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. The 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 the 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 be strictly avoided.

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

  • Let the child sit on the potty with clothes.
  • Let the child sit on the potty without clothes.
  • Put the child on the 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 to 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.

A child can be considered toilet trained when no longer requires help or supervision to use the toilet (or potty). He or she can take responsibility for independent toilet use and can keep him/her clean and dry, i.e., not wetting or soiling their pants.

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% of the kids carrying the condition up to 18 years of age.

Types of Enuresis

Enuresis can be classified using various ways such as:

Enuresis be classified on time of occurrence into:

  1. Nocturnal enuresis (bedwetting).
  2. Diurnal enuresis.
  3. Mixed enuresis – includes a combination of nocturnal and diurnal type; therefore, urine is passed during both waking and sleeping hours.

Another classification classifies enuresis as follows:

Primary enuresis

It is the most common type which is characterized by an imbalance between the urine production at night, bladder capacity, and the child’s ability to awaken because of a full bladder. In primary enuresis, the child never develops urinary continence for longer than 6 months. 80% of the enuresis cases are of a primary type; here, the children who have never been successfully trained to control urination. This represents a fixation.

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. This represents a regression.

Nocturnal enuresis

This type of enuresis occurs at night.

Daytime wetting

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

Monosymptomatic enuresis

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

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 an involuntary loss of urine.
  • Wetting for approximately three months, at least twice a week.

Causes of Enuresis

There are different factors that are associated with enuresis:

  • The inability to control a full bladder at night due to the 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. The 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 the 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% of the cases. It includes the use of voiding alarm systems, bladder training, and a reward system.
  • Reassurance to the parents.
  • Waking the child at night to go to the bathroom.
  • Repeated voiding of urine into bed or clothes (either involuntary or intentional).
  • Use of moisture alarms at night.

Medication of Enuresis

Medication is not recommended for children who are less than 6 years of age. Moreover, medication is not curative of enuresis; they only reduce the frequency or temporarily cure the condition. Medication helps in boosting the hormones responsible for the condition.  Only two FDA approved drugs are recommended for therapy in children; they are:

  1. Oral desmopressin (DDAVP):  Patients spray a mist containing desmopressin into their nostrils, to help treat this condition.
  2. Imipramine (TCA): Is also used to treat sleep wetting. It acts on both the brain and the urinary bladder.

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 a clogged toilet.
  • Lower abdominal pain.
  • Lack of appetite.

Management

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

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

Rules of toilet sitting

  • The child should use the 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 a high fiber diet.
  • If the causes are psychological, counseling is recommended.
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