Toilet training includes training your child to control their bladder and bowels. Girls achieve bladder and bowel control earlier than boys. Enuresis is the voluntary or involuntary voiding of urine during sleep after bladder control is expected to have been achieved. Soiling, also known as encopresis, occurs when the child fails to use the toilet for bowel motions resulting in dirty pants. It is caused by emotional stressor and chronic constipation resulting in large stool volumes to signal the need to defecate.
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Potty training

Training starts when a child is emotionally and developmentally ready. Following points must be met before starting to train the child:

  • The child has the ability to sense the urge to urinate and defecate
  • The child has achieved ability to tighten external sphincters
  • The child can follow simple directions.
  • The child is able to communicate desires.

Potty training should be an extremely positive experience. There is supposed to be a huge emphasis on praise. Punishments should strictly be avoided.

As the potty training starts, let the child go through the following steps:

  • Let the child sit on potty with clothes
  • Let the child sit on potty without clothes
  • Put child on potty when he desires to go to the bathroom
  • Reward the child immediately. The reward can be praise, a small prize, or other forms of attention.
  • Give the child plenty of drink to encourage episodes of learning. This should be done on weekends so that parents can handle the repeated urinary urge of the child.

Even when things go wrong, praise the child.

Enuresis

It is the voluntary or involuntary voiding of urine during sleep after the age when bladder control is expected to have been achieved. Enuresis affects children who are 5 years or older. More than 5 million children suffer this condition in the US. Boys have a greater tendency for enuresis compared to girls. As the child grows, the condition subsides with only 1 percent of the kids carrying the condition up to 18 years of age.

Types of Enuresis

There are different types of enuresis.

1. Primary enuresis

It is the most common type. There is an imbalance between the urine production at night, bladder capacity, and child’s ability to awaken as a result of a full bladder. In primary enuresis, the child never develops urinary continence for longer than 6 months. 80 percent of the enuresis cases are of a primary type.

2. Secondary enuresis

It is related to secondary causes such as psychological issues, behavior problems, or medical conditions. Urinary incontinence in this case is achieved at first, but then control is lost after 6 months.

3. Nocturnal enuresis

This type of enuresis occurs at night.

4. Daytime wetting

This kind of urinary incontinence occurs during daytime when the child is awake.

5. Monosymptomatic enuresis

There are no symptoms related to lower urinary tract other than nocturia. Moreover, bladder dysfunctional history is not present.

6. Non-monosymptomatic enuresis

There are symptoms related to the lower urinary tract such as urinary urgency, daytime wetting, intermittent stream, dribbling after urination, genital or lower abdominal discomfort.

Symptoms of Enuresis

The main symptoms of enuresis include:

  • There is frequent bed-wetting
  • Wetting in the garment due to involuntary loss of urine.
  • Wetting for approximately three months, at least twice a week.

Causes of Enuresis

There are different factors that are associated to enuresis.

  • Inability to control full bladder at night due to decreased functional capacity of the bladder.
  • Instability of detrusor muscles.
  • Family history
  • Developmental delay in a child such as delayed maturation of CNS, delay in the motor skills and language development.
  • Nocturnal polyuria due to decreased ADH secretion at night.
  • Psychological factors such as neglect, sexual abuse, parental divorce, anxiety, school related trauma, and behavior disorders.
  • Smaller bladder
  • Repeated or persistent urinary tract infections

Children with enuresis have an abnormally deep sleep pattern which is why they are not awakened by enuresis.

Night enuresis

  • This is due to an inability to wake up in response to a full bladder.
  • Genetic influence is common.
  • Bladder control is usually achieved at age 3-5.

Daytime enuresis

  • This type is more common in girls
  • It relates to waiting too long to urinate.
  • Bladder control is usually achieved by age 2-4

Children who do not develop bladder control by the age of 5 have an organic problem. Following conditions should be considered in such cases:

  • Chronic Urinary tract infections
  • Overactive bladder
  • Diabetes
  • Spinal cord lesion such as tethered cord
  • Urethritis
  • Vaginitis
  • Sexual abuse

Secondary Enuresis is associated with following conditions

  • Dysfunctional bladder
  • Hyperthyroidism
  • Diabetes mellitus
  • Obstructive sleep apnea
  • Pinworm infection
  • Constipation
  • Stress
  • UTIs

Management of Enuresis

  • Behavioral therapy is usually effective in 75 percent of the cases. It includes the use of voiding alarm systems, bladder training, and reward system.
  • Reassurance to the parents.
  • Waking the child at night to go to bathroom

Medication of Enuresis

Medications are not recommended for children who are less than 6 years of age. Moreover, medications are not curative of enuresis, they only reduce the frequency or temporarily cure the condition. Only two FDA approved drugs are recommended for therapy in children. They are

1. Oral desmopressin (DDAVP)

2. Imipramine (TCA)

Those who do not respond to desmopressin may be prescribed anticholinergics such as oxybutynin. It is only helpful in primary nocturnal enuresis and enuresis caused by hyperactivity of detrusor muscle.

Day or night time soiling beyond the stage of toilet training (4 years)

Soiling, also known as encopresis, occurs when the child fails to use the toilet for bowel motions resulting in dirty pants.

Causes

  • Chronic constipation resulting in large stool volumes to signal the need to defecate
  • Emotional stressors

Clinical presentation

  • There are usually skin marks or streaking of stool in the garment.
  • Large stools which lead to clogged toilet
  • Lower abdominal pain
  • Lack of appetite

Management

It includes the use of polyethylene glycol, stool softeners, and enemas

In several cases, administration of large volumes of NG polyethylene glycol may be required for a clean out.

Bathroom-reading-toilet-training

Image : “Bathroom reading” by
thejbird
License: CC BY 2.0

Rules of toilet sitting

  • The child should use toilet twice daily for half an hour whether the patient has the urge or not.
  • Rewards and praise for the child.
  • Punishment is strictly prohibited.
  • Use of high fiber diet
  • If the causes are psychological, counseling is recommended.
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