Elimination disorders
Sponsored Links
This presentation is the property of its rightful owner.
1 / 30

Elimination Disorders PowerPoint PPT Presentation


  • 201 Views
  • Uploaded on
  • Presentation posted in: General

Elimination Disorders. May 3, 2012 Napatia Tronshaw , MD Child and Adolescent Fellow University of Illinois at Chicago Institute of Juvenile Research. Normal Development. Toddler Phase (18 months- 3 years) Bowel Continence Bladder Continence. Enuresis. Nocturnal Enuresis

Download Presentation

Elimination Disorders

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Elimination Disorders

May 3, 2012

NapatiaTronshaw, MD

Child and Adolescent Fellow

University of Illinois at Chicago

Institute of Juvenile Research


Normal Development

  • Toddler Phase (18 months- 3 years)

  • Bowel Continence

  • Bladder Continence


Enuresis

  • Nocturnal Enuresis

    Monosymptomatic

    Polysymptomatic

  • Diurnal Enuresis

  • Primary Enuresis

  • Secondary Enuresis


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


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


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


Differential Diagnosis

  • Maturational

  • Anatomical Abnormalities

  • Endocrine

  • Urinary Tract Disease

  • Neurological

  • Medications

  • Psychological


Diagnostic Workup

  • Child’s Age

  • Onset of Symptoms (Primary/Secondary)

  • Timing (Nocturnal/Diurnal/Both)

  • Frequency

  • Family History

  • Developmental History


Physical Exam

  • Neurological Exam

  • Throat and Neck Exam

  • Skin Exam

  • Abdominal Exam

  • Routine Blood Draw

  • UA


Consults

  • Pediatric Urology

  • Ultrasound of Genitourinary system

  • Voiding Cystourethrogram

  • Renal Ultrasound

  • Pediatric Neurology

  • Sleep Study


Treatment

  • Education

  • Watchful Waiting

  • Non-pharmacological Management

  • Pharmacological Management

  • Therapeutic Interventions


Non-Pharmacological Interventions

  • Education

  • Advice

  • Bell and Pad


Non-Pharmacological Interventions

  • Bladder-Volume Alarm

  • Star Chart System

  • Nightlifting

  • Timed Night Awakening

  • Bladder Training Exercises/Overlearning


Pharmacological Interventions

  • Desmopressin

  • Imipraminine

  • Oxybutynin

  • TCAs, SSRIs & Psychostimulants

  • NSAIDs


Additional Treatments

  • Cognitive Behavioral Therapy

  • Psychodynamic Psychotherapy

  • Biofeedback

  • Acupuncture


Encopresis

  • Primary Encopresis

  • Secondary Encopresis

  • Retentive Encopresis

  • Nonretentive encopresis


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


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.


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


Etiology

  • Delay in Maturation

  • Underlying Medical Condition

  • Psychological/Behavioral

  • Constipation


Primary Retentive Encopresis

  • Delayed Physical Maturation

  • Inappropriate Toilet Training


Retentive Encopresis

  • Represents 80-95% of cases

  • Infrequent Bowel Movements

  • Large Stools

  • Painful Defecation


Secondary Encopresis

  • Birth of sibling

  • Parental Divorce

  • Abuse

  • ODD or CD

  • MR/Autism/ Psychosis/RAD


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


Physical Exam

  • Abdominal pain/distention

  • Height/Weight

  • Neurological Exam

  • Skin Exam

  • Rectal Exam

  • Abdominal XRAY

  • Stool Collection

  • Blood Testing

  • Rectal Biopsy/Barium Enema


Treatment

  • Advice/Education

  • Nonpharmacological

  • Pharmacological Intervention


Advice/Education

  • Dietary Changes (foods high in fiber)

  • Increase Fluid Intake

  • Make Toilet Training Non-Threatening

  • Make Toilet Accessible

  • Regular Bathroom Times


Nonpharmacological

  • CBT

  • Psychodynamic Psychotherapy

  • Biofeedback

  • Acupuncture


Pharmacological

  • Laxatives

  • Suppositories

  • Enemas

  • Mineral Oil

  • Stool Softeners


  • Login