of enuretic children have spontaneous resolution of symptoms each year • 2-3% of 12 year olds meet criteria for nocturnal enuresis • 1% of 18 year olds still have enuretic symptoms

6. Diagnostic Criteria Diagnostic criteria for 307.6 Enuresis • 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 (occupa­tional), 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

7. Differential Diagnosis • Maturational • Anatomical Abnormalities • Endocrine • Urinary Tract Disease • Neurological • Medications • Psychological

8. Diagnostic Workup • Child’s Age • Onset of Symptoms (Primary/Secondary) • Timing (Nocturnal/Diurnal/Both) • Frequency • Family History • Developmental History

9. Physical Exam • Neurological Exam • Throat and Neck Exam • Skin Exam • Abdominal Exam • Routine Blood Draw • UA

10. Consults • Pediatric Urology • Ultrasound of Genitourinary system • Voiding Cystourethrogram • Renal Ultrasound • Pediatric Neurology • Sleep Study

11. Treatment • Education • Watchful Waiting • Non-pharmacological Management • Pharmacological Management • Therapeutic Interventions

12. Non-Pharmacological Interventions • Education • Advice • Bell and Pad

13. Non-Pharmacological Interventions • Bladder-Volume Alarm • Star Chart System • Nightlifting • Timed Night Awakening • Bladder Training Exercises/Overlearning

14. Pharmacological Interventions • Desmopressin • Imipraminine • Oxybutynin • TCAs, SSRIs & Psychostimulants • NSAIDs

15. Additional Treatments • Cognitive Behavioral Therapy • Psychodynamic Psychotherapy • Biofeedback • Acupuncture

16. Encopresis • Primary Encopresis • Secondary Encopresis • Retentive Encopresis • Nonretentive encopresis

17. Prevalence • Secondary encopresis is more common • Between ages 7-8 prevalence is 1.5% • 3:1 male to female ratio • Retentive type is 80-95% of cases

18. 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.

19. Diagnostic Criteria • The DSM-IV recognizes two subtypes with constipation and overflow incontinence, and without constipation and overflow incontinence. In the subtype with constipation, the feces are usually poorly formed and leakage is continuous, and occurs both during sleep and waking hours. • In the type without constipation, the feces are usually well-formed, soiling is intermittent, and feces are usually deposited in a prominent location. This form may be associated with oppositional defiant disorder or conduct disorder, or may be the consequence of large anal insertions, or more likely due to chronic encopresis that has radically desensitized the colon and anus

20. Etiology • Delay in Maturation • Underlying Medical Condition • Psychological/Behavioral • Constipation

21. Primary Retentive Encopresis • Delayed Physical Maturation • Inappropriate Toilet Training

22. Retentive Encopresis • Represents 80-95% of cases • Infrequent Bowel Movements • Large Stools • Painful Defecation

23. Secondary Encopresis • Birth of sibling • Parental Divorce • Abuse • ODD or CD • MR/Autism/ Psychosis/RAD

24. Diagnosis • Child’s age • Onset (primary/secondary) • Timing (day/night) • Frequency • Location of soiling • Bowel Habits (frequency, stool size, consistency) • Melena/Hematochezia • Pain with Defecation/Fluid and Dietary Habits

25. Physical Exam • Abdominal pain/distention • Height/Weight • Neurological Exam • Skin Exam • Rectal Exam • Abdominal XRAY • Stool Collection • Blood Testing • Rectal Biopsy/Barium Enema

26. Treatment • Advice/Education • Nonpharmacological • Pharmacological Intervention

27. Advice/Education • Dietary Changes (foods high in fiber) • Increase Fluid Intake • Make Toilet Training Non-Threatening • Make Toilet Accessible • Regular Bathroom Times

28. Nonpharmacological • CBT • Psychodynamic Psychotherapy • Biofeedback • Acupuncture

29. Pharmacological • Laxatives • Suppositories • Enemas • Mineral Oil • Stool Softeners