Elimination disorders

Elimination disorders manifest in childhood or adolescence as repeated voiding of urine (enuresis) or defecation (encopresis) that is inappropriate for the developmental age. Patients may have a history of other psychiatric disorders or of psychosocial stressors. The diagnosis is established based on enuresis occurring 2 times per week for at least 3 consecutive months and encopresis occurring once per month for at least 3 consecutive months. Management of enuresis consists of psychoeducation, behavioral training, and pharmacologic treatment with desmopressin or imipramine. Management of encopresis involves behavioral training and treatment of underlying constipation, if present. Both conditions have a good prognosis with high rates of spontaneous remission.

• Definition: repeated involuntary elimination of urine that is inappropriate for developmental age (e.g., pants- or bed-wetting)
• Epidemiology: affects 5–10% of 5-year-olds; prevalence decreases with age
• Etiology
  • Risk factors: positive family history, psychosocial stressors (e.g., recent move, sexual abuse, conflicts in the family)
  • Associations: other psychiatric disorders, e.g., ADHD, conduct disorders, autism
• Diagnostic criteria
  • Occurs 2x/week for ≥ 3 months or causes clinical distress
  • Patient's developmental age must be ≥ 5 years
  • Symptoms not caused by a medication or another medical condition
• Types
  • Nocturnal (♂ > ♀) or diurnal (♀ > ♂)
  • Primary (patient never achieved continence) or secondary (onset of symptoms after patient had achieved continence)
• Treatment
  • Treatment not typically recommended in children under 5 years of age
  • In children, treatment may become indicated as soon as enuresis causes distress or impairs social function
  • Organic causes (e.g., urinary tract infections, urinary tract abnormalities, renal disorders) must be excluded before any treatment is started.
  • First-line
    • Fluid restriction at night
    • Behavioral training
    • Timed voiding
    • Parent management training (focused on positive reinforcement of a proper voiding)
    • Psychoeducation
  • Second-line
    • Desmopressin
    • Alternatively: imipramine (more side effects than desmopressin)
    • Behavioral training with an enuresis alarm
      • A device equipped with a moisture sensor that is placed inside the child's underwear.
      • It will buzz or ring when urination begins, alarming the child or parent.
      • This alarm gives the child a chance to go to the toilet and complete urination.

Treatment of enuresis is not indicated before 5 years of age. Most cases resolve spontaneously.

• Definition: repeated involuntary or intentional elimination of feces inappropriate for developmental age (e.g., into clothes or on the floor)
• Epidemiology
  • More common in boys
  • Approx. 1% of 5-year-olds affected
• Etiology
  • Retentive encopresis: due to underlying constipation or stool impaction that then leads to overflow incontinence (approx. 80% of cases)
  • Nonretentive encopresis: no organic cause (approx 20% of cases)
  • Risk factors: psychosocial stressors (potty training, transition to solid food, starting school), positive family history
  • Associations: other psychiatric disorders, e.g., ADHD, conduct disorders, autism
• Diagnostic criteria
  • Occurs ≥ 1/month for ≥ 3 months
  • Patient's developmental age must be ≥ 4 years.
  • Symptoms not caused by a medication or another medical condition
• Treatment
  • If encopresis is due to constipation, treat the underlying constipation with fecal disimpaction, stool softeners, and dietary changes (see “Treatment” in the article “Constipation.”).
  • Behavioral training with operant conditioning (e.g., rewarded scheduled toilet visits) biofeedback sessions

References:^[1]