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Elimination Disorders May 3, 2012 Napatia Tronshaw, MD Child and Adolescent Fellow University of Illinois at Chicago Institute of Juvenile Research Normal Development Toddler Bowel Phase (18 months- 3 years) 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 Star Alarm 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 Biofeedback Acupuncture Psychotherapy Encopresis Primary Encopresis Secondary Retentive Encopresis Encopresis Nonretentive encopresis Prevalence Secondary Between 3:1 encopresis is more common ages 7-8 prevalence is 1.5% 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 Infrequent Large 80-95% of cases Bowel Movements 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 Biofeedback Acupuncture Psychotherapy Pharmacological Laxatives Suppositories Enemas Mineral Stool Oil Softeners