Elimination Disorders

Enuresis: Overview

Definition

• Involuntary urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence in children 
• Most common form: monosymptomatic nocturnal enuresis (bedwetting in children > 5 years old with no signs of urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy symptoms)

Epidemiology

• Monosymptomatic nocturnal enuresis
  • Occurs in up to 15% of 5-year-olds
  • Boys are twice as likely to experience nocturnal urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence.
  • The incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency resolves spontaneously, with approximately a 15% decrease per year.
• 75% of enuretic children have nighttime incontinence.
• 25% of enuretic children have daytime incontinence.

Classification

• Mono- versus non-monosymptomatic
  • Monosymptomatic: occurs in children with no history of bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess problems and no signs of urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy symptoms
  • Non-monosymptomatic: occurs in children with signs of lower urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy symptoms
• Primary versus secondary
  • Primary: Urinary continence has never been achieved.
  • Secondary:
    • Urinary continence is achieved for at least 6 months and control is later lost.
    • Often associated with major changes in a child’s life (birth of a sibling, parental divorce) or emotional trauma (abuse)
• Timing of enuresis
  • Diurnal: daytime incontinence
  • Nocturnal: nighttime incontinence
  • Mixed: both nocturnal and diurnal incontinence

Enuresis: Diagnosis and Management

Clinical assessment

The primary goal of assessment is to determine if an underlying medical condition is present that could explain the incontinence (e.g., constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus, diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus insipidus).

• History:
  • Increased urinary frequency and/or urgency
  • Frequency of incontinence
  • Intake of liquids at night
  • Volume of urine lost during episodes
  • Length of prior “dry periods”
  • Association with tenesmus or laughter
  • Recent stressful changes in the household
  • Formal assessments:
    • Dysfunctional voiding scoring system
    • Vancouver Symptom Score for dysfunctional elimination Elimination The initial damage and destruction of tumor cells by innate and adaptive immunity. Completion of the phase means no cancer growth. Cancer Immunotherapy syndrome
• Physical exam:
  • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension (risk of nephropathy)
  • Painful abdomen on palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination due to retained stool ( constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation)
  • Abnormalities on neurologic examination of the perineum Perineum The body region lying between the genital area and the anus on the surface of the trunk, and to the shallow compartment lying deep to this area that is inferior to the pelvic diaphragm. The surface area is between the vulva and the anus in the female, and between the scrotum and the anus in the male. Vagina, Vulva, and Pelvic Floor: Anatomy and/or lower extremities ( spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy abnormalities)
  • Delayed developmental milestones Developmental milestones Developmental milestones are the skills or abilities that most children are able to perform when they reach a certain age. Understanding the appropriate milestones and at what age they are reached helps clinicians identify symptoms of delayed development. Developmental milestones are divided into 5 important domains: gross motor, fine motor, language, social, and cognitive. Developmental Milestones and Normal Growth (autism)
  • Other behavioral changes (abuse)

Diagnosis

The diagnosis of enuresis is primarily through history, physical examination, and urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children.

• Urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children:
  • Usually of the first urine output of the day
  • Screening Screening Preoperative Care tool for:
    • Hydration status
    • Proteinuria Proteinuria The presence of proteins in the urine, an indicator of kidney diseases. Nephrotic Syndrome in Children
    • Hematuria Hematuria Presence of blood in the urine. Renal Cell Carcinoma
    • Diabetic ketoacidosis Ketoacidosis A life-threatening complication of diabetes mellitus, primarily of type 1 diabetes mellitus with severe insulin deficiency and extreme hyperglycemia. It is characterized by ketosis; dehydration; and depressed consciousness leading to coma. Metabolic Acidosis
    • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus insipidus
    • Water intoxication
    • Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infection
• Renal ultrasound and voiding cystourethrogram Voiding Cystourethrogram Urinary Tract Infections (UTIs) in Children:
  • If the child:
    • Is very symptomatic during the day
    • Has a history of urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
    • Is suspected of having renal structural abnormalities
  • Often used in conjunction with ultrasound to determine postvoid residual volume Residual volume The volume of air remaining in the lungs at the end of a maximal expiration. Common abbreviation is rv. Ventilation: Mechanics of Breathing

Management

• Initial management includes the treatment of any underlying medical conditions.
• Behavioral therapy:
  • Reassure parents and set reasonable goals.
  • Educate parents to not reprimand bedwetting.
  • Reduce the impact of bedwetting.
  • Wake the child at night so that they can go to the bathroom at scheduled times.
  • Use voiding alarms (enuresis alarm).
• Lifestyle modifications:
  • Voiding diary
  • Limiting liquid intake after 6 or 7 pm
  • Limiting sugar and caffeine Caffeine A methylxanthine naturally occurring in some beverages and also used as a pharmacological agent. Caffeine’s most notable pharmacological effect is as a central nervous system stimulant, increasing alertness and producing agitation. Several cellular actions of caffeine have been observed, but it is not entirely clear how each contributes to its pharmacological profile. Among the most important are inhibition of cyclic nucleotide phosphodiesterases, antagonism of adenosine receptors, and modulation of intracellular calcium handling. Stimulants consumption after 5 pm 
  • Encouraging urination before going to bed
• Medical therapy:
  • First line: desmopressin Desmopressin Hemophilia
  • Second line: tricyclic antidepressants Tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants

Encopresis: Overview

Definition

Encopresis is the involuntary or unintentional passage of feces in inappropriate situations in children older than 4 years of age in the absence of neuromuscular disease.

Epidemiology

• Occurs in 1%–4% of 4-year-olds
• More common in boys than girls (4–6:1)

Classification

Etiology

• Approximately 80% of cases can be attributed to constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation (retentive). There are 3 time points in life at which children are particularly susceptible:
  • First introduction of solid foods
  • Potty training
  • Starting school
• Both retentive and non-retentive encopresis can be associated with emotional or environmental factors, including:
  • Premature Premature Childbirth before 37 weeks of pregnancy (259 days from the first day of the mother’s last menstrual period, or 245 days after fertilization). Necrotizing Enterocolitis or unplanned difficulty with toilet training
  • Alterations in a child’s schedule, including diet, starting school, and toilet training
  • Birth of another child or parental divorce

Encopresis: Diagnosis and Management

Clinical assessment

A careful history is important to determine if there is an underlying condition or if there are any recent stressors in the child’s life.

• Encopresis or functional constipation Functional Constipation Pediatric Constipation can be diagnosed by the Rome IV criteria. A child must have two of the following, at least once a week for a minimum of one month:
  • One episode of fecal incontinence Fecal incontinence Failure of voluntary control of the anal sphincters, with involuntary passage of feces and flatus. Pediatric Constipation 
  • Retentive posturing or purposefully withholding feces
  • Evidence of a large volume of stools in the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy
  • Episodes of large-volume stools that may clog the toilet
  • Painful bowel movements
  • Two or fewer defecations each week
• Retentive:
  • Parents may report large stool volume when defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility does occur.
  • Defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility may be described as painful.
  • Abdominal pain Abdominal Pain Acute Abdomen is a common associated complaint.
  • A careful diet history may give clues to causes of constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation:
    • Excessive dairy intake
    • Insufficient fiber intake
• Non-retentive: often associated with urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence
• Both:
  • History of concurrent behavior problems or a recent change in school performance due to bullying from peers
  • Recent history of potentially traumatic changes at home
  • Recent birth of a new sibling, especially in only children

Physical examination

• Retentive
  • General: streaking of stool in underwear
  • Rectal exam:
    • Reveals large fecal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with functional constipation Functional Constipation Pediatric Constipation
    • May help in evaluating sphincter tone to rule out neurologic disease
  • Abdominal exam may indicate constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation:
    • May be distended and somewhat tender to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination
    • Stool may be palpated in the suprapubic region
• Non-retentive: physical examination is usually non-contributory
• Both:
  • Physical examination is important to rule out signs of other pathological causes of constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation/incontinence.
  • General inspection Inspection Dermatologic Examination:
    • Evaluate for anterior anus.
    • Evaluate for signs of spina bifida occulta Spina bifida occulta A common congenital midline defect of fusion of the vertebral arch without protrusion of the spinal cord or meninges. The lesion is also covered by skin. L5 and s1 are the most common vertebrae involved. The condition may be associated with an overlying area of hyperpigmented skin, a dermal sinus, or an abnormal patch of hair. The majority of individuals with this malformation are asymptomatic although there is an increased incidence of tethered cord syndrome and lumbar spondylosis. Neural Tube Defects (sacral dimple or tufts of hair on the lower back).
  • Neurological exam: evaluate for underlying neuromuscular disease, e.g.:
    • General muscular tone 
    • “Anal wink” reflex
    • Lower extremity reflexes

Imaging

• Retentive:
  • Abdominal X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests not recommended for routine evaluation 
  • If exam is non-conclusive due to patient body habitus/cooperativity, it may be useful to document stool burden.
• Non-retentive: Abdominal X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests can be useful to prove that there is no fecal burden.
• Both: Abdominal X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests shows the level of fecal impaction and identifies if  megacolon Megacolon Megacolon is a severe, abnormal dilatation of the colon, and is classified as acute or chronic. There are many etiologies of megacolon, including neuropathic and dysmotility conditions, severe infections, ischemia, and inflammatory bowel disease. Megacolon or intestinal pseudo-obstruction Intestinal pseudo-obstruction A type of ileus, a functional not mechanical obstruction of the intestines. This syndrome is caused by a large number of disorders involving the smooth muscles or the nervous system. Large Bowel Obstruction are present.

Management

• Medical management for underlying constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation:
  • Polyethylene glycol Polyethylene Glycol Laxatives (PEG)
  • Stool softeners
  • Oral cathartics ( lactulose Lactulose A synthetic disaccharide used in the treatment of constipation and hepatic encephalopathy. It has also been used in the diagnosis of gastrointestinal disorders. Laxatives, magnesium Magnesium A metallic element that has the atomic symbol mg, atomic number 12, and atomic weight 24. 31. It is important for the activity of many enzymes, especially those involved in oxidative phosphorylation. Electrolytes hydroxide) or enemas (saline solution ± glycerin) 
  • Chronic laxative Laxative Agents that produce a soft formed stool, and relax and loosen the bowels, typically used over a protracted period, to relieve constipation. Hypokalemia therapy
• Lifestyle modifications:
  • Toilet-sitting rules: for a half-hour, twice a day, whether or not the child has to defecate
  • Include a positive association with the intervention (e.g., books or a tablet).
  • Reward the child for successfully defecating in the toilet.
  • Do not punish the child for unsuccessful attempts.
• Dietary modifications: 
  • High-fiber diet (rich in vegetables and fruits)
  • Increased intake of fluids 
  • Removal of cow’s milk
• Psychological counseling if the cause is psychological

Differential Diagnosis

Enuresis

Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infection ( UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections (UTIs)): infection of the urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy by a pathogen, usually fecal Escherichia coli. In children, UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections (UTIs) may present as cystitis Cystitis Inflammation of the urinary bladder, either from bacterial or non-bacterial causes. Cystitis is usually associated with painful urination (dysuria), increased frequency, urgency, and suprapubic pain. Urinary Tract Infections (UTIs), pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess, or asymptomatic bacteriuria Asymptomatic Bacteriuria Urinary Tract Infections (UTIs) in Children. Dysfunctional voiding (neurogenic bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess) and bowel dysfunction ( pediatric constipation Pediatric constipation Constipation is a common complaint in children that is relatively defined for individual age groups based on the frequency and difficulty of defecation and stool consistency. The majority of constipation cases are functional or non-organic. Clinical presentation may vary, from insufficient evacuation noted by the parents, to complaints of abdominal pain, to secondary incontinence. Pediatric Constipation) are among the most common causes.

Encopresis

• Pediatric diarrhea Pediatric diarrhea Diarrhea is described as passage of large amounts stools that are often loose, liquid, or watery, resulting in excess loss of fluids and electrolytes. Diarrhea is one of the most common illnesses in children, representing the largest percentages of morbidity and mortality worldwide in the pediatric age group. Pediatric Diarrhea: defined as stool output > 10 ml/kg/day in infants and > 200 g/day in older children; can be acute (< 2 weeks) or chronic (> 2 weeks) and features excessive loss of fluid and electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes, and even failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive. Staining of underwear seen in children with encopresis may be confused with diarrheic stools. 
• Infant dyschezia: straining for at least 10 minutes with associated signs of discomfort (crying) in infants before successfully stooling. Thought to be due to discoordinated contraction of abdominal muscles or failure to relax of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscles. Infant dyschezia spontaneously self-resolves over time.