Bowel & Bladder - normal & issues Flashcards
How common is bed wetting and general epidemiological features?
-Very common
-20% 5 yr olds
-5% 10 yr ols
-Higher frequency in boys
-Day time incontinence usually 5-6 years
-Bed wetting usually 7-8 years
Spontaneous remission rate only 15%
Aetiology of bed wetting?
High nocturnal urine production
a. Nocturnal ADH production is still elevated in children ??
Small nocturnal functional bladder capacity
a. Overactive bladder, detrusor instability, irritable bladder
Poor arousal from sleep to a full bladder
a. Heavier sleepers than others but not as simple as this – usually they have poorer sleep quality
Important features to ask in HOPC for child presenting with bed wetting?
Characterize bed wetting
-Duration of issue, Frequency, Volume
Do they wake during the night with need to void? Do they wake after wetting?
Context - Fluid intake, Intercurrent illness, Sleep history
Monosymptomatic vs. non-monosymptomatic
- Are daytime symptoms present?
- Wetting, jiggling, urgency, frequent passage of small volumes
Differentiate primary vs. secondary cause
- Have they had continuous bed wetting? i.e. no ‘dry periods’
- Previously been dry and recently started bed wetting?
Question for secondary causes
- Constipation, Signs of neurogenic bladder, Signs of diabetes
Psychosocial impact
Is there a significant event coming up where this may be an issue? i.e. school camp, holiday
Important PMHx and FHx to ask child presenting with bed wetting?
i. Diabetes
ii. Spinal cord trauma/injury
iii. OSA
iv. Epilepsy
v. Bed wetting or day time incontinence in childhood
What are important points when counselling child/parents about bed wetting?
a. Reassure child it is not their fault
b. Explain inherited nature of problem
c. Explain the prevalence – i.e. in a class your size, 2 other kids would be bed wetting also
What examinations would you perform for child presenting with bed wetting?
- Urinalysis
a. Infection
b. Glycosuria - Back/spine examination
- Abdominal examination
? genital examination
What is the management for bed wetting?
Usually don’t treat unless > 7 years
>10 years require urgent attention
Exclude UTI; treat constipation if present
Motivation
a. Child should be involved in plan
b. Can be helpful to make a record chart
c. Positive reinforcement without negativity if bet is wet
Behaviour modification
a. Avoid caffeinated drinks, esp. late at night
b. Avoid nappies/pull ups use
c. Alarms
Symptom minimisation
a. Mattress and bedding protectors
Medications
a. Anticholinergics -Oxybutynin
b. Desmopressin -ADH analogue
Clinical features of UTI in infants/young children?
- Fever
a. Can be sole feature - Non-specific
a. Lethargy
b. Irritability
c. Vomiting
d. Poor feeding - Urine
a. Offensive odour is not sensitive or specific for UTI
Clinical features of UTI in older children?
- Fever
- Irritative symptoms dysuria, frequency, urgency, incontinence
- Haematuria
- Abdominal pain
Diagnosis of UTI?
Clinical diagnosis adequate
Bacterial growth on:
a. MSU, Catheter sample, SPA
d. Clean catch prone to contamination
Screening
a. Full ward test/urine dipstick
b. Useful for screening if low index of suspicion
Should NOT be used if high chance nitrites, leucocytes negative in 50% children with UTI
Management of UTI?
Consider admission
a. Very unwell febrile child traffic light system
b. Most children < 6 months (all <1 mth need IV antis)
c. IV antibiotics +/- fluid resuscitation - Gentamycin + Benzylpenicillin
Oral medication if admission not required
a. Trimethoprim or cephalexin
b. 10 day course if < 2 yrs, 7 days if > 2 yrs
3. Consider follow-up investigation
Ultrasound
i. All children <6mo with 1st UTI
ii. Consider in >6mo with 1st UTI
Epidemiological features of faecal incontinence?
Boys 3-6 times more than girls
Most common in 7 – 8 yr age range
Associations which can result in faecal incontinence?
- Painful or frightening event associated with defecation in early childhood
- Nocturnal enuresis
- Day wetting – irritable bladder
- Limited attention-concentration, learning disability
Causes of faecal incontinence?
- Constipation
Rare:
- Neurological
- Congenital/structural
- Inflammatory
- Psychogenic
Causes of constipation?
Functional causes most common – ignoring urge leading to build up, painful defaecation – avoidance
If < 6 weeks’ alert for organic disease
Less common causes – malabsorptive diseases, cow milk allergy, neurological cause, hypothyroidism, hypocalcaemia
Commonly occurs around time of introduction of solids, toilet training and school entry
Important features on history for child presenting with constipation?
Timing of meconium passage
Previous painful or frightening precipitant to opening bowels
Bowel habits - usual and change, timeframe of change, description of stool
Associated features - Straining, Toilet refusal, Hiding while defecating , Crossing legs or other with-holding behaviour, Faecal or urinary incontinence day or night, Pain when defecating
Red flags of constipation for organic disease cause?
Weight loss Vomiting PR bleeding Constitutional symptoms Onset before 1 month Delayed passage of meconium Ribbon stools Abdominal distension and vomiting Growth faltering Protective concerns Abnormal neurology lower limbs Abnormality of anus/buttocks/sacrum
Ix for child with constipation?
Ix not recommended unless red flags or persistence despite adequate Rx AXR not recommended
Consider Ix for less common causes if constipation persists despite adequate behaviour modification 1. Coeliac antibodies 2. TFT 3. FBE, iron studies 4. Calcium Surgical referral
Management of constipation?
- Educate - Not the child’s fault, Demystify and reassure
1st line = Toileting retraining & behavioural modification - Toilet sits, Posture (Feet should be supported, knees above hips, legs apart and bulge tummy, Chart/reward system for positive reinforcement
Laxatives – may require initial ‘clear out’ and sometimes maintenance laxatives
Remove barriers
2nd line = diet
3rd line = Laxatives
Long-term follow up - at least 6 months
What are the laxative options for a constipated child?
Avoid rectal medication in young children
Osmotic laxatives good for clear out but not as good for maintenance (stools too loose)
1st line = osmotic or lubricant laxative
i. Macrogol
ii. Lactulose or sorbitol
iii. Paraffin oil
2nd line = stimulants (if not regular after 2-3 mths)
i. Bisacodyl or Senna
ii. Sodium picosulfate
3rd line (faecal impaction)
i. High dose macrogol for 3 days
ii. Hospital admission
