Common Elimination Problems in Childhood

Question 1

average age to achieve bowel/bladder controls

Answer 1

Normal Toilet Learning: average age to achieve bowel/bladder controls varies from 24 months-48 months.

Girls overall tend to achieve continence at a slightly younger age.

Average time from initiation of toilet learning to independence is 3-6 months.

Question 2

Assessing Readiness to Toilet Learn:

Answer 2

able to walk to the potty chair, stable while sitting on the potty, able to remain dry for several hours, receptive language skills allow the child to follow simple commands. Expressive language skills permit the child to communicate the need to use the potty with words or gestures, desire to please based on positive relationship with caregiver, desire for independence, and control of bladder and bowel function.

Question 3

definition and epidemiology of primary nocturnal enuresis

Answer 3

Definition: bed wetting >2 times per week persisting beyond the age of 5 years.

Considered primary when bladder control has never been attained.

Considered a variation in the development of normal bladder control

Epidemiology: more common in boys, 10-15% of five year olds, 6-8% 8 year olds, 1-2% of 15 year olds.

Question 4

etiology of primary nocturnal enuresis

Answer 4

Etiology: matruational delay, genetics (both parents 77%), sleep disorders, antidiuretic hormone.

Assessment: history + impact on child, physical exam, +/- urinalysis

Management: education and reassurance. Advise to avoid punishment, no caffeinated beverages, limit fluid intake before bedtime, empty bladder right before bedtime.

Tertiary measures: desmopressin (high relapse rate upon discontinuation)

Question 5

Etiologies and assessment of daytime wetting

Answer 5

Question 6

3 high risk times for developing functional constipation

Answer 6

Functional constipation: constipation with no underlying anatomic or biochemical cause. >95% of children with constipation

Three high risk times for developing functional constipation:

◼ 1. Infancy: Introduction of cereals (6 months)

◼ 2. Toddler: Toilet training (2-3 years)

◼ 3. Start of school: Ages 5-6

Question 7

Red Flags in Constipation

Answer 7

No stooling on own since birth and delayed passage of meconium

Thin ribbon-like stools

Signs of significant abdominal distention

Gush of air/stool with rectal

Associated neurologic/endocrine/muscular disease

Question 8

general management of constipation

Answer 8

Medications: clean out followed by maintenance

Enema: for disimpaction

Stool softeners: PEG3350, lactulose, prune juice

Bulk forming laxatives

Lubricants

Stimulants: senna, bisacodyl

+ incrase fluid and fiber. treat underlying medical or behavioural cause and manage expectations.

• try and form the gastro-colic reflex.

Question 9

functional, behavioural, medical and structural causes of day time wetting

Answer 9

• Bladder Function: overactive bladder (filling defect), dysfunctional voiding (emptying defect), voiding postponement, giggle incontinence, vaginal voiding
• Behavioural: psychosocial stressor (new sibling, parental separation), anxiety
• Medical: constipation, DM, DI, UTI, CKD
• Structural: spinal cord pathology, ectopic ureter, posterior urethral valve