Pediatric incontinence Flashcards
What is colorectal motility?
- Provided by intrinsic enteric NS
- Modulated by extrinsic NS; sacral parasympathetics modulate enteric NS via interneurons - increase digestion
- Lumbar sympathetics decrease digestion and motility
Reasons children have voiding issues
- Avoiding defecation secondary to fear
- Refusal to use toilet
- Toilet phobia
- Painful bowel movement
- Emotional stress
- Sensory issues in bathroom
- Physical discomfort
- Emotional upset
- Situation where they are pressured to hold it
Onset of constipation
- Insidious onset - painful BM, holding back
- Stool builds up and stretches colon
- Stool becomes harder and larger over time
What is the rectoanal inhibitory reflex (RAIR)?
- Sensation signals to brain indicating need to defecate
- Disruption needs greater pressure to inhibit internal sphincter contraction
How can constipation cause urinary incontinence?
- Full rectum puts pressure on bladder neck; non-neurological
- Bladder compression decreases capacity
- Increases risk of UTI
Signs of constipation with overflow diarrhea
- Abdominal pain
- Offensive body odor
- Stools plug toilet
- Lack of appetite
- Urinary incontinence
- Bypass diarrhea - liquid stool passes around impacted stool
What is urge incontinence?
- Urge to have a bowel movement with inability to get to toilet in time
- Weak pelvic floor
What is passive incontinence?
Inability to sense full rectum
What is encopresis?
- Fecal leakage
- Primary - longest clean interval < 6 months
- Secondary - relapse after 6 months or more being clean
Causes of encopresis
- Weak closure of anal canal - soft stool leaks after evacuation
- Difficulty wiping/cleaning
- Reflexive withholding of stool
- Can be associated with physical activity - similar to stress incontinence
- Urgency that cannot hold 15 minutes - external anal sphincter problem
- Gas/liquid incontinence - internal anal sphincter problem
T/F Encopresis is voluntary
False, child is unable to sense the need to defecate - rectoanal inhibitory reflex
Treatment for encopresis
- Treat bowel before urinary symptoms
- Education - simple anatomy and physiology
- Behavior modification - diet and toileting
- Medical intervention
- Duration of 3-6 months
Toileting recommendations
- 5-10 minutes 3x/day
- Warm beverage
- After a meal - gastrocolic reflex
- Proper toilet posture
- Incentives - reward
- Bowel diary
What are causes of uncontrollable leakage?
- Congenital malformation - ectopic ureter, lost external sphincter control
- Intermittent - day or nighttime, leaks in discreet amounts
What is enuresis?
Intermittent nocturnal incontinence
Monosymptomatic vs non-monosymptomatic enuresis
- Monosymptomatic - without other lower urinary tract symptoms or bladder dysfunction
- Non-monosymptomatic - with other symptoms of daytime incontinence, urgency holding maneuvers
Primary vs. secondary enuresis
- Primary - child has been dry < 6 months, normal exam, negative UA
- Secondary - child previously dry for > 6 months
What is voiding postponement?
- Daytime incontinence with habitual holding maneuvers
- Low voiding frequency
- Urgency due to full bladder
- Possible incontinence due to full bladder
What is extraordinary daytime urinary frequency?
Child voids often with very small volumes
What are questionnaires for pediatric incontinence?
- Dysfunctional voiding symptoms score
- Pediatric urinary incontience quality of life score
- Shor screening instrument for psychological problems in enuresis
PT objectives of pediatric incontinence
- Posture, tone, strength
- Pelvic floor muscle testing and sensation
- EMG - baseline resting tone, fast twitch, slow twitch
- Education - voiding schedule, decrease bladder irritants, bowel program
Diaphragm and pelvic floor couple
- Inhaling - diaphragm contracts, transverse abdominus relaxes and pelvic floor drops
- Exhaling - diaphragm relaxes, transverse abdominus and pelvic floor contract
