disorder of elimination Flashcards
what are the normal ages of acquisition of bowel and bladder control
2 to 3 yrs
how old should a child be when not being toilet trained is concerning
By age 4yr
causes of nocturnal enuresis
occurs in normal children and is due to a delay in the development of the normal sphincter control mechanisms.
Causes of diurnal enuresis
poor bladder sensation or bladder muscle instability
Define secondary enuresis
refers to wetting in a child who had previously been dry and is often associated with psychological stress
Who gets primary nocturnal enuresis
10% in 6yr and 3% are 12yr once a week
Causes of primary nocturnal enuresis
Delayed maturation - often familial May be reduced ADH production Reduced bladder awareness Emotional stress UTI Polyuria due to DM or renal disease
Causes of secondary enuresis
Emotional upset
UTI
DM
threadworm infection
Causes of diurnal enuresis
UTI Neurogenic bladder congenital abnormality eg ectopic ureter Severe constipation Psychogenic due to stress Sexual abuse - RED FLAG Physiological urgency
Hx question when asking elimination disorders
Ever been dry, what age, any triggers FmHx of primary nocturnal enuresis Stresses Sexual abuse Dysuria, polyuria, systemic upset - UTI? constipation ? DM - polyuria polydipsia or wt loss What has been done by parents at home? any punishment or criticised the child when wetting. False expectation? Pattern of bed wetting, running to get to toilet, dribbling.
O/E for bedwetting
evidence with neurological or congenital abnormality
check leg reflexes and perineal sensation
spina bifida occulta eg lipoma or hairy patch over the sacral area.
Palpable faecal mass
Renal disease
Hypertension
Ix for bed wetting
Urine MCS - to exclude UTI
Urine dipstick - exclude glycosuria
Renal USS - ectopic ureter strongly suspected
Mx of bedwetting/daytime wettiing
Enuresis is common- 15% of 5 yr
There is rarely an organic cause
Majority respond to behavioural management
Psychological stress should be considered in secondary enuresis.
no intervention until 7 yr
Behavioural management with star charts and rewards for dry nights
Enuresis alarm
Bladder training - full bladder during day
Avoid caffeinated drinks and fruit juice
Medication - Desmopressin (nasal spray or tb), Oxybutynin - reduces detrusor muscle instability in children with a call bladder capacity and urgency.
Tx any constipation
Differentiated between constipation and Hirschsprung’s disease
Hirschsprung's Onset - after newborn period Passage of meconium - 48 hr Vomiting Soiling - uncommon Wt gain - poor Size of bowel motion - thin "rabbit like" Anal fissure - uncommon Xray - barium and AXR Manometry Tx - bowel irrational and surgery within the first week of life
tx for Posterior urethral valves
Surgical corection
Causes of UTI in children
UTI in children may indicate congenital renal anomaly
Vesicoureteric reflux (leads to hydronephrosis)
Obstructed urinary systems
- Pelviureteric obstruction
- Urinary stones
- Posterior urethral valves- boys with poor urinary stream
- Duplex kidney with obstructed pole
- Horseshoe kidney (turner’s)
Idiopathic
Poor hygiene - wet nappies, and wipes back to front in girls
Constipation
Neuropathic bladder - spinal cord defect can result in impaired continence and infection
Presentation of posterior urethral valves
Poor force of stream in infant boys Antenatal - bilateral dilated renal helix abnormal urinary stream Multiple UTI Kidney failure
Congenital renal anomalies
Solitary kidney - due to unilateral renal genesis
Ectopic kidney - due to abnormal migration during embryogenesis leads to pelvic or horseshoe kidney.
Multi cystic dysplastic kidney - it is non functioning and usually involutes and disappears by school age.
Autosomal dominant polycystic kidney disease - may cause haematuria, HTN and renal failure.
Autosomal recessive polycystic kidney disease - reduced fluid production antenatal -> Secondary pulmonary hypoplasia. If child survives the neonatal period = end stage renal failure in early childhood.
List urological abnormalities
Predispose to UTI and if severe can lead to renal impairment or failure.
- Pelviureteric obstruction - abnormal tissue or external compression at the point the renal pelvis joins the ureter. 75% improve without surgical intervention
- Posterior urethral valves - 1/10000 male infant. cause = persistence of an embryological fold across urethra causing bladder hypertrophy, bilateral hydronephrosis and renal impairment.
- Hypospadias - mild = no tx, severe = surgical. Advice them not to circumcised.
- Phimosis - Non retractile. only surgery if obstruction problem
- Paraphimosis - foreskin trapped behind the glans causing pain and swelling. usually reducible without surgery.
- Circumcision
vesicoureteric reflux
Retrograde flow of urine into ureters.
Can cause Hydronephrosis and predispose to UTI, pyelonephritis, HTN or end stage renal failure.
Cause is from an abnormally short and straight insertion of the ureters through the wall so that they are not properly occluded during bladder contraction.
Ix - USS for dilation of ureters, renal pelvis and calyces.
Mx - conservative tx - surveillance and ABX for infection. Some may need surgery for breakthrough infection or deteriorating renal function.
Causes of Encopresis
Chronic constipation - retentive encopresis Hirschsprung disease Hypothyroidism Hypercalcemia, Spinal cord lesion Anorectal malformations
Define Encopresis
Feacal incontinuence in a child >4 yrs at least once a month for 3 months
Define retentive encopresis
Child holds bowel movement, develops constipation, leading to fecal impaction and seepage of soft or liquid stool = overflow incontinence
