HandoutsLeonard Rappaport MD, MS, Professor of Paediatrics, Harvard

What a Pain for Children and Parents - There is Much You Can Do!

ENCOPRESIS - A Model for the Treatment of Childhood Dysfunction

Encopresis - Term coined 1926 (Weissenberg) as fecal equivalent to enuresis

I. Definition

A. Regular soiling of underwear or pajamas

B. Greater than 4 years of age

C. No organic disease

D. Primary and secondary

II. Prevalence

A. Varies in studies from 1.5% -- 10%

B. Male: female ~ 6:1

C. All social classes

III. Common Manifestations - often misinterpreted *

*A. Similar time of day - late afternoon, early evening

*B. No perceived urge to go to bathroom

*C. No realization of body odor

D. Recurrent abdominal pain - usually in recent onset encopresis (50%)

E. Enuresis (25-30%)

F Urinary tract infections in females

G. Quiet children - somewhat withdrawn

H. Often very ingenious

I Soiling tends to happen after school in late afternoon

IV. Differential Diagnosis

A. Any problem that can cause constipation can cause encopresis

B. Hirschprung's disease

C. Child abuse and sexual abuse

VI. TREATMENT

A. Demystification - Education

B.Catharsis - "clean out" - Many regimes - need to see patient afterwards

C.Bowel retraining - toilet sitting, stool softener, close follow-up

VII. OUTCOME

A. 75 - 80% cured or significantly improved with

medical management alone

B. Risk factors for poor outcome

1.) Frequent or exclusive night time accidents

2) Low score on KUB = no stool retention =

different group

3) Hyperactivity and poor attention

4) External locus of control

5) Poor compliance

C. Factors that do not place a child at increased risk for poor outcome:

1) Duration of encopresis

2) Age

3) Sex

4) Outcome at 2 weeks

D. Referral - When?

VIII What’s new?? Toilet School!

 

 

 

 

 

ENURESIS

I. Definition - Urinary incontinence beyond the age of 4 for diurnal enuresis and beyond 6 for nocturnal enuresis or any age after continence has been attained for at least 3 months.

II. Etiology

A. Diseases and structural differences/abnormalities

1. Increased urinary output

a. Diabetes mellitus

b. Diabetes insipidus

c. Excessive water intake

d. Sickle cell anemia

2. Increased bladder irritability, decreased

bladder stability or size.

a. Urinary tract infection

b. Bladder spasm

c. Constipation

3. Abnormal urinary sphincter control

a. Spinal cord abnormalities

b. Sphincter weakness

4. Structural problems

a. Ectopic ureter

b. Vaginal reflux

c. Epispadias

B. Hypothesized causes

1.Genetics - Now real data in several family trees - e.g. 13Q area

2.Bladder capacity (true Vs functional)

3.Central nervous system

a. ADH secretion - less Vs insensitivity to ADH

b. Developmental abnormalities or immaturity

4.Sleep and arousal

5.Stress

III. Work Up

A. History - Complete

1.Pattern of enuresis 2.Attribution 3.Family history

4.Previous and current illnesses 5.Perinatal history 6.Previous interventions 7.Child's understanding and description of problem

B. Full physical exam

1.Neuro exam including DTR's and perineal and perianal sensation

2.Palpation of lower spine

3.Exam of genitalia

C. Laboratory evaluation

1.Urinalysis 2.Culture in females

3.Other exams as specifically directed

IV. Treatment

A. Treat diurnal first

1.Exercises for urgency - bladder spasm 2.Alarms - contingent and noncontingent 3.Medication - perhaps ditropan

B. Nocturnal - Spontaneous cure rate - 15%

1.Motivational interventions (25) 2.Bladder stretching exercises -35%

3.Alarms - 70-80% 4.Imipramine (Tofranil) - 60-70% (60% regress)

5.Desmopressin (DDAVP) - nasal spray or pills - 60-70% (50% regr)

6.Hypnosis - data unclear but 60% success reported

V. Long term follow up - 6 months therapy - 12 months follow up

A. Observation - 6% dry at 6 months, 16% at 12 months

B. Imipramine - 36% dry at 6 months on medication, 16 % at 12 months

C. Desmopressin acetate (DDAVP) - 68% dry at 6 months on medication, 10% at 12 months

D. Alarm therapy - 63% at 6 months, 56% at 12 months

E. Each form of therapy was better than observation alone (p<0.01), only alarm system demonstrated persistent effectiveness (p<0.001)