Elimination Disorders (Enuresis)

Elimination Disorders (Enuresis)

اسلاید 1: Elimination Disorders

اسلاید 2: Enuresis

اسلاید 3: DefinitionsEnuresis refers to the involuntary or intentional voiding of urine.Primary enuresis: child never established urinary continence.Secondary enuresis: occurs after a period of urinary continence(roughly six months or more).Diurnal includes daytime episodes.Nocturnal includes nighttime episodes.

اسلاید 4: Epidemiology The point prevalence figures cited in DSM-IV-TR are 7 percent of boys and 3 percent of girls at 5 years of age, 3 percent of boys and 2 percent of girls by 10 years of age. Only 1 percent of boys still wet at age 18 years of age, and still fewer girls wet at this age.Primary Enuresis: Male predominance. decreases with age.Secondary Enuresis: Usually equal in both.Between 3% and 9% of school age girls experience daytime urinary incontinence

اسلاید 5: Epidemiology DSM-IV-TR also cites a spontaneous remission rate of between 5 percent and 10 percent per year after 5 years of age. Secondary enuresis may occur at any time but most commonly begins between 5 years of age and 8 years of ageMental disorders are present in 20% of patients.Bed Wetting > daytime incontinenceTypical occurs 30 minutes to 3 hours after sleep onset.

اسلاید 6: Etiology  Familial: 70% of children with Enuresis ( particularly boys) have 1st degree relative functional enuresis.Maturational etiology*.Anatomical abnormalities or UTSGiggle incontinenceMedicationsEpidemiologic studies have shown a correlation between psychological disturbance and enuresis.Link to emotional disturbances.Higher rates of behavioral problems(Anxiety states, Opposionality, ADHD)Secondary Enuresis related to stress, trauma, or psychological crisis or infection …

اسلاید 7:

اسلاید 8: Medical CausesUTIUrethritisDiabetesSickle cell anemiaSeizure disorderNeurogenic bladderAnatomyObstruction

اسلاید 9: Diagnosis and Clinical Featuresrepeated voiding of urine during the day or at night into bed or clotheswhether involuntarily or intentionallythe behavior is clinically significant as manifested a frequency of at least twice per week for at least three consecutive months or impairment in social, academic (occupational) or other important areas of functioning.” 

اسلاید 10: DSM-IV-TR Diagnostic Criteria for Enuresis

اسلاید 11: Diagnostic Criteria for Nonorganic EnuresisA. The childs chronological and mental age is at least 5 years.B. Involuntary or intentional voiding of urine into bed or clothes occurs at least twice a month in children younger than 7 years of age and at least once a month in children 7 years of age or older.C. The enuresis is not a consequence of epileptic attacks or of neurological incontinence and is not a direct consequence of structural abnormalities of the urinary tract or any other nonpsychiatric medical condition.D. There is no evidence of any other psychiatric disorder that meets the criteria for other ICD-10 categories.E. Duration of the disorder is at least 3 months.

اسلاید 12: Differential diagnosisGenitourinary pathology such as obstructive uropathy, spina bifida occulta, and cystitis.Diabetes mellitus.Seizures, and side effects of medication, such as antipsychotics or diuretics.Because urinary tract infections can produce enuresis, a urinalysis should be part of every evaluation. Using radiographic procedures with contrast media to detect an anatomical or physiological are invasive and painful, and the diagnostic yield is low.( 3.7%)

اسلاید 13: Course and prognosisusually self-limited; remissions are frequent between 6 and 8 years and puberty.Primary: high spontaneous remissionSecondary: Usually begins b/w ages 5-8 years.Adolescent onset signify more psychiatric problems and less favorable outcome.Complication include embarrassment, anger from and punishment by care givers, teasing by peers, avoidance of overnight visits and socializing, angry outbursts.

اسلاید 14: Treatment ( Factors to consider)Age of childMedical cause has been ruled outRate of spontaneous remission Behavioral conditioning with bell and pad or similar methodologyEqually effective as pharmacological treatmentLower rate of relapse than with pharmacological treatmentSafer than pharmacological treatmentMost commonly used pharmacological intervention is Desmopressin acetate (DDAVP)Most serious side effect (rare) is hyponatremia, leading to seizuresImipramine is no longer first-line choice for pharmacological treatment, but can be used for refractory individualsCombination of behavioral and pharmacological treatment can be considered for refractory enuresisBehavioral treatment should be attempted first because it is usually more innocuous than pharmacologic intervention. The bell and pad method of conditioning is a reasonable first approach. success rate of 75%,

اسلاید 15: Treatment General measures :- Restrict fluid intake 3-4 hours beforebedtime. - Empty bladder before retiring to bed.-Keep a chart of wet and dry nights [ STAR CHART ].- Reward for dry nights. -Avoid punishment/criticism.

اسلاید 16: Behavioral therapy such as buzzer that wakes child up when sensor detects wetness.

اسلاید 17: B. Psychotherapy not an effective treatment alone, but can be useful in dealing with coexisting psychiatric problems and emotional and family difficulties.

اسلاید 18: C. Pharmacotherapy include antidiuretics (such as desmopressin) or Tricyclic antidepressant (such as imipramine)ImipramineMost children respond in the 75- to 125-mg range.  A baseline electrocardiogram should be obtained before instituting treatment with imipramine, and monitoring is advised above 3.5 mg/kgrelation to blood level  ?!The standard maximal limit for dosage is 5 mg/kg body weight.

اسلاید 19: DDVAPDDVAPThe newest research into treatment for enuresis involves the use of DDAVPReview Studies: 10%-91% success rateIn general, wetting resumes once the medication is discontinued as only 5.7% remained dry.The most common side effects were nasal stuffiness, headache, epistaxis, and mild abdominal pain. Combination with behavioral methods works better.

اسلاید 20: Encopresis

اسلاید 21: DefinitionEncopresis : repeated passage of feces into inappropriate placesat least once a month for at least 3 monthsthe mental or chronological age of the child must be at least 4 years

اسلاید 22: Epidemiology.Prevalence is about 1% of 5-year-old children.Prevalence decreases with ageA significant relation between encopresis and enuresis has also been foundSchool age: Male> female: 2.5:1-6:1Higher rates in MR and Low socioeconomic classes.

اسلاید 23: EtiologyConstipation with overflow incontinence can be caused by nutrition; structural disease of the anus, rectum, or colon; medical side effects; or endocrine disorders. Children without constipation and overflow incontinence often have lack of sphincter control.Inadequate training or Emotional issues. Emotional stress also may trigger encopresis. A child may experience stress from premature toilet training or an important life change — for instance, the divorce of a parent or the birth of a sibling.

اسلاید 24: DSM-IV-TR Diagnostic Criteria for Encopresis

اسلاید 25: Diagnostic Criteria for Nonorganic EncopresisA. The child repeatedly passes feces in places that are inappropriate for the purpose (e.g., clothing or floor), involuntary or intentionally. (The disorder may involve overflow incontinence secondary to functional fecal retention.)B. The childs chronological and mental age is at least 4 years of age.C. There is at least one encopretic event per month.D. Duration of the disorder is at least 6 months.E. There is no organic condition that constitutes a sufficient cause for the encopretic events.

اسلاید 26: Differential diagnosisHirschprung diseaseThyroid diseasesHypocalcaemiaLactase deficiencyPseudo obstructionMyelomeningioceleCerebral palsy with hypotoniaRectal stenosisAnal fissureAnal traumaAnxiety or Phobia

اسلاید 27: Course and prognosisOutcome depends on the cause, the chronicity of the symptoms, and coexisting behavioral problems.Many cases are self-limiting, rarely continuing beyond mid-adolescence.25% co morbid enuresisPsychiatric or medical co-morbidity: major determinant of prognosis.

اسلاید 28: FACTORS TO CONSIDER for TREATMENTSubtypes of encopresisRetentive (most common)NonretentiveVolitional (least frequent)A thorough history is essential that documents frequency, nature, and circumstances of eventFirst line of treatment for retentive subtype usually includes:Education about bowel functioning with both parents and childPhysiological treatment with laxatives or mineral oilBehavioral component with time intervals on toilet and positive reinforcement

اسلاید 29: TreatmentThe most widely accepted first line of treatment is one that encompasses educational, psychological, and behavioral approachesThe goal of treatment is to prevent constipation and encourage good bowel habits. Educating the child and family about the disorder is another important part of treatment.

اسلاید 30: Behavioral approachInitial meeting: designed to educate both the parents and child about bowel function and to diffuse the psychological tension that may have developed in the family around the encopresis.  2nd stage: Initial bowel catharsis, after which the child receives daily doses of laxatives or mineral oil. There also is a behavioral component to the treatment, which consists of daily timed intervals on the toilet with rewards for success A 78% success rate

اسلاید 31: TreatmentThere are several methods for clearing the colon and relieving constipation including:Stool softeners, such as lactulose Colon lubricants, such as mineral oil Rectal suppositories Enemas More oral fluids   Pharmacological treatment with imipramine also has been reported as useful for encopresis.