Elimination disorders Flashcards
Enuresis
general
bed wetting
Primary vs secondary
Involuntaryloss of urine in children
Can occur in the daytime, at night, or both
Most common form:
Monosymptomatic nocturnal enuresis
Bedwetting in children > 5 years old with no other urinary tract symptoms
Classified as:
Primary
Urinary continence has never been achieved
Secondary
Urinary continence is achieved for at least 6 months and control is later lost
Often associated with major changes in a child’s life (birth of a sibling, parental divorce) or emotional trauma (abuse)
Enuresis
RF
Younger age
Becomes less prevalent with advancing age
Male sex
3x more common
Family history of enuresis
1 parent → 44%
2 parent → 77%
Psychological stress
Parental divorce, birth of a sibling
Enuresis
Patho
Multiple factors
Decreased arousal from sleep in response to a full bladder
Delayed bladder maturation
Decreased ADH (vasopressin) production or alteration in circadian release
Decreased functional capacity of the bladder
Enuresis
history
Primary goal of assessment is to determine if an underlying medical condition is present that could explain the incontinence
Diagnosis is primarily through history, physical examination, andurinalysis
History:
Current medications
Increased urinary frequency and/or urgency
Frequency of incontinence
Intake of liquids at night (amount and type of fluids consumed)
Volume ofurine lost during episodes
Length of prior “dry periods”
Association with tenesmus, laughter, physical activity
Recent stressful changes in the household
Psychological or behavioral disturbances
Family history of enuresis
enuresis
Urinalysis
Firsturine output of the day
Specific gravity:
Hydration status; Diabetes insipidus
Ketones:
Diabetic ketoacidosis
Leukocyte esterase:
Urinary tract infection
Proteinuria
Hematuria
enuresis
diagnostics
Renal ultrasound andvoiding cystourethrogram
History of recurrent UTIs
Symptomatic during the day
Abdominal x-ray for associated constipation
Sleep study for patients with decreased arousal from sleep
Seizure workup
enuresis
DMS-V
Diagnostic Criteria
Repeated voiding of urine into the bed or clothes (involuntary or intentional)
Behavior occurs at least twice a week for a minimum of 3 consecutive months
Chronological age is at least 5 years of age
Behavior is associated with clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning
Behavior is not attributed to any general medical condition or medication
Enuresis
Non-Pharm Management
Treat anyunderlying medical conditions
Lifestyle modifications:
Voiding diary
Limiting liquid intake after dinner
Limiting sugar andcaffeine consumption after 5 pm
Encouraging urination before going to bed
Behavioral therapy – First-line treatment
Reassure parents and set reasonable goals
Educate parents to not reprimand bedwetting
Planned nighttime awakenings
Bladder training
Teaching the patient to hold their urine for an increased amount of time
Use voiding alarms (enuresis alarm) → 75% success rate
Enuresis
Pharm Tx
Medical therapy –Second-line treatment
Desmopressin/DDAVP
First pharmacological agent used
Synthetic analog of ADH
Initial dose: 0.2 mg PO given 30-60 minutes before bedtime
Titrate after 7 days to desired effect; maximum dose is 0.6 mg daily
Treatment for ~6 months
Imipramine
Tricyclic antidepressants commonly used in children ≥ with associated emotional trauma
Initial dose: 25 mg PO daily
Titrate after 7 days to goal dose of 75-125 mg daily
Encopresis
general
Involuntary or unintentional passage of feces in inappropriate situations in children older than 4 years of agein the absence of neuromuscular disease
More common inboysthan girls(3:1 ratio)
Classified as:
Retentive- 80% of cases
Associated with constipation
Secondary overflow and leakage of stool around the obstruction
Non-retentive
Withoutconstipation
Subclassified as:
Primary
Fecal continence has never been achieved
Secondary
Fecal incontinence returns after successful toilet training
Marked by a higher level of stressors and psychological disorders
Encopresis
withholding stool
Playing with friends and they do not want to miss out on what is happening
Afraid to poop
Painful poop in the past, so they do not want that to happen again, so they will withhold to keep from hurting
Scared of the toilet
Afraid they will fall in (maybe they have fallen in the past and are scared of it happening again)
The toilet seat is not comfortable
Fearful of using the bathroom in places other than home
Encopresis
Diagnosis
Key is to determine if there is an underlying condition or if there are any recent stressors in the child’s life
Encopresis orfunctional constipation
Diagnosed using theRome IV criteria
Must have two of the following, at least once a week for a minimum of one month:
One episode offecal incontinence
Retentive posturing or purposefully withholding feces
Evidence of a large volume of stools in therectum
Episodes of large-volume stools that may clog the toilet
Painful bowel movements
Two or fewer defecations each week
Encopresis
DSM-V
Diagnostic Criteria
Chronological age must be at least 4 years;
Intentional or involuntary repeated passage of feces into inappropriate places (clothing or floor)
At least one event must occur every month for at least 3 months
The behavior is not attributable to the effects of a substance or another medical condition, with the exception of a mechanism involving constipation
Encopresis
Physical examination
Retentive
General: streaking of stool in underwear
Rectal exam
Reveals large fecalmass(functional constipation)
Evaluate sphincter tone to rule out neurologic disease\
Abdominal exam may indicateconstipation
May be distended and somewhattendertopalpation
Stool may be palpated in the LLQ or suprapubic region
Non-retentive: physical examination is usually non-contributory
Both
Generalinspection
Evaluate for anterior anus
Evaluate for signs ofspina bifida occulta (sacral dimple or tufts of hair on the lower back)
Neurological exam
Evaluate for underlying neuromuscular disease
General muscular tone
“Anal wink” reflex
Lower extremity reflexes
Encopresis
imaging
Flat and upright abdominalX-ray
Shows the level of fecal impaction
Identify ifmegacolon orintestinal pseudo-obstructionare present
Imaging of the spinal cord
Neurologic complaints or physical symptoms of spinal cord abnormalities
