Elimination Disorders

The elimination disorders that most commonly occur in childhood are enuresis ( 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) and encopresis (fecal incontinence in inappropriate situations). Enuresis is usually diagnosed when children > 5 years of age continue to wet the bed. Enuresis can occur both in the daytime (diurnal) and at night (nocturnal). The incidence of nocturnal enuresis spontaneously resolves at a rate of approximately 15% per year. Management of nocturnal enuresis primarily consists of behavior and lifestyle modifications but can include desmopressin. Encopresis is most often secondary to 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, although emotional stressors may also be involved. Management is primarily through treating 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.

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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 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 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 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 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 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 mellitus Diabetes mellitus 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, diabetes insipidus Diabetes Insipidus Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of DI: central DI (CDI) and nephrogenic DI (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes 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 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 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 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 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:
    • Usually of the first urine output of the day
    • Screening tool for: 
      • Hydration status
      • Proteinuria
      • Hematuria
      • Diabetic ketoacidosis Diabetic ketoacidosis Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are serious, acute complications of diabetes mellitus. Diabetic ketoacidosis is characterized by hyperglycemia and ketoacidosis due to an absolute insulin deficiency. Hyperglycemic Crises
      • Diabetes insipidus
      • Water intoxication
      • Urinary tract infection
  • Renal ultrasound and voiding cystourethrogram: 
    • If the child:
      • Is very symptomatic during the day
      • Has a history of urinary tract infections Urinary tract infections 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
      • Is suspected of having renal structural abnormalities
    • Often used in conjunction with ultrasound to determine postvoid residual volume

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 consumption after 5 pm 
    • Encouraging urination before going to bed
  • Medical therapy: 
    • First line: desmopressin
    • 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

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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

Type Explanation
Retentive With 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 and secondary overflow and leakage around obstruction; more common
Non-retentive Without 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
Primary Seen in boys from infancy; often associated with global developmental delay and enuresis
Secondary Seen in children after successful toilet training; often functional in nature, marked by a higher level of stressors and psychological disorders

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 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 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 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 
    • 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
    • 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 does occur.
    • Defecation may be described as painful.
    • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 in patients with functional 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 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
      • 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:
      • Evaluate for anterior anus.
      • Evaluate for signs of spina bifida occulta (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 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 can be useful to prove that there is no fecal burden.
  • Both: Abdominal X-ray 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 are present.
Elimination disorder x-ray

Abdominal X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays in the standing (A) and supine (B) position, showing a large amount of stool in the ascending and descending colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix, sigmoid, and 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. Dilation in the rectosigmoid segment, secondary to the presence of stool, can also be observed.

Image: “Radiografias de abdome em posição ortostática” by Traslaviña, G. A., Del Ciampo, L. A., & Ferraz, I. S. License: CC BY 4.0

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 (PEG)
    • Stool softeners
    • Oral cathartics (lactulose, magnesium hydroxide) or enemas (saline solution ± glycerin) 
    • Chronic laxative 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

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Differential Diagnosis

Enuresis

Urinary tract 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): 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 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 may present as cystitis, 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. Dysfunctional voiding (neurogenic bladder) 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 muscles. Infant dyschezia spontaneously self-resolves over time.

References

  1. Elder, J. S. (2020). Enuresis y disfunción miccional. In R. M. Kliegman MD et al. (Eds.), Nelson. tratado de pediatría (pp. 2816-2821). https://www.clinicalkey.es/#!/content/3-s2.0-B9788491136842005586
  2. Traslaviña, G. A. et al. (2015). Retenção urinária aguda em pré-escolar feminina com constipação intestinal [Acute urinary retention in a pre-school girl with 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]. Revista paulista de pediatria: orgao oficial da Sociedade de Pediatria de Sao Paulo, 33(4), 488–492. https://doi.org/10.1016/j.rpped.2015.03.007
  3. Kliegman, R. M. et al. (2020). Trastornos de la motilidad y enfermedad de hirschsprung. In R. M. Kliegman MD et al. Nelson. tratado de pediatría (pp. 1955-1958). https://www.clinicalkey.es/#!/content/3-s2.0-B9788491136842003587
  4. Tu ND et al. Nocturnal enuresis in children: Etiology and evaluation. Torchia MM, ed. UpToDate. Waltham, MA: UpToDate Inc. Retrieved July 9, 2020, from https://www.uptodate.com/contents/nocturnal-enuresis-in-children-etiology-and-evaluation

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