Elimination Disorders

The elimination disorders that most commonly occur in childhood are enuresis (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, although emotional stressors may also be involved. Management is primarily through treating constipation.

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Enuresis: Overview

Definition

  • Involuntary urinary incontinence in children 
  • Most common form: monosymptomatic nocturnal enuresis (bedwetting in children > 5 years old with no signs of 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.
    • 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 symptoms
    • Non-monosymptomatic: occurs in children with signs of lower 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, diabetes mellitus, 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 (risk of nephropathy)
    • Painful abdomen on palpation due to retained stool (constipation)
    • Abnormalities on neurologic examination of the perineum and/or lower extremities (spinal cord abnormalities)
    • Delayed developmental milestones (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
      • 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
      • 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

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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

TypeExplanation
RetentiveWith constipation and secondary overflow and leakage around obstruction; more common
Non-retentiveWithout constipation
PrimarySeen in boys from infancy; often associated with global developmental delay and enuresis
SecondarySeen 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 (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 can be diagnosed by the Rome IV criteria. A child must have 2 of the following, at least once a week for a minimum of 1 month:
    • 1 episode of fecal incontinence 
    • Retentive posturing or purposefully withholding feces
    • Evidence of a large volume of stools in the rectum
    • Episodes of large-volume stools that may clog the toilet
    • Painful bowel movements
    • 2 or fewer defecations each week
  • Retentive:
    • Parents may report large stool volume when defecation does occur.
    • Defecation may be described as painful.
    • Abdominal pain is a common associated complaint.
    • A careful diet history may give clues to causes of constipation:
      • Excessive dairy intake
      • Insufficient fiber intake
  • Non-retentive: often associated with 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
      • May help in evaluating sphincter tone to rule out neurologic disease
    • Abdominal exam may indicate 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/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 or intestinal pseudo-obstruction are present.
Elimination disorder X-ray

Abdominal X-rays in the standing (A) and supine (B) position, showing a large amount of stool in the ascending and descending colon, sigmoid, and rectum. 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:
    • 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): infection of the urinary tract by a pathogen, usually fecal Escherichia coli. In children, UTI may present as cystitis, pyelonephritis, or asymptomatic bacteriuria. Dysfunctional voiding (neurogenic bladder) and bowel dysfunction (pediatric constipation) are among the most common causes.

Encopresis

  • 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, and even 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]. 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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