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

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Midnight LaundryEnuresis, Encopresis and Diarrhea

• Tory Davis, PA-C

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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

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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)?

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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

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Primary Enuresis
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Daytime Enuresis

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

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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

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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)?

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Diagnosis

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

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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

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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

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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

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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

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Functional Encopresis Types

• Retentive
• Continuous
• Discontinuous
• Toilet phobia

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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?

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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

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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)?

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Etiologic considerations

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

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Consequences

• Fear
• Shame
• Isolation
• Depression

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History

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

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Physical Exam
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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

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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

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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

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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

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Follow-Up

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

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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

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Poop Song

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

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Acute Diarrhea

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

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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

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Acute diarrhea management

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

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Chronic Diarrhea

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

• IBS
• IBD
• Giardiasis
• Laxative abuse
• AIDS enteropathy

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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

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Toddlers diarrhea

• Motility disorder with rapid transit
• Positive FHx for IBS
• Dx r/o infectious causes
• Tx high fat, high fiber, low sugar diet

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Cows Milk Intolerance

• Infants lt1year old
• Stools contain WBCs, eosiniphils
• Even in breast-fed babes whose moms drink cow
  milk
• Diarrhea, vomiting, mucus in stools
• FTT
• Assoc with atopy, rhinitis, eczema
• Dx Stool studies, CBC
• Tx alimentum, nutramagen (not soy) or nursing
  mom avoid milk