Elimination Disorders

Objectives:

1. Review the causes for nocturnal enuresis.
2. Understand the prognosis and various treatments for nocturnal enuresis.
3. Understand the pathophysiology underlying functional encopresis.
4. Review the differential diagnosis for encopresis and recognize warning signs of that may signal an underlying anatomical, metabolic or neurological issue.
5. Review treatment options for disimpaction and maintenance therapy for constipation/fecal impaction.

Articles:

• Management and treatment of nocturnal enuresis—an updated standardization document from the International Children's Continence Society (Journal of Pediatric Urology, 2020)
• Enuresis in Children: A Case-based Approach (AFP, 2014): Contains useful algorithm for diagnostic and therapeutic approach of enuresis in children.
• Enuresis (Peds in Review, 2009)
• Encopresis (Peds in Review, 2010)

Additional Resources:

• CHOP Open Access Medical Education: Elimination Disorders (2018): Video recording of a lecture presentation by Carissa Jackel, MD covering the causes, evaluation, and management of encopresis and enuresis.
• The Mt Sinai Keystones curriculum has a toilet training section!
• CHOP Clinical Pathways has an emergency room algorithm and an inpatient algorithm, too!
• Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN (2014): Clinical guidelines for the treatment of functional constipation. Includes useful algorithms for evaluation and treatment. Additionally, there are useful tables for the differential diagnoses, alarm signs and dosages of most frequently used medications for disimpaction and maintenance therapy.
• Toilet Training Guidelines: Clinicians – The Role of Clinicians in Toilet Training (Pediatrics, 1999): A useful aid to guide your advice and conversations with parents prior to and during potty training.
• org – Toilet Training (AAP): Parent education website with links to a wide range of easily digestible articles covering topics including child’s developmental readiness, choosing a potty, creating a training plan, training special needs children, bedwetting, and other setbacks.
• Wet Stop 3: Affordable bedwetting alarm
• In our UMass Epic, be sure to use our Pediatric Cleanout orderset, with 3 different pre-dosed options for PO or NG cleanouts

Self-Assessment:

From Peds in Review (“Enuresis,” 2009;“Encopresis," 2010)

1. A 7-year-old boy has isolated primary enuresis (nocturnal wetting only). Of the following, he is most likely to have:

1. Abnormal non-rapid eye movement sleep
2. A positive family history
3. Bladder outlet obstruction
4. Occult spinal dysraphism
5. Urinary tract infection

2. A 7-year-old boy has newly diagnosed primary nocturnal enuresis. The likelihood of eventual spontaneous remission has been fully explained, but the child and the family want to try therapy. The most effective treatment for ending the enuresis for this boy is:

1. A bedwetting alarm
2. An anticholinergic medication
3. An oral alpha blocker
4. Nasal desmopressin
5. Oral imipramine

3. The most common cause of chronic encopresis is:

1. Deficiency of rectal ganglion cells
2. Hyperparathyroidism
3. Hypothyroidism
4. Rectal stenosis
5. Voluntary stool withholding

4. The most helpful modality for diagnosing functional encopresis is:

1. Abdominal plain film
2. Barium enema
3. Colonic motility studies
4. History and physical exam
5. Magnetic resonance imaging

5. The clinician’s first choice of therapy for functional encopresis should be:

1. Behavior modification
2. Disimpaction
3. Increased dietary fiber
4. Simulant laxatives
5. Stool softeners

Find the answers here.