Midnight%20Laundry%20Enuresis,%20Encopresis%20and%20Diarrhea

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Title: Midnight%20Laundry%20Enuresis,%20Encopresis%20and%20Diarrhea

1
Midnight LaundryEnuresis, Encopresis and Diarrhea

Tory Davis, PA-C

2
Enuresis

Urinary incontinence in child who should be
continent
5-6 years (or developmental equivalent) or older
Not caused by medication or medical condition
Peeing in clothes or in the bed
Involuntary or intentional

3
Enuresis

Primary enuresis
has never had a sustained period of dryness.
90 nocturnal
Secondary enuresis
has had a sustained period of bladder control
(6-12 months)?

4
Primary Enuresis

Boys 3x girls
Most become continent by adolescence, even
without intervention
FHx , esp father
Likely maturational delay of
sleep/wake mechanisms
development of bladder capacity and urethral
sphincter control

5
Primary Enuresis
6
Daytime Enuresis

More common in
Kids with hyperactivity
Timid/shy kids
Boys Girls
60-80 also have nocturnal wetting

7
Secondary Enuresis

Onset after child has had sustained period of
continence
Often follows a stressful event
Loss, new sibling, family discord, move, new
school, abuse

8
Differential

UTI MC
Distal urethritis (bubble bath)?
Neurological disorders- congenital or acquired
Congenital anomalies (spina bifida)?
Seizure disorders
Diabetes (mellitus or insipidus)?
Structural abnormalities of the urinary tract
(urethral cyst, urethral duplication,
obstruction)?

9
Diagnosis

Take a good history
Do a good physical
Observe childs urinary stream
Straining, dribbling, stress incontinence?
Urinalysis and urine culture

10
Treatment

Emphasize that noc wetting is likely
developmental lag
NOT acting out, etc
Patient understanding and encouragement
Spontaneous cure 15/year
Avoidance of punitive measures
Encourage child participation

11
Treatment

Counseling
Child has active role keeps calendar, helps
with the midnight laundry, talk to the PA
Positive reinforcement, remove guilt/blame
Bladder training
Hold urine longer during day, limit fluids after
dinner, practice start/stop urine flow on toilet,
pee just before bed. Helpful 40
Potty pager/ alarm

12
Meds

DDAVP (desmopressin acetate) intranasal qhs.
Complete remission during tx 50, high relapse on
discontinuation. Good for special events (camp,
sleepovers) and as bridge
Imipramine (TCA) 25-50 qhs
Anticholinergic side effects

13
Encopresis

Fecal incontinence in child who should be
continent.
4 years (or developmental equivalent) or older
Not due to medication or medical condition
Involuntary (usually) or intentional
1-1.5 of school-aged kiddos, very rare in
adolescence
Boys 4x girls

14
Functional Encopresis Types

Retentive
Continuous
Discontinuous
Toilet phobia

15
Retentive Encopresis MC

Psychogenic Megacolon
Child withholds BMs ? constipation ? fecal
impaction ?seepage of liquid feces (Type 7!)
around impaction and out onto skivvies.
Marked constipation?
Painful defecation
Retention ?reduced sensory feedback
Rectal wall stretch causes ? contractile strength
Harder stools due to increased water absorption
Then what happens?

16
Continuous Encopresis

Children who have never gained primary control of
bowel function.
Poop in underwear. Doesnt care. No regard for
social norms.
Typically lacks bowel/potty training
Often family social/intellectual disadvantage
The encopresis is the least of your worries with
this child

17
Discontinuous Encopresis

Hx of normal bowel control for extended period
Like secondary enuresis, usually in response to
stressful event
Sometimes voluntary follow-through (smearing,
etc)?

18
Etiologic considerations

Inefficient motility
Medical management for (perceived?) bowel
disorder
Painful defecation (fissures, etc)?
Surgical hx (imperforate anus)?
Unrealistic parental expectation

19
Consequences

Fear
Shame
Isolation
Depression

20
History

Bowel pattern since birth
Age of onset of problems/symptoms
Management attempt and effects
Associations (ie with stressors)?

21
Physical Exam
22
Management (Levine)Counseling Phase

Demystify
Review colon function
Normal and abnormal
Draw a picture
Show imaging
Remove blame
Explain treatment plan
Emphasize intestinal muscle building

23
Inpatient Catharsis

When?
Severe retention
Poor outlook for home compliance
What?
Saline enemas bid 3-7 days
Bisacodyl suppositories bid 3-7 days
Sit on toilet 15 min pc

24
Outpatient Catharsis

Mild Senna daily x 1-2 weeks
Moderate-Severe 3 day cycles
Day 1 Fleets enema bid
Day 2 Bisacodyl suppository BID
Day 3 Bisacodyl suppository once
Follow-up x-ray to confirm catharsis

25
Maintenance

Sit on toilet bid x 10 min, after meals
2 T mineral oil po bid x 4-6 months
MVI supplement
Eat fiber!
Oral laxative (senna) q day
or qod x 1 month
Read Anna Karinina ??
Reward- sticker chart, etc

26
Follow-Up

q 1-2 months
Check compliance
Monitor for relapse
Document progress

27
Thoughts on Potty Teaching

Teach your parents well
Readiness signals dry periods, interest in
toilet,wants to be changed when wet, can follow
directions
No power struggles
Respect childs autonomy
Applaud childs success
Accidents happen

28
Poop Song

http//www.youtube.com/watch?vP-OIgXyvzUUfeature
rec-rn

29
Acute Diarrhea

Gastroenteritis
Infectious
Food poisoning
Antibiotic-associated
Overfeeding
Great Ddx chart in Nelson text

30
Acute diarrhea

Complete history
Include day care, travel, animal contact, foods,
antibiotics
Physical Exam
Stool- check for WBCs and occult blood
If neg, think viral
If pos- r/o (or in) bacterial cause, then
consider IBD

31
Acute diarrhea management

Cure initiating event
Correct dehydration and e-lyte deficits
Manage complications from mucosal injury
NO Imodium, Lomotil, paragoric, etc

32
Chronic Diarrhea

Post-infectious secondary lactase deficiency
Cows milk intolerance
Toddlers diarrhea
Celiac disease
CF

IBS
IBD
Giardiasis
Laxative abuse
AIDS enteropathy

33
Toddlers Diarrhea- MC Chronic diarrhea in infants

Nonspecific diarrhea of infancy
6m-3y onset, duration gt3 weeks
Painless
First stool of the day formed, become
increasingly liquid thru day
Exacerbated by teething, infections, also by
fruit juices with unabsorbable sugars that
increase diarrhea

34
Toddlers diarrhea