disorder of elimination

Question 1

what are the normal ages of acquisition of bowel and bladder control

Answer 1

2 to 3 yrs

Question 2

how old should a child be when not being toilet trained is concerning

Answer 2

By age 4yr

Question 3

causes of nocturnal enuresis

Answer 3

occurs in normal children and is due to a delay in the development of the normal sphincter control mechanisms.

Question 4

Causes of diurnal enuresis

Answer 4

poor bladder sensation or bladder muscle instability

Question 5

Define secondary enuresis

Answer 5

refers to wetting in a child who had previously been dry and is often associated with psychological stress

Question 6

Who gets primary nocturnal enuresis

Answer 6

10% in 6yr and 3% are 12yr once a week

Question 7

Causes of primary nocturnal enuresis

Answer 7

Delayed maturation - often familial
May be reduced ADH production
Reduced bladder awareness
Emotional stress
UTI
Polyuria due to DM or renal disease

Question 8

Causes of secondary enuresis

Answer 8

Emotional upset
UTI
DM
threadworm infection

Question 9

Causes of diurnal enuresis

Answer 9

UTI
Neurogenic bladder
congenital abnormality eg ectopic ureter
Severe constipation
Psychogenic due to stress
Sexual abuse - RED FLAG
Physiological urgency

Question 10

Hx question when asking elimination disorders

Answer 10

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.

Question 11

O/E for bedwetting

Answer 11

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

Question 12

Ix for bed wetting

Answer 12

Urine MCS - to exclude UTI
Urine dipstick - exclude glycosuria
Renal USS - ectopic ureter strongly suspected

Question 13

Mx of bedwetting/daytime wettiing

Answer 13

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

Question 14

Differentiated between constipation and Hirschsprung’s disease

Answer 14

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

Question 15

tx for Posterior urethral valves

Answer 15

Surgical corection

Question 16

Causes of UTI in children

Answer 16

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

Question 17

Presentation of posterior urethral valves

Answer 17

Poor force of stream in infant boys
Antenatal - bilateral dilated renal helix
abnormal urinary stream
Multiple UTI
Kidney failure

Question 18

Congenital renal anomalies

Answer 18

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.

Question 19

List urological abnormalities

Answer 19

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

Question 20

vesicoureteric reflux

Answer 20

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.

Question 21

Causes of Encopresis

Answer 21

Chronic constipation - retentive encopresis
Hirschsprung disease
Hypothyroidism
Hypercalcemia,
Spinal cord lesion
Anorectal malformations

Question 22

Define Encopresis

Answer 22

Feacal incontinuence in a child >4 yrs at least once a month for 3 months

Question 23

Define retentive encopresis

Answer 23

Child holds bowel movement, develops constipation, leading to fecal impaction and seepage of soft or liquid stool = overflow incontinence