Elimination Disorders (Enuresis)

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3) ) Elimination 

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Definitions Enuresis refers to the wokrotary or tetectiocal voice oP rice. 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. 

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0 Dre potat prevdlewse ‏وا لا یت‎ DGO-1O-DR are °P pervedt oF boys onl 9 pervect of yids ut GS pears of age, 9 perved of boys ond O pervect oP yids by IO pears oP ace: Ody 0 percedt oF boys stil wet ot age JO pears of age, ood stil Paver is wet ot this oe. © Primary Couresis: Ode predowiccae, ‏ضيه علدب جوج دصل‎ 0 Gevowdey Couresis: Osudly equal ta bok. © Orwers 9% und O% vf school oye yids expericwe dovie جصمج وا رونت 

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مت اه جام و مه و ‎OGO-10-TR dso cies‏ وه ۲اه ور 9 اه مه و موم 4106 له مسسم © Geovadary ‏براجت نوم قحا جوملا رجه ك وه روت وه‎ beqjus betwerd S pears oP age und © peas oP ‏جه‎ QOvutd disorders ure presedt 1 CO% vf patients. ed Orting > ‏جنس مرول‎ Dypicd voours OO wisutes to O hows oPter sleep ‏اجه‎ 

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‎oP chien wits Pouresis (particu) boys) bave 1‏ ۹۵ :لماص ‎deqrer retoive Puontiogal eouresis. ‎Octwratizcal ‏*توعكصاصاع‎ . ‎Ovatowird abuorwutiies vr ONG Crete teovutceure ‎Dedicatiogs ‎Cpidewivloyir studies kave shows ‏ای و‎ betwers psychological dsturbouwe ocd ecuresis. ‎Lick to exrvtiocal disturboaes. ‎ ‎rates oP bebaviord problews((Duxtety states, Opposincntliy,‏ نا ‎COW)‏ ‎Gevowkey Couresis related to stress, trou, or psychological prisis pr ‏اه‎ ... 

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75% risk where both parents have been enuretics as children PP) 45% isk wher only one parent 4!) has been enuretic 15% risk where there is no parental history of enuresis 

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repected void oP urice duro the doy or ot cight toto bed or clothes Uhether tovchuatary or ietectiocraty the behavior is vloicdly siqaiPiccdt os wooested cu Prequeuny oP ot beast twice per week Por ot feust three couse cuiive woot or kypuiredt io socid, acadewic (oecupuived) or viher iportot ‏".موسا خم جوضن‎ 

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0۵0-۳1017 ‏م0‎ )0 ۳) ©. Repeated verde of orice hiv bed or coker (whether Ruckntary or Kiecirad). ©. Phe behavior ip chicdly okmPocdt cs wraaPested by o Prequeay of ture a werk Por ot fet O creer ive ‏سس تون‎ preseure of ‏یطوط راو‎ or ‏راهم مس‎ exis (pom urdiond), or cher keportact areas of Puactckny. O. ‏هه لام‎ of cet S pare of axe (or equivdet developarrcid evel). ©. Phe behavor © wet he ‏اه سوام تس سا و‎ of ‏ریدم) لو و‎ u hires) or 3 second weded rntics (e.., dobetes, spat bide, ov a setzure deorder). ‎ype:‏ سوه باه مهو( ‎Onur oo‏ ‎Oorturcd ced choco‏ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ 

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عوویه۲) وم و() سا تمعن عصرم() عوجر 9 با و وه ولج ماو حلاو ۱۳۰ .ظ), ۱ ‏لا‎ pourger thao “P pears oP age ord of eust gare ‏لاه دا مت و‎ “Po years of age or ‏و‎ ۱), ۲۳۲ ‏اوه ان همجن و او ها موه‎ utacks or oP aeurdogicd iaovoitceace ord & ot ‏مرو ان رو سس ما تووویی سا خان ا هم وووواه ام مجموه اه و اس و‎ ‏له ال‎ ۵ ‏مه بت جا و‎ oP oy other peyohiairic disorder that wets the oiterta Por other IOO- AO rxteypries .. Qurctica oP the disorder ts of least 9 wvuhe 

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تاه متا رد روم ‎us vbstructive‏ اس امن نوتمه ad petits Onbetes weltius. Getwes, od side ePPevis of wedicuiva, suck os catipsychotios or hhuretios Oeruuse utcary trod iePevioes coo produce esuresis, ounces should be port oP every evaluation. Ostey radiographic procedures wis pootrast wedho ty detent oo ocaizeicdl or physiclogicd ore twosive ved poioPul, ocd the dhaapste vied t bw.( 9.2%) 

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* ‏و موه رای‎ ore Prequed betwerd O ood © peus uid puberty. rivary: high spootcoevus rewission, * Geooaday: Osuly begics bh ages G-O pews. ° Odolesvedt coset siqaihy wore psychiatric problews ud less Favorable vuteowe. Cowplcaivg tochide ewbharusswed, arger Pow ont pucishkweat by ‏طلست روم برط موه ,وه ور‎ oF overnight visits ord ۱ any vulbursts. 

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۱2 Ger een eee) ye oF chil QOeded couse has bero rued ut Rate oP spoutcevus rewssiva @ekaviord coodiccicgy wih bell ced pod ‏رالات اه‎ — Cqunly ePPevive os phornworviyiod ireokrent — bower rote oP relapse too with: phocwarddedicd treater — @xPer thon pharnwacvlyicd treakreot ‏موسوم لح ره بو‎ inervecion ts Deswopressia aretae (DDPOP) Oost servos side ePP ert (rove) is hypeodtrewin, beady to ‏یه‎ ‏ها او‎ a7 Imager Pirstice choice Por phorwacoloyicd treater, but cod be used Por ‏له رها‎ Corebieatica of bebaviord ‏ام اجه‎ apoyo” reared cao be aocsidered Por ‏رخا‎ ‏اد‎ « سح سوه اسك طاة عصخححصا بصو سوت با له مس ‎Qekaviord‏ ‏واه مهم ۳ bell ced pod ceted of ‏او وه او مت موس و وولو‎ oP 78%, 

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© General measures : - Restrict fluid intake 3-4 hours beforebedtime. - Empty bladder before rej -Keep a chart of wet and a - Reward for dry nights. ¥ -Avoid punishment/critic! 

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A. Behavioral therapy such as buzzer that wakes child up when sensor detects i / _ر‎ 

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

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Cc. Pharmacotherapy include antidiuretics (such as desmopressin) or Tricyclic antidepressant (such as imipramine) v نم و * Dost chides respod ia the PG- ty WEG-ry rere. ° © boselee elevirovandoqracn shoud be ‏اس شا لها لاه‎ wily ieipraice, cod wouioriog is advised above © .© ‏الب‎ °° rekatioa ty bled level! © Dke storrdard wart feat Por dosage is G wey body weigh. 

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لهاك 2000 ۶ ‏ویو‎ researck toto treater Por rouresis wolves the ‏اه و‎ 000 Review Grades: (0%-O0% success rote ‎coe the wedicatios is‏ عمج بو وی و ‎rewutced dry.‏ ‎us vay SP %‏ هجو ‎ ‎Dke wost coww0s side ePPevts were cosd stuPPicess, headache, epistaxis, ood ‏موه ار‎ pai. ‎Coxpbieation wits bekavioral wetkods works better. 

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° Cuvoprests | repecied pussaye of Peces ivio ‏ام موه‎ * atleast voce o wok Por ot east OD ‏اموب‎ ‎* the weotd or ‏امه‎ age oP the chit oust be ot feust P peas 

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Prevalence is about 1% of 5-year-old children. Prevddeuse decreuses with age © siqeiPhiccdt relotiod betueed euoopresis wed eouresis hos ‏معا مه‎ Poured Gcbkool age! Dule> Pewdle: C.G:0-0:0 Wiser votes ic OR ced Low soviverourwir chosses. 

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Etiology * Constipation 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. 

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OGO-10-TR Orccawstc Criterta Por Gacopresis 0. Repeated passer oP Peoes kip keppropriie pares ‏اوه ری‎ or Poor) wheter ‏بصم اسم‎ or kicctrd 0. @tleast coe suck ‏مرو‎ a wrk Por of becst O wrath ‎pears of axe (or eqaideat devebpwrectd evel)‏ ® ماه جا جيب مپسا( ‎0. Phe behavior is ot exctisively due to the direct physicloyicdl ef Pevis oP o substaace ), Uknvtives) or yecerd weded coudiivg, except through o wevhuaise voles mcstizatic: ‎(Onde as Polos ‏وه وله ای رای زط)‎ ‏ی تاه له ماه تمازط‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ 

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a Oicxpwsir Criteria Por Ovowrceiz 2 ‏طاو روص‎ ©. Dh 3 ‏سم ۲ موه نا ار ما موم رآ‎ (ear, ‏یه وه چاه نون لبط )رم و را لا و اه‎ ‏ما متخ و زورمین‎ ( (0. ۳ ‏وه ای له موه جلله‎ te ot east P pears oP oe .O. Vhere 6 ot ewst vor europretic evedl per ‏عادصب‎ ‎.0( . Qurctica oF the disorder ts ot beast O ‏ای‎ AB. Shere is oo ‏مس‎ coodica thot cvosttuies 0 suPPidect couse Por the ‏وه موس‎ 

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‎Ovpelbwesicgiocele *‏ ؟ تسوا اس بطم مساو ‎Rect stewsis Oud Fissure ۴ Oud tna ° uxiety or Phobia * 

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له ,مرو علا ۲اه روط عا رصصجه عا مه مرول من ۶ ‎voexistog behavior problews.‏ ® Os coses a seP-icviticg, rarely cvoticuiag beyood wid CS % ov worbid ‏وه‎ ®) @spchiaiic or wediod o-worbidiy: war deterxpiccat ‏رو وه‎ 

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موست ان و66 (سس ‎(sore‏ مسا Ovwrtecive Ootioca (lecst Precuect) © honak hetory & esseutd ba doouceus Prequewy, cure, ood ‏ام‎ oP ev iret hoe ‏مج چاه‎ Por reteuive subtype ‏امه رای‎ (Bducation cbout bowel Purity wits bok parecer orn chil ‎wits knees or coker ol‏ موس لوط ‎ ‎Orkwiord cowpooedt wi ite titervals 70 tle cod postive reicPorce wet 

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2 YD ke wost widely accepted Pirst hur of treukpedt is poe ‏موی‎ لو موه امه ماه جر وا مرو ‎Dke wool of‏ ۷ اه ارو Y Edurattag the chit ood Rasiy obout the disorder is carter ieportoct pod DP treukvet. 

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Sond ‏واصصيه‎ desiqaed ‏ده ها‎ bots he pores ‏يجيه اداح لحي‎ bowel Puoctico ood to dPPuse the psychologic teasiva thot way hove developed to the Pocoiy occu the eucopresis. ‎the chitt receives chy‏ ارت اه ,واه انوا اه نم دق که ‎doses of kasatives pr cicerdl ol.‏ ‎° Dhere ‏لوصوو تمت اممو فحاصتا ه ها فطل‎ te the ireakved, whirk ‏اوه‎ ‎OP daly teed tatervals oo the tollet wi: rewards Por success ‎0 PO% sucess rate 

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°° Dhere ore severd wethods Por ‏روا‎ he ool ood retevicg ‏:ولس اعد سكج ااعمكمج‎ لها عه اس ,وا امن ‎٠١‏ ‏لاه اس جه اصی روا واون ...رز ‎fi, (Recta suppositories‏ جوا .با 2 Dore orc Phuicds * Phonweovlodicd treokvedt wik imipeanice ds kas bers reported or 

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Elimination Disorders Enuresis Definitions • Enuresis 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. Epidemiology ℓ 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. ℓ Primary Enuresis: Male predominance. decreases with age. ℓ Secondary Enuresis: Usually equal in both. ℓ Between 3% and 9% of school age girls experience daytime urinary incontinence Epidemiology ℓ DSM-IV-TR also cites a spontaneous remission rate of between 5 percent and 10 percent per year after 5 years of age. ℓ Secondary enuresis may occur at any time but most commonly begins between 5 years of age and 8 years of age ℓ Mental disorders are present in 20% of patients. ℓ Bed Wetting > daytime incontinence ℓ Typical occurs 30 minutes to 3 hours after sleep onset. Etiology  Familial: 70% of children with Enuresis ( particularly boys) have 1 st degree relative functional enuresis.  Maturational etiology*.  Anatomical abnormalities or UTS  Giggle incontinence  Medications  Epidemiologic 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 … Medical Causes UTI • Urethritis • Diabetes • Sickle cell anemia • Seizure disorder • Neurogenic bladder • Anatomy • Obstruction • Diagnosis and Clinical Features • • • • repeated voiding of urine during the day or at night into bed or clothes whether involuntarily or intentionally the 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.” DSM-IV-TR Diagnostic Criteria for Enuresis A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional). B. The behavior is clinically significant as manifested by a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. C. Chronological age is at least 5 years of age (or equivalent developmental level). D. The behavior is not due to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, or a seizure disorder). Specify type: Nocturnal only Diurnal only Nocturnal and diurnal Diagnostic Criteria for Nonorganic Enuresis .A. The child's 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 Differential diagnosis A. Genitourinary pathology such as obstructive uropathy, spina bifida occulta, and cystitis. B. Diabetes mellitus. C. Seizures, and side effects of medication, such as antipsychotics or diuretics. D. 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%) Course and prognosis • usually self-limited; remissions are frequent between 6 and 8 years and puberty. • Primary: high spontaneous remission • Secondary: 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. Treatment ( Factors to consider) • • • • • • • • • • Age of child Medical cause has been ruled out Rate of spontaneous remission Behavioral conditioning with bell and pad or similar methodology – Equally effective as pharmacological treatment – Lower rate of relapse than with pharmacological treatment – Safer than pharmacological treatment Most commonly used pharmacological intervention is Desmopressin acetate (DDAVP) Most serious side effect (rare) is hyponatremia, leading to seizures Imipramine is no longer first-line choice for pharmacological treatment, but can be used for refractory individuals Combination of behavioral and pharmacological treatment can be considered for refractory enuresis Behavioral 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%, 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. A. Behavioral therapy such as buzzer that wakes child up when sensor detects wetness. B. Psychotherapy not an effective treatment alone, but can be useful in dealing with coexisting psychiatric problems and emotional and family .difficulties C. Pharmacotherapy include antidiuretics (such as desmopressin) or Tricyclic antidepressant (such as imipramine)  Imipramine  Most 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/kg  relation to blood level ?!  The standard maximal limit for dosage is 5 mg/kg body weight. DDVAP  DDVAP  The newest research into treatment for enuresis involves the use of DDAVP  Review Studies: 10%-91% success rate  In 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. Encopresis Definition • Encopresis : repeated passage of feces into inappropriate places • at least once a month for at least 3 months • the mental or chronological age of the child must be at least 4 years Epidemiology. • Prevalence is about 1% of 5-year-old children. • Prevalence decreases with age • A significant relation between encopresis and enuresis has also been found • School age: Male> female: 2.5:1-6:1 • Higher rates in MR and Low socioeconomic classes. Etiology • Constipation 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. DSM-IV-TR Diagnostic Criteria for Encopresis A. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether .involuntary or intentional .B. At least one such event a month for at least 3 months .C. Chronological age is at least 4 years of age (or equivalent developmental level) D. The behavior is not exclusively due to the direct physiological effects of a substance (e.g., .laxatives) or a general medical condition, except through a mechanism involving constipation :Code as follows With constipation and overflow incontinence Without constipation and overflow incontinence Diagnostic Criteria for Nonorganic Encopresis A. 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 child's 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 Differential diagnosis Hirschprung disease • Thyroid diseases • Hypocalcaemia • Lactase deficiency • Pseudo obstruction • Myelomeningiocele • Cerebral palsy with hypotonia • Rectal stenosis • Anal fissure • Anal trauma • Anxiety or Phobia • Course and prognosis  Outcome depends on the cause, the chronicity of the symptoms, and coexisting behavioral problems.  Many cases are self-limiting, rarely continuing beyond midadolescence.  25% co morbid enuresis  Psychiatric or medical co-morbidity: major determinant of prognosis. FACTORS TO CONSIDER for TREATMENT Subtypes of encopresis Retentive (most common) Nonretentive Volitional (least frequent) A thorough history is essential that documents frequency, nature, and circumstances of event First line of treatment for retentive subtype usually includes: Education about bowel functioning with both parents and child Physiological treatment with laxatives or mineral oil Behavioral component with time intervals on toilet and positive reinforcement Treatment  The most widely accepted first line of treatment is one that encompasses educational, psychological, and behavioral approaches  The 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. Behavioral approach  Initial 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 Treatment  There are several methods for clearing the colon and relieving constipation including: i. Stool softeners, such as lactulose ii. Colon lubricants, such as mineral oil iii. Rectal suppositories iv. Enemas v. More oral fluids  Pharmacological treatment with imipramine also has been reported as useful for encopresis.