Enuresis and Encopresis Flashcards
Define enuresis
Involuntary discharge of urine by day or night or both, in a child aged 5 or older, in the absence of congenital or acquired defects of the nervous system or urinary tract
Primary vs secondary enuresis
Primary - the child has never achieved continence
Secondary - the child has been dry for at least 6 months before
Anatomical issues causing enuresis
Detrusor instability
Bladder neck weakness
Neurogenic bladder (failure to empty properly, irregular thickened wall; associated spina bifida, etc)
Ectopic ureter
Disease states causing enuresis
UTI
Constipation
Investigations in enuresis
daytime
Urine MC+S
US bladder
Urodynamic studies
XR + MRI spine
Investigations in enuresis
nocturnal
Urine dip - only if recent onset, daytime enuresis, features of UTI, DM or general ill health
In secondary consider urine osmolarity and renal USS
Management of enuresis
Look for possible underlying causes/triggers
Advice on fluid intake + toileting patterns
Rewards systems e.g. star charts
Enuresis alarm generally first line
Desmopressin if short-term control needed/alarm has not been successful
Define encopresis
Soiling after 4 years of age
Aetiology of encopresis
Sphincter dysfunction
Poor coordination or relaxation
Constipation can occur, as a sequela of dehydration
Inhibition of defecation due to pain, or fear of punishment, or anxieties
Classification of encopresis
According to whether retention is present or not
Pathophysiology of soiling with retention
Once retention established, large bolus of faeces may contribute to retention
Rectal loading leads to rectal dilation, possibly leading to habituation to distention
Stool may seep out with spontaneous involuntary contraction
Pathophysiology of soiling without retention
Urgency defecation for apparent constitutional reasons
Neuropathic bowel (secondary to occult spinal abnormalities, usually associated with urinary incontinence), diarrhoea
General learning disability (<4yrs mental age is another cause)
Children may defecate intentionally as a hostile act
Investigations in encopresis
Palpate to ascertain whether retention is present
Management of encopresis
Identify obvious anal pathology
Stool softeners e.g. macrogol for a few weeks
If failing to shift use stimulant laxatives
Once disimpacted, maintenance laxative therapy
Child encouraged to defecate regularly (star chart)
Requires time for dilated rectum to return to normal calibre, regular laxatives still required
Psych review if child denying problem/using problem as a measure of control parents
