Elimination Disorders: Enuresis and Encopresis, Lecture notes of Health, psychology

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Elimination Disorders

• Introduction
• Enuresis
• Encopresis
• Other Specified Elimination Disorder
• Unspecified Elimination Disorder Edits: L Jia 2021 Slides: B Chow

Elimination Disorders – Introduction

• Inappropriate elimination of urine or feces
  • Usually first dx in childhood or adolescence
• Minimum age requirements
  • Based on developmental age (not solely chronological)
• Both may be voluntary or involuntary
• Typically occur separately à but may co-occur

Enuresis – Diagnostic Criteria

A. Voiding of urine into bed/clothes (involuntary or intentional)

B. Clinically significant, either :

1. Frequency of 2 + times per week for 3+ consecutive months
2. Significant distress or impairment in functioning

C. At least age 5 (chronological or developmental)

D. Not due to substance or AMC

Enuresis – Diagnostic Specifiers

• Specify subtype:
  • Nocturnal only: only during nighttime sleep
    • MOST COMMON subtype à typically first third of night
    • “monosymptomatic enuresis”
  • Diurnal only: only during waking hours
    • “urinary incontinence” à 2 groups
      • “urge incontinence” à sudden urge sx + detrusor instability
      • “voiding postponement” à defer urges until incontinence results
  • Nocturnal and diurnal
    • “non-monosymptomatic enuresis”

Enuresis – Associated Features

• Nocturnal enuresis
  • May be during REM sleep à child may recall dream involving urinating
• Daytime enuresis
  • May defer voiding until incontinence, due to reluctance to use toilet
    • Result of social anxiety or preoccupation with activity
  • Typically in early afternoon on school days
    • May be assoc with disruptive behavior
• Enuresis often persists after treatment of UTI

Enuresis – Prevalence

• Age 5 à 5 – 10%
• Age 10 à 3 – 5%
• Age 15+ à 1%

Enuresis – Risk & Prognostic Factors

• Environmental
  • Delayed or lax toilet training
  • Psychosocial stress
• Genetic & Physiological
  • Delays in development of normal circadian rhythms of urine production
    • Nocturnal polyuria , or abnormal central AVP receptor sensitivity
  • Reduced functional bladder capacity with bladder hyperreactivity
    • “Unstable bladder syndrome”
  • Genetically heterogenous disorder à heritability shown in studies
  • Risk of childhood nocturnal/diurnal enuresis increased if:
    • Offspring of enuretic mothers à 3.6x
    • Presence of paternal urinary incontinence à 10.1x

Enuresis – Culture-Related Issues

• Across nations à similar prevalence rates + course
• Very high rates in orphanages + residential institutions
  • Likely related to toilet training mode + environment

Enuresis – Functional Consequences

• Impairment/limitations/effects
  • Social activities
  • Self-esteem
  • Social ostracism by peers
  • Anger, punishment, rejection by caregivers

Enuresis – Differential Diagnosis

• Neurogenic bladder or AMC
  • Also untreated diabetes mellitus, diabetes insipidus, acute UTI
• Medication side effect
  • Antipsychotics, diuretics, etc

Encopresis

Encopresis – Diagnostic Criteria

A. Passage of feces in inappropriate places

B. 1+ times per month, for 3+ months

C. At least age 4 (chronological or developmental)

D. Not due to substance or AMC (except constipation)

Encopresis – Diagnostic Features

• If involuntary feces à often related to constipation + overflow
• Constipation
  • Psychological reasons à leads to avoidance of defecation
    • Anxiety about defecating , general anxiety or oppositional behavior
  • Physiological reasons
    • Ineffective straining
    • Paradoxical defecation dynamics (contracts sphincter/pelvic floor)
    • Dehydration (febrile illness, hypothyroidism, medication side effect)
  • May be complicated by anal fissure, pain, further fecal retention
• Stool consistency varies

Encopresis – Associated Features

• Often ashamed, wanting to avoid situations/embarrassment
  • Self-esteem, social ostracism, caregiver anger/punishment/rejection
• Smearing feces à may be deliberate/accident
  • May be attempt to clean or hide feces
• If clearly deliberate incontinence à may have ODD/CD features
• If encopresis + chronic constipation à often enuresis sx
  • Assoc urinary reflux in bladder/ureters à may lead to chronic UTIs
  • May remit with tx of constipation