10/6/2016 PEDIATRIC ELIMINATION DISORDERS

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DISCLOSURES Objectives: 1. Define elimination disorders 2.

1 PEDIATRIC ELIMINATION DISORDERS SOPHIA L. THOMAS MN, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP I HAVE NO KNOWN CONFLICTS OR DISCLOSURES Objectives: 1. Define elimination disorders 2. Discuss diagnostic criteria for enuresis and encopresis 3. Differentiate classifications of these disorders 4. Discuss treatments for these disorders 1

1 NORMAL DEVELOPMENT Toddler Phase (18 months- 3 years) Bowel Continence Bladder Continence TOILET TRAINING 101 Readiness for Toilet Training Major milestone in physical and

2 ELIMINATION DISORDERS Elimination disorders are disorders that concern the elimination of feces or urine from the body. The American Psychiatric Association recognizes two elimination disorders: Enuresis F98.0 Encopresis F98.1 NORMAL DEVELOPMENT Toddler Phase (18 months- 3 years) Bowel Continence Bladder Continence TOILET TRAINING 101 Readiness for Toilet Training Major milestone in physical and social development that is often achieved during the day by 36 months although accidents may continue through 5 years Readiness Criteria Bladder control (should empty completely and stay dry) Physical readiness (fine- and gross-motor coordination) Instructional readiness (ability to follow directions) 2

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2-10% of children affected Nocturnal enuresis is more commonly known as bedwetting ENURESIS CLASSIFICATIONS Nocturnal Enuresis Monosymptomatic Polysymptomatic Diurnal

4 Enuresis (urinary incontinence) is the persistent inability to control urination that is not consistent with one s development age. Enuresis is derived from the Greek word enourein, which means to void urine. 2-10% of children affected Nocturnal enuresis is more commonly known as bedwetting ENURESIS CLASSIFICATIONS Nocturnal Enuresis Monosymptomatic Polysymptomatic Diurnal Enuresis Primary Enuresis Secondary Enuresis Regressive Enuresis TYPES OF ENURESIS Monosymptomatic Nocturnal Enuresis Polysymptomatic Nocturnal Enuresis Functional Enuresis Nonfunctional Enuresis Revenge Enuresis Enuresis due to lack of training Detrusor Dependent Enuresis Volume-Dependent Enuresis 4

boys/4% girls age12 years meet criteria for nocturnal enuresis 1% of 18 year olds still have enuretic symptoms Resolution of 15% per year 30% of children with ADHD ENURESIS Health and Psychological

5 PREVALENCE 30% of US children achieve continence by age 2 More common in males. Age 7: 9% boys and 6% girls Mortality: only due to fatal abuse At age 4, 25% of kids wet the bed; 5-10% of 7 year olds 15% of enuretic children have spontaneous resolution of symptoms each year 8% of boys/4% girls age12 years meet criteria for nocturnal enuresis 1% of 18 year olds still have enuretic symptoms Resolution of 15% per year 30% of children with ADHD ENURESIS Health and Psychological Consequences Could be marker for medical conditions such as urinary tract infections Psychosocial consequences result from shaming, blaming and characterological attributions that are directed to incontinent children in addition to increased risk of child abuse secondary to incontinence Evidence-based Assessment No widely used tools Most research using instruments that incorporate items into larger constellation of items on psychosocial issues Dysfunctional Voiding Scoring System assesses enuresis and other co-morbid voiding and/or elimination symptoms Domains of interest include wet or dry days or nights and size of urine spot 5

ENURESIS DIAGNOSTIC CRITERIA DSM-5 Diagnostic Criteria for Enuresis F98.0 A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional). B.

in social, academic (occupational), or other important areas of functioning. C. Chronological age is at least 5 years (or equivalent developmental level). D.

6 ENURESIS DIAGNOSTIC CRITERIA DSM-5 Diagnostic Criteria for Enuresis F98.0 A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional). B. The behavior is clinically significant as manifested by either 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 (or equivalent developmental level). D. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition ( e.g., diabetes, spina bifida, a seizure disorder). Specify type: Nocturnal Only Diurnal Only Nocturnal and Diurnal 6

DIFFERENTIAL DIAGNOSIS Maturational Anatomical Abnormalities Endocrine Urinary Tract Disease Neurological Medications Psychological

Developmental History Hydration and nutrition history Daytime voiding pattern Toilet training history Sleep history Behavior,

7 DIFFERENTIAL DIAGNOSIS Maturational Anatomical Abnormalities Endocrine Urinary Tract Disease Neurological Medications Psychological DIAGNOSTIC WORKUP Child s Age Onset of Symptoms (Primary/Secondary) Timing (Nocturnal/Diurnal/Both) Frequency Family History Developmental History Hydration and nutrition history Daytime voiding pattern Toilet training history Sleep history Behavior, personality, and emotional status PHYSICAL EXAM Neurological Exam Throat and Neck Exam Skin Exam Abdominal Exam CMP (but blood tests usually not necessary) UA 7

COMMON UNDERLYING PROBLEMS Overactive bladder or dysfunctional voiding Cystitis or UTI Constipation Neurogenic bladder Sleep-disordered breathing Urethral obstruction Major motor seizure Ectopic

8 COMMON UNDERLYING PROBLEMS Overactive bladder or dysfunctional voiding Cystitis or UTI Constipation Neurogenic bladder Sleep-disordered breathing Urethral obstruction Major motor seizure Ectopic ureter Diabetes mellitus or insipidus CONSULTS Pediatric Urology Ultrasound of Genitourinary system Voiding Cystourethrogram Renal Ultrasound Pediatric Neurology Sleep Study TREATMENT Education Watchful Waiting Non-pharmacological Management Pharmacological Management Therapeutic Interventions 8

9 NON-PHARMACOLOGICAL INTERVENTIONS Education Behavioral Modification Bell and Pad NON-PHARMACOLOGICAL INTERVENTIONS Bladder-Volume Alarm Star Chart System Nightlifting Timed Night Awakening Bladder Training Exercises/Overlearning ENURESIS Evidence-based Interventions Bell-and-Pad or Urine-Alarm Training treatment success is higher and relapse rate lower than any other method, especially when combined with Desmopressin 9

ENURESIS Medications Desmopressin Acetate

INTERVENTIONS Desmopressin Oxybutynin Imipramine

PATHYPHYSIOLOGY, CLASSIFICATION, & TREATMENT

10 ENURESIS Medications Desmopressin Acetate Oxybutynin Chloride Imipramine Other Treatment Approaches Hypnosis Sphincter exercises Restriction of fluids before bed PHARMACOLOGICAL INTERVENTIONS Desmopressin Oxybutynin Imipramine TCAs, SSRIs & Psychostimulants NSAIDs PATHYPHYSIOLOGY, CLASSIFICATION, & TREATMENT STRATEGIES Wright, A. (2016) Childhood enuresis. Paediatrics and Child Health, 26( 8)

11 DESMOPRESSIN (DDAVP) For polyuria A synthetic analogue of ADH Increases water uptake of the renal distal tubules === diminishes urine production Must restrict fluids 1 hr before and 8 hrs after administration (risk of hyponatremia) May use in conjunction with the alarm 1/3 of children don t respond most have small nocturnal bladder capacity Dose age 6 and older: tablets 0.2mg q hs, max 0.6mg *nose spray no longer indicated for primary enuresis due to hyponatremia risk Not all children will respond; not all kids with enuresis have low ADH or overproduce urine PATHYPHYSIOLOGY, CLASSIFICATION, & TREATMENT STRATEGIES Wright, A. (2016) Childhood enuresis. Paediatrics and Child Health, 26( 8) OXYBUTYNIN Anticholinergic Beneficial for children who have small bladder capacity, daytime symptoms of frequency and urgency, or those who wet more than once at night Does not decrease urine production For detrusor overactivity: Relaxes bladder smooth muscle: Allows the bladder to hold more urine Start in ages over 5 years old 5mg BID Maximum dose is a total of 15 mg per day Onset 1 hr, t1/2 2 3 hrs Extended release for children older than 6 at 5mg po daily Maximum is 20 mg po daily (increase by 5mg weekly) 11

IMIPRAMINE (TOFRANIL) Tricyclic antidepressant Facilitates urine storage by decreasing bladder contractility and increasing outlet resistance Inhibits reuptake of norepinephrine and seratonin at the

12 IMIPRAMINE (TOFRANIL) Tricyclic antidepressant Facilitates urine storage by decreasing bladder contractility and increasing outlet resistance Inhibits reuptake of norepinephrine and seratonin at the presynaptic neuron First prescribed for enuresis when psych causes of enuresis were considered common Dose 1 hr before bed: 6-12 years mg qhs, max 50 mg 12+ years mg qhs, max 75 mg Dose earlier in early night wetters Black box warning suicide risk, worsening MDD Caution in cardiovascular disease, possibility of arrhythmias Baseline EKG TREATMENT ALGORHYTHM FOR NOCTURNAL ENURESIS 12

ADDITIONAL TREATMENTS Cognitive Behavioral Therapy Psychodynamic Psychotherapy Biofeedback Acupuncture Encopresis is a repeated passage of feces into inappropriate places, such

13 ADDITIONAL TREATMENTS Cognitive Behavioral Therapy Psychodynamic Psychotherapy Biofeedback Acupuncture Encopresis is a repeated passage of feces into inappropriate places, such as on clothing or the floor. Usually involuntary in nature, often related to constipation, impaction and retention with a resultant overflow May be intentional in some cases 13

ENCOPRESIS Primary Encopresis Secondary Encopresis Retentive Encopresis Nonretentive encopresis ENCOPRESIS PREVALENCE Secondary encopresis is more common Between ages 7-8 prevalence is 1.

water intake; Presence of chaos or unpredictability in the patient s life; Lack of physical exercise; Refusal to use the bathroom, especially public restrooms; Presence of a neurological

14 ENCOPRESIS Primary Encopresis Secondary Encopresis Retentive Encopresis Nonretentive encopresis ENCOPRESIS PREVALENCE Secondary encopresis is more common Between ages 7-8 prevalence is 1.5% 3:1 male to female ratio Retentive type is 80-95% of cases 25% of encopretic kids have enuresis ENCOPRESIS RISK FACTORS Abuse or neglect; Diet that is rich in fat and/or sugar; Inadequate water intake; Presence of chaos or unpredictability in the patient s life; Lack of physical exercise; Refusal to use the bathroom, especially public restrooms; Presence of a neurological impairment; History of constipation or painful defecation; Cognitive delays, such as autism or mental retardation; Presence of obsessive/compulsive disorders; ADHD or difficulty focusing; Learning disabilities 14

Delay in Maturation ENCOPRESIS ETIOLOGY Underlying Medical Condition Psychological/Behavioral Constipation ENCOPRESIS Etiology Biological Variables Genetics Developmental Delay?

s disease Emotional Variables Early theories assumed psychodynamic etiology

15 Delay in Maturation ENCOPRESIS ETIOLOGY Underlying Medical Condition Psychological/Behavioral Constipation ENCOPRESIS Etiology Biological Variables Genetics Developmental Delay? Hirschsprung s disease Emotional Variables Early theories assumed psychodynamic etiology (e.g., unconsious conflict, personality profiles) Etiology (Cont) Learning Variables Most useful view considers types Manipulative Stress-induced Constipation (80-95% of cases) Manipulative soiling follows reinforcement model Chronic diarrhea and loose bowels Chronic Constipation Diet Toilet habits/withholding School bathroom conditions ENCOPRESIS DSM-V Diagnostic Criteria for Encopresis A. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional. B. At least 1 event a month for at least 3 months. C. Chronological age is at least 4 years (or equivalent developmental level). D. The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation. 15

DIAGNOSTIC CRITERIA The DSM-IV recognizes 2 subtypes: 1. constipation and overflow incontinence Feces poorly formed, leakage continuous, occurs sleeping and waking hours 2.

16 DIAGNOSTIC CRITERIA The DSM-IV recognizes 2 subtypes: 1. constipation and overflow incontinence Feces poorly formed, leakage continuous, occurs sleeping and waking hours 2. without constipation and overflow incontinence the feces are usually well-formed, soiling is intermittent, and feces are usually deposited in a prominent location. This form may be associated with oppositional defiant disorder or conduct disorder, or may be the consequence of large anal insertions, or more likely due to chronic encopresis that has radically desensitized the colon and anus ENCOPRESIS SYMPTOMS Occasional passage of very large stools; Secretive behavior associated with the act of having a bowel movement; Inability to retain feces (bowel incontinence); The passage of stool in inappropriate places (for example in the child s clothing); Constipation and/or hard stools 16

17 PRIMARY RETENTIVE ENCOPRESIS Delayed Physical Maturation Inappropriate Toilet Training 17

Represents 80-95% of cases RETENTIVE ENCOPRESIS Infrequent Bowel Movements Large Stools Painful Defecation SECONDARY ENCOPRESIS Birth of sibling Parental Divorce Abuse ODD or CD MR/Autism/

18 Represents 80-95% of cases RETENTIVE ENCOPRESIS Infrequent Bowel Movements Large Stools Painful Defecation SECONDARY ENCOPRESIS Birth of sibling Parental Divorce Abuse ODD or CD MR/Autism/ Psychosis/RAD ENCOPRESIS Health and Psychological Consequences Most serious/common involves urinary tract infections from contamination of urinary tract with feces from child s underwear Most serious social consequence is teasing and ridicule from peers, classmates, friends, and siblings Evidence-based Assessment One of the available general parent and teacher rating scales (BASC, CBCL, Connors CBRS) to identify comorbidities such as ODD and ADHD which may interfere with parent s ability to implement treatment recommendations 18

pain/distention Height/Weight Neurological Exam Skin Exam Rectal Exam Abdominal XRAY Stool Collection Blood

19 DIAGNOSIS Child s age Onset (primary/secondary) Timing (day/night) Frequency Location of soiling Bowel Habits (frequency, stool size, consistency) Melena/Hematochezia Pain with Defecation/Fluid and Dietary Habits Abdominal pain/distention Height/Weight Neurological Exam Skin Exam Rectal Exam Abdominal XRAY Stool Collection Blood Testing Rectal Biopsy/Barium Enema PHYSICAL EXAM Advice/Education TREATMENT Nonpharmacological Pharmacological Intervention 19

20 Dietary Changes (foods high in fiber) EDUCATION Increase Fluid Intake Make Toilet Training Non-Threatening Make Toilet Accessible Regular Bathroom Times 20

ENCOPRESIS Other Treatment Approaches Biofeedback no better than Medical-Behavioral For Manipulative Soiling Behavioral and family therapy Coping and communication skills emphasized

effective coping skills Systematic desensitization and hypnosis Relaxation training, stress inoculation training, assertiveness training, general stress management Supportive

21 ENCOPRESIS Other Treatment Approaches Biofeedback no better than Medical-Behavioral For Manipulative Soiling Behavioral and family therapy Coping and communication skills emphasized Reward appropriate behaviors and do not reinforce soiling behavior Other Treatment Approaches (Cont) For Chronic Diarrhea or Irritable Bowel Syndrome Stress reduction and learning effective coping skills Systematic desensitization and hypnosis Relaxation training, stress inoculation training, assertiveness training, general stress management Supportive psychotherapy and antidiarrheal medications NONPHARMACOLOGICAL CBT Psychodynamic Psychotherapy Biofeedback Acupuncture PHARMACOLOGICAL Laxatives Suppositories Enemas Mineral Oil Stool Softeners Fiber supplements 21

22 MAINTENANCE MEDICATIONS Osmotic laxatives Mechanism of Action: Retain water in stool, which adds bulk and softness, results in distension and promotes peristalsis Lactulose (concentration: 10 g / 15 ml) Lactulose is a synthetic, nonabsorbable disaccharide. Dose: 1 to 3 ml/kg/day divided doses BID Tastes sweet Abdominal cramping, flatus Sorbitol: 1 to 3 ml per kg per day given in divided doses twice daily Less costly than lactulose MAINTENANCE MEDICATIONS Magnesium hydroxide (MOM, Pedia-Lax) Magnesium is a divalent cationmaximally absorbed at distal small intestine Dose: 1 to 3 ml/kg/day divided doses BID for > 2 years old Thick, chalky. May mix with milk/choc milk May cause cramping (increased Mag levels stimulate GI motility and secretion) With OD/renal insufficiency: risk of hypermagnesemia, hypophosphatemia, or secondary hypocalcemia Polyethylene glycol powder (Miralax) Long chain of ethylene glycol, poorly absorbed Dose: 17 g /240 ml water/juice // 6 months and older: g/kg/day for no more than 2 weeks Titrate dosage at three-day intervals to achieve mushy stool consistency. Benefits: Solution may be prepared in advance for administration over one to two days. Better adherance, tasteless and odorless, dissolve in all liquids MAINTENANCE MEDICATIONS Mineral Oil Suspension: Lubricant Nonabsorbable fat Softens stool, decreases water absorption from GI tract, and eases passage Dose: age ml/day, > ml/day tasteless, chill or give with juice Don t use > 1 week Adherence problems: Leakage may occur if dose is too high or impaction is present. 22

23 THANK YOU! 23

15. Prevention of UTI and lifestyle modifications

15. Prevention of UTI and lifestyle modifications Key questions: Does improving poor voiding habits help prevent UTI recurrence? Does improving constipation help prevent UTI recurrence? Does increasing