An Innovative Program for Children with Dysfunctional Elimination Kimberly S. Jarczyk, M.S.N., C.P.N.P. Pediatric Continence Program Nemours Children s Clinic Jacksonville, Florida Disclosure Information Speaker: Kimberly Jarczyk I have nothing to disclose. Accreditation Statement APSNA is an approved provider of continuing nursing education by NAPNAP. The NAPNAP contact hours is accepted by ANCC. Purpose Statement The purpose of this presentation is to: conceptually reframe our approach to the care of children with incontinence and dysfunctional elimination present innovative testing and treatment options to enhance outcomes for this population 1
Objectives Upon completion of this presentation, participants will be able to: 1. Recognize the complex interplay of bowel, bladder, pelvic floor, central nervous system, developmental and psychosocial factors that contribute to incontinence and dysfunctional elimination in children 2. Identify new technologies that may assist in the evaluation of children with fecal incontinence due to structural and neurogenic etiologies 3. Identify appropriate utilization of animated pelvic floor biofeedback in the treatment of fecal and urinary incontinence Incontinence is a Problem Incontinence past the expected time of toilet training can have devastating consequences Managing incontinence can be challenging Current Evidence Existing research supports numerous interrelated associations between dysfunctional voiding and defecation dynamics within a psychosocial network Disruption in any one of these systems can create dysfunctional patterns in all of them It is important to address these issues comprehensively to obtain good outcomes 2
Linkages Between Bowel and Bladder Function 30% of children with constipation have lower urinary tract symptoms * Dysfunctional elimination is associated with delayed resolution and post-operative recurrence of VUR ** *Belman, 1998, Dohil, Roberts, Verrier, Jones & Jenkins, 1994; Loening-Baucke, 1997; Neuman, DeDomenico, & Nogrady, 1973; O Regan, Yazbeck, Hamburger, & Schick, 1986 ** Chen, Mao, Homayoon, & Steinhardt, 2004; Halachmi & Farhat, 2008; Koff, 1992; Koff, Wagner, & Jayanthi, 1998 Bladder Ultrasound Demonstrating the Impact of Rectum Full of Stool on the Bladder Interrelationships Between Bowel, Bladder, & Pelvic Floor Function Pelvic floor dynamics are often a key contributor to dysfunctional elimination * Rectal distention is associated with abnormal urodynamic parameters ** Children with severe constipation and bladder dysfunction have abnormal colonic motility and urodynamics *** * Shafik, 1984 ** Burgers, Liem, Canon, Mousa, Benninga, Di Lorenzo, & Koff, 2010 *** Lucanto, Bauer, Hymen, Flores, & DiLorenza, 2000 3
Central Nervous System Associations Shared embryonic origins and spinal cord innervation Disruption in spinal cord at any level has the potential to significantly impact bowel and bladder function Neuromuscular disorders impact elimination dynamics Functional enuresis and encopresis associated with a higher rate of abnormal electroencephalography Neuroplasticity has relevance in dysfunctional elimination Trabeculated Bladder with VUR Psychological Associations Increased rate of psychiatric co-morbidities in children with dysfunctional elimination Common co-morbid conditions include: ADD/ADHD Anxiety ODD OCD 4
Nurse-Run Subspecialty Referral Program Our model was developed with the express purpose of integrating services to allow for comprehensive assessment and treatment Diagnostics include: Sitz Marker Study to evaluate colonic transit time EMG Uroflow Urodymanics High resolution anorectal manometry including 3D assessment Innovative treatment includes animated pelvic floor biofeedback Sitz Marker Study Delayed Transit High Resolution Manometry Catheters 5
Given Imaging High Resolution Manometry - RAIR Given Imaging High Resolution Anorectal Manometry - Anismus 3D Anorectal Manometry 6
American Pediatric Surgical Nurses Association 23rd Annual Scientific Conference May 26-29, 2014 Phoenix, AZ Biofeedback Animated Pelvic Floor Biofeedback Video Games 7
American Pediatric Surgical Nurses Association 23rd Annual Scientific Conference May 26-29, 2014 Phoenix, AZ Video Games Title Video Games Title Video Games Title 8
Evidence Supporting Pelvic Floor Biofeedback Effectiveness Systematic review demonstrated a pooled estimate of 80% effectiveness in children with dysfunctional elimination * Animated pelvic floor biofeedback yielded similar results to non-animated method but in a significantly shorter time ** *Desantis, D. J., Leonard, M. P., Preston, M. A., Barrowman, N. J., & Guerra, L. A. (2011). **Kaye, J. D., & Palmer, L. S. (2008). Continence Clinic 9