Elimination Disorders

in Children

Dr Hauwa Mustapha

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• Introduction
• Epidemiology
• Types
• Pathophysiology
• Clinical presentation
• Investigation
• Treatment
• Outcome/prognosis
• Conclusion
• References
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 Introduction
• Elimination Disorders are commonly diagnosed in
childhood characterised by absence of bladder or
bowel control that would be expected based on
child’s age or current stage of development.

• Most children achieve full continence by 5years of

age

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 Normal sequence of control
Nocturnal faecal continence

Diurnal faecal continence

Diurnal bladder control

Nocturnal bladder control

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 Types of elimination disorders
1. Enuresis

2. Encopresis

• Both disorders can be voluntary or involuntary

• Typically occur separately but co-occurence may be

observed

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 Enuresis
• Enuresis – derived from Greek word enourein which
means to void urine

• It is the passage of urine into bed or clothing at least

twice in a week for more than 3 months in a child at
least 5 years of age, chronologically or
developmentally.

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• At five years of age, 15% of children are incompletely
continent of urine.

• Most of these children have isolated nocturnal

enuresis

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 DSM 5 Diagnostic criteria for enuresis
• A) repeated voiding of urine into bed or clothes
• B) frequency of twice a week for at least 3
consecutive months or presence of clinically
significant distress or impairment in social, academic
or other important areas of functioning
• C) chronological age at least 5 years
• D) behaviour is not due exclusively to direct
physiologic effect of a substance or a general medical
condition

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 Types of Enuresis
• Monosymptomatic: primary and secondary

• Non – monosymptomatic

• Bladder dysfunction

• Bladder and Bowel Dysfunction

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 Epidemiology
• Longitudinal study by Butler et al, 2008 estimated at
least 20% of first graders experience occasional
bedwetting, while 4% wet the bed at least twice a
week.

• Approximately 10% of school-age children

experience nocturnal enuresis compared to the 2%
to 3% who experience diurnal enuresis

• Only approximately 1% to 2% of adolescents

experience enuresis
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 Epidemiology

• More frequent in boys

• Associated with comorbidities ( ADHD,

developmental delay, learning disabilities)

• Secondary enuresis: related to stress, trauma,

psychological crisis

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 Normal bladder maturation
• At birth, bladder function is coordinated through lower
spinal cord and/or primitive brain centers.

• May also be stimulated neurologically stimulating

activities e.g. feeding, bathing etc.

• Voiding is efficient but uncontrolled

• Uninhibited contraction is caused by progressive and

sustained bladder filling.
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• 1st three years, bladder capacity increases
disproportionately relative to body surface area

• The child first becomes aware of bladder filling then

develops the ability to suppress detrusor contractions
then learns to coordinate sphincter and detrusor
function.

• Daytime continence usually achieved by 4yrs and night

time continence months to years later (5 to 7 years).
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 Conditions of achieving bladder control
• Awareness of bladder filling

• Cortical inhibition of reflex bladder contractions

• Ability of consciously tighten the external sphincter to

prevent incontinence

• Normal bladder growth

• Motivation by child to stay dry

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 Pathogenesis of Enuresis
• Maturational delay

• Genetic factors: twins, offspring, defect on Ch 12 and

13q

• Environmental factors e.g. delayed toilet training,

psychosocial stress, excessive fluid intake at night,
deep sleep

• Developmental and biologic factors: reduced bladder

capacity, detrusor inactivity
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 Evaluation
• Detailed history taking
– How often and when it occurs
– Volume of urine lost during episodes
– Environmental issues (daily fluid intake, bedtime
ritual, proximity to bathroom)
– Urgency, holding manouvers, weak stream,
straining, interrupted micturition
– Types of solutions tried
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 – Medical history (DM, SCA, Epilepsy etc).

– Developmental history

– Family history of enuresis

– Psychosocial factors

– Child’s perception

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 Physical Examination

• Identify organic causes of incontinence

• Short stature
• Hypertension
• Palpable kidneys or bladder
• Labial adhesions
• Sacral abnormality

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 Investigation
• Urinalysis, urine m/c/s
• Imaging: when medical causes are suspected
– Voiding cystourethrogram
– Renal scan
– Uroflow study with electromyography
– MRI
• Bladder diary

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 Factors to consider before treatment for
Enuresis
• Age of the child
• Medical cause has been ruled out
• Rate of spontaneous remission
• Behavioural treatment
• Co-existing constipation
• Goals and expectation

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 Treatment
• Spontaneous remission: about 15% at age 5yrs, 5% at
10yrs, 1-2% at 15yrs

• Education and motivational therapy

• Behavioural treatment : bell and pad method, fluid

restriction, reward systems, avoidance of high sugar and
caffeine

• Treatment of co exisiting condition (sleep disorder,

encopresis etc)

• Pharmacologic methods; imipramine, desmopressin,

reboxetin
21
 Bell and pad treatment
• For children who have enuresis more than twice per
week and in whom short term improvement is not a
priority

• An alarm is used that sounds at the first detection of

urine

• Lower relapse rate but requires commitment

• Adherence is challenging especially if enuresis occurs

>1/night
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• Desmopressin: decreases nocturnal urine production
but causes hyponatremia
• 0.2mg – 0.4mg 60mins before bedtime

• Tricyclic anti-depressants
• Imipramine: stimulates vasopressin secretion and relax
the detrusor muscle.
• Usually reserved for refractory enuresis or relapse
• 10-25mg one hour before bedtime
• S.E: nervousness, sleep disturbance, personality
changes.

• Raboxetin
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 Other forms of treatment
• Waking child to urinate

• Bladder training/ retention control training

• Anticholinergic drugs e.g oxybutynin

• Complementary and alternative therapies: hypnosis,

psychotherapy, acupuncture

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 Outcome
• Initial outcome:

• No response: <50% reduction of baseline symptom

frequency

• Partial response: 50 – 99% reduction of baseline

symptom frequency

• Complete response: 100% reduction of baseline

symptom frequency

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• Long – term outcome:

• Relapse: >1 symptom recurrence per month

• Continued success: no relapse within 6 months after

interruption of treatment

• Complete success: no relapse within 2 years after

interruption of treatment

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 Prognosis
• Primary: high spontaneous remission

• Secondary: usually begins by 5-8yrs, adolescent

onset signify more psychiatric problems and less
favourable outcome

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 Complications
• Low self esteem

• Anger

• Avoidance of overnight visits

• Social rejection

• Embarrassment

• Anxiety

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 Diurnal Incontinence
• Causes
– Overactive bladder
– Infrequent voiding
– Voiding postponement
– Nonneurogenic neurogenic bladder (Hinman
Syndrome)
– Giggle incontinence
– Ectopic ureter
– Posterior urethral valves
– Etc.
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 Overactive Bladder
(DIURNAL URGE SYNDROME)
• Bladder is functionally smaller than normal and
exhibits strong uninhibited contractions

• Typically exhibit urine frequency, urgency, urge

incontinence

• Females will squat down on foot to try to prevent

incontinence

• Associated with recurrent UTI

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• INVESTIGATION:
• VCUG: dialted urethra (spinning top deformity) with
narrow bladder neck

• Treatment:
• Biofeedback: Kegel exercise
• Anticholinergic: reduce bladder overactivity e.g
Oxybutinin, trospium, hyoscyamine

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• α- adrenergic blockers: aid in emptying and bladder
neck relaxation e.g terazosin

• Sacral nerve stimulation

• Intravesical botilinum toxin injection

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 Nonneurogenic Neurogenic Bladder
(Hinman Syndrome)
• Failure of external sphincter to relax during voiding in
children without neurologic abnormalities

• Learning abnormal voiding habits during toilet

training

• Children exhibit staccato stream, day & night wetting

• Associated with recurrent UTI, encopresis,

constipation.

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• VCUG: Trabeculated bladder with an intermittent
pattern

• Treatment
• Anticholinergic, adrenergic blocker
• Timed voiding, behavioural modification and
encouragement of relaxation during voiding
• Intermittent catheterization

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 Infrequent voiding
• Behavioural disorder more common in females
• Voiding twice a day (normal 4 – 7 times)
• Associated with recurrent UTI
• Incontinence is from overflow or urgency

• Treatment:
• Antiobiotic prophylaxis
• Encouragement of frequent voiding

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Other causes of incontinence in females
• Vaginal voiding:
• Typically occurs after voiding when a female stands
up, volume of urine is usually 5 to 10mls
• Cause: labial adhesion, narrow separation of legs
during urination

• Treatment:
– Topical estrogen
– Lysis of adhesion
– Behavioural modification
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• Ureteral Ectopia
• Associated with duplicated collecting system,
duplicated ureter drains outside the bladder into the
distal urethra or vagina
• Females have constant urine dribbling even though
child voids regularly

• Investigations: ultrasound, IVU, CT of kidneys

• Treatment: partial nephrectomy or ipsilateral

ureteroureterostomy

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• Giggle Incontinence
• Sudden relaxation of the urinary sphincter
• Incontinence occurs suddenly during giggling and
entire bladder volume is lost

• Treatment:
• Low dose methylphenidate: stabilizes external
sphincter
• Anticholinergic medications
• Timed voiding

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• Pollakuria: Self limited condition that occurs due to
sudden urinary frequency without incontinence,
more common in males aged 4 – 6yrs.

• Dysuria – Hematuria Syndrome: dysuria

without UTI but with hematuria. Often due to
hypercalciuria ( 24hr Ca excretion >4mg/kg)
• Treartment: Thiazide diuretics to prevent urolithiasis

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 FUNCTIONAL FECAL INCONTINENCE
(ENCOPRESIS)
• Repeated defecation in inappropriate places (clothing,
floor, bed) with episodes occurring at least once a
month for 3 months (APA 2013)
• Types:
1. Primary, Secondary
2. Retentive and Non – retentive

• Retentive: with constipation and overflow incontinence

• Non-retentive: without constipation and overflow
incontinence
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 DSM IV Diagnostic Criteria for Encopresis

• A) repeated passage of faeces into inappropriate

places whether involuntary or intentional
• B) At least once a month for at least 3 months
• C) Chronologic age is at least 4 years
• D) The behaviour is not due exclusively to the direct
physiological effects of a substance or general
medical condition except through a mechanism
involving constipation

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 Epidemiology
• Typically occurs during the day
• More common in males
• 1.5% and 7.5% of youth between 6 and 12 years
(Doleys 1983, Levine 1975)
• 50 – 60% have secondary encopresis (usually starts
by 8years of age)
• Associated with chronic constipation, ADHD, and
Conduct Disorder

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 Retentive Encopresis
• A cycle of several days of retention, a painful
expulsion, and another period of retention
• While faecal mass is growing, there may be leakage
around the mass

• Causes:
• Inadequate or punitive toilet training
• Fear of school bathroom, or toilet related fears

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Rome IV Criteria for functional constipation

 Presence of at least 2 below at least once per

week for at least one month
• 2 or fewer defecation in toilet per week
• At least one episode of faecal incontinence per
week
• History of retentive posturing
• History of hard bowel movements
• Presence of large fecal mass in rectum
• Large diameter stools that clog the toilet
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• Mechanism:
• Altered colon motility

• Contraction factors

• Obstruction

• Stretched and thinned colon walls

• Decreased sensation

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 Non-retention Encopresis
• Children who simply do not control the expulsion of
faeces on a psychological, physiologic, or both

• It may be a deliberate attempt as a means of

avoiding stressors or communicating anger

• It is unclear whether the associated psychological

problems are a cause or consequence of the
incontinence.

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 Evaluation
• Detailed history taking
– When it first started
– How often and when it occurs
– Painful defecation
– Consistency of the stool (soft/hard)
– Problems with toilet training (child resistance, fear)
– Nutrition (change in diet, low fiber diet, starvation,
anorexia nervosa)
– Medical history (neurogenic, endocrine and metabolic,
anatomic causes, medications )
– Solutions tried and response
– Developmental history
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• Physical examination:
– Abdominal distention
– Palpable mass
– Soiled underwear
– Anal fissures
– Anal fistula/ anteriorly displaced anus
– Anal sphincter tone
– Impacted stool
– Explosive expulsion of stool after examination

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 Treatment
• Initial meeting: parents and child are educated about
bowel function and diffuse psychological tension
• Diet: sorbitol containing juices like apples, pears
• Behavioural component: daily timed interval on the
toilet with rewards for success.
• Disimpaction and bowel cattarhsis
• Maintenance Laxative therapy

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• Glycerin Suppositories: for disimpaction
• Polyethylene glycol 3350: 1 – 1.5g/kg

• Lactulose: 1ml/kg once or twice daily

• Sorbitol: 1ml/kg once or twice daily

• Older Children: Enema (mineral oil, saline, sodium

phosphate), disacodyl
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 Prognosis
• 30-50% recover after treatment with laxatives with
no recurrence after 1 year, 48-75% after 5 years

• Psychiatric or medical co morbidity are major

prognostic factors

• 25% have co morbid enuresis

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 Conclusion
• About 15 – 20% of children with enuresis also have
encopresis

• Both have severe psychological effects on children

and parents

• Behavioural training and parental support is

essential in treatment

• Main goal of management is achievement of

continence and bowel control
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 REFERENCES
• American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders, 5th ed., text rev. Arlington, VA: American Psychiatric
Publishing.
• Azrin, N. H., Sneed, T. J., & Foxx, R. M. (1974). Dry-bed training: Rapid
elimination of childhood enuresis. Behaviour Research and Therapy, 12, 147–
156.
• Bernard-Bonnin, A. C., Haley, N., Bélanger, S., & Nadeau, D. (1993). Parental
and patient perceptions about encopresis and its treatment. Journal of
Developmental and Behavioral Pediatrics, 14, 397–400.
• Butler, R. J., Redfern, E. J., & Holland, P. (1994). Children’s notions about
enuresis and the implications for treatment. Scandinavian Journal of
Nephrology, 163(Suppl.), 39–47.
• Butler, U., Joinson, C., Heron, J., von Gontard, A., Golding, J., & Emond, A.
(2008). Early childhood risk factors associated with daytime wetting and
soiling in school-age children. Journal of Pediatric Psychology, 33, 739–750.
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• Campbell, L. K., Cox, D. J., & Borowitz, S. M. (2009). Elimination
disorders: Enuresis and encopresis. In M. C. Roberts, & R. G. Steele
(Eds.), Handbook of pediatric psychology, 4th ed. (pp. 481-490).
• von Gontard, A., & Nevéus, T. (2006). Management of disorders of
bladder and bowel control in childhood. London, UK: MacKeith Press.
• Jaclyn A.S.,LEE M.R, Francis P.T.(2012), Elimination Disorders: Enuresis
and Encopresis. 16, 315 - 330.
• Jack S Elder (2019) Enuresis and Voiding Dysfuntion. Nelson Textbook
of Paediatrics 21st Ed. 558

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