Eliminative Disorders: Enuresis and Encopresis

1
Eliminative Disorders Enuresis and Encopresis

• James H. Johnson, Ph.D.
• University of Florida
• Click for Normal Toilet Training Guidelines

2
Enuresis

• Children are considered as enuretic if they
• fail to develop control over urination by an age
  at which it is usually acquired by most children
  or
• if they revert to wetting the bed or clothing
  after initially (for at least 6 months)
  developing control over micturition.
• Daytime control is typically accomplished by the
  age of 3 or 4.
• Nighttime control is typically present by four of
  five years.

3
Some Statistics on Enuresis

• An estimated 5 million to 7 million children in
  the United States have primary nocturnal enuresis
  (wetting at night).
• Fifteen to 20 percent of children will have some
  degree of nighttime wetting at five years of age.
• By age 15 only 1 to 2 percent will still wet the
  bed.
• Boys wet the bed more frequently than do girls.
• About 80 percent of children with enuresis wet
  the bed only at night.

4
Enuresis DSM IV Criteria

• Repeated voiding of urine into bed or clothes.
• The behavior is manifested by
• a frequency of twice a week for 3 consecutive
  months
• the frequency can be less given the presence of
  clinically significant distress or impairment in
  social, academic (occupational), or other
  important areas of functioning. 
• Chronological age is at least 5 years. 
• The behavior is not due to the direct effect of a
  substance or a general medical condition.
• Note Approximately 90 of cases of involuntary
  voiding are considered examples of "functional
  enuresis" with no medical problem

5
Enuresis Some Definitions

• The disorder may be of either the primary or
  secondary type.
• Primary enuresis refers to cases where the child
  has never developed control.
• Secondary enuresis refers to instances where the
  child has, at some time, developed control over
  wetting (for at least 6 months) but has
  subsequently resumed wetting.

6
Enuresis Etiology

• Biologically-oriented researchers have emphasized
  the importance of delays in the development of
  cortical control over reflexive voiding.
• The higher incidence of enuresis in children
  whose parents were enuretic has also highlighted
  possible genetic factors.
• In families where both parents have a history of
  enuresis, 77 percent of children will have
  enuresis.
• In families where one parent has had enuresis, 44
  percent of children will be affected
• Only about 15 percent of children will have
  enuresis if neither parent was enuretic.

7
Enuresis Genetics

• Heredity as a causative factor of primary
  nocturnal enuresis has also been strongly
  suggested by the identification of a genetic
  marker associated with the disorder.
• In one study, Danish researchers evaluated 11
  families with primary nocturnal enuresis. The
  trait showed nearly complete penetrance in these
  families.
• This seems to suggest the existence of a major
  dominant gene for primary nocturnal enuresis.
• While this gene appears to be located on
  chromosome 13, no specific locus on this
  chromosome has yet been identified.

8
Depth of Sleep and Enuresis

• It has been suggested that enuretic children are
  deep sleepers and more difficult to arouse than
  non-enuretic children.
• This would make it more difficult for them to
  awaken to cues associated with a full bladder
  while asleep.
• Some investigators studying sleep EEGs have
  reported a higher incidence of increased slow
  brain-wave activity in patients with nocturnal
  enuresis.
• Most other studies have not supported this
  finding and demonstrate no consistent correlation
  between abnormal sleep patterns, or stage of
  sleep and bed-wetting.
• Some have documented more difficulty in waking.

9
Enuresis and Upper Airway Obstruction

• Nocturnal enuresis has, in some cases, also been
  associated with upper airway obstruction in
  children.
• In these instances, surgical relief of the
  obstruction by tonsillectomy, adenoidectomy or
  both has been reported to diminish nocturnal
  enuresis in up to 76 percent of patients who
  display this condition.
• Immaturity in motor and language development has
  also been implicated although the specific
  mechanisms have not been determined.

10
Enuresis and Anatomic Factors

• In cases of primary enuresis, anatomic
  abnormalities are not usually found.
• Findings from some studies, however, have
  suggested that functional bladder capacity may be
  reduced in patients with nocturnal enuresis.
• These findings have been disputed by other
  research which have not found abnormalities in
  bladder function or size when only nocturnal
  enuresis cases were considered.
• While some parents report a small bladder
  capacity in children with enuresis, this
  condition usually is accompanied by daytime
  symptoms.

11
Secretion of Antidiuretic Hormone

• It has been found that humans show both diurnal
  and nocturnal variations in the secretion of
  antidiuretic hormone, when assessed over a
  24-hour period.
• Normal increases in the secretion of antidiuretic
  hormone are typically found in response to
  extended periods of sleep.
• During this period, the bladder does not empty

12
Secretion of Antidiuretic Hormone

• In normal children who sleep between 8 - 12 hours
  per night, the increase in the secretion of
  anti-diuretic hormone reduces the amount of urine
  produced by the kidneys, thus decreasing the
  amount of urine stored by the bladder.
• There is some evidence that children with
  enuresis excrete significantly higher volumes of
  urine during sleep than children without
  enuresis.
• This suggests that abnormal (e.g., lower)
  secretion of antidiuretic hormone at night may be
  a significant contributor to nocturnal enuresis
  in some children.

13
Other Possible Etiological Factors Dynamic and
Behavioral Factors

• Dynamically oriented clinicians have argued that
  enuresis results from underlying psychological
  conflict.
• The available evidence would, however, seem to
  suggest that the majority of enuretic children
  show no signs of significant emotional problems
• When psychological problems are present these may
  often be secondary to the enuresis rather than
  causal.
• Behavioral regression due to stress (divorce,
  abuse, school trauma, hospitalization) does seem
  to be involved in many cases of secondary
  enuresis.
• Neglect can also contribute to primary enuresis.

14
Etiology

• Behaviorally oriented psychologists have
  emphasized faulty learning experiences (perhaps
  compounded by stressful approaches to toilet
  training) in the development of enuresis.
• While behavioral approaches to treatment have
  been shown to be quite effective, behavioral
  causes of enuresis have not been well documented.
• Despite research related to a range of possible
  etiological factors, findings have often been
  conflicting and have failed to provide clear
  information regarding the specific causes of
  enuresis.

15
Treatment of Enuresis

• The most widely used treatment methods involve
  the use of drugs, conditioning approaches, and
  psychodynamic psychotherapy.
• Historically, the drug most commonly used with
  enuretics has been Tofranil (Imipramine) which is
  a tricyclic antidepressant.
• This drug has been shown to be superior to a
  placebo treatment and to show 40 to 60
  effectiveness.
• A major problem, however is that the relapse rate
  is on the order of 50 when the drug is
  discontinued (also concern over side effects).

16
Biological Treatments

• Another drug, desmopressin (DDAVP), which is a
  synthetic antidiuretic hormone - administered in
  the form of a nasal spray or tablet - is being
  increasingly used to treat enuresis.
• In many clinical settings it seems to have become
  the pharmacological treatment of choice.
• While becoming increasingly popular, available
  research suggest effects not unlike Tofranil.
• Compared to controls, up to 60 of children
  treated with this drug show significant
  reductions in bed wetting, although relapse rates
  may be as high as 80 when the medication is
  stopped

17
Biological Treatments (cont.)

• Despite the high probability of relapse, it has
  been suggested that desmopression is fast acting
  and may have fewer side effects than Tofranil.
• It may be a useful treatment for older children
  who do not respond well to other treatments or
  who simply wish to decrease the probability of
  wetting the bed while sleeping away from home for
  the night.

18
Behavioral Treatments
19
Conditioning Treatments

• The most common behavioral treatment is the bell
  and pad approach.
• This method, originally developed by Mowrer and
  Mowrer (l938), involves having the child sleep on
  a urine-sensitive pad, constructed so that when
  the child wets a circuit is completed, which
  activates a buzzer or bell loud enough to awaken
  the child.
• The rationale for this approach is that if the
  bell, which results in the child waking up, can
  be paired over time with the sensations
  associated with a distended bladder, the child
  (due to classical conditioning) will come to
  awaken and inhibit urination in response to these
  sensations.
• http//www.nitetrain-r.com

20
Bell and Pad Treatment

• The bell and pad method has been found to be
  quite effective in dealing with bed wetting, with
  success rates of from 70 to 90 percent being
  reported.
• While relapse rates of anywhere from 20 to 30
  have been found with this procedure, several
  studies suggest that over learning approaches
  that involve continued use of the bell and pad
  (after wetting has ceased) combined with gradual
  increases in fluid intake seem to significantly
  reduce the likelihood of relapse
• http//www.bedwettinghandbook.com/buyersguide/enur
  esisalarms.html

21
Other Behavioral Approaches to Enuresis

• Other behavioral approaches include Retention
  Control Training (Kimmel Kimmel, l970).
• Here, the child is reinforced for inhibiting
  urination for longer and longer periods of time.
• Although there is research suggesting that this
  approach is less effective than the bell and pad
  with bed wetting, it may be useful with daytime
  enuresis (Doleys, 1989).
• Sometimes use in combination with the Bell and
  Pad Case Example.

22
Other Behavioral Approaches

• An additional behavioral approach, developed by
  Azrin, et al (1974), is Dry Bed Training.
• This is an intense training program that includes
  a number of elements
• nighttime awakening,
• positive practice in appropriate toileting (e.g.,
  getting up from bed, going to toilet, pulling
  pants down, setting on toilet for several
  seconds, pulling pants up and returning to bed),
• retention control training (as described above),
• positive reinforcement for appropriate toileting
  behaviors, and cleanliness training (e.g.,
  removing wet sheets, cleaning mattress, making
  bed, showering after accidents, dressing self in
  fresh night clothes, etc.).

23
Other Behavioral Approaches

• These procedures are combined in an intensive
  treatment package, carried out in one evening,
  with maintenance procedures being employed until
  the child has 14 dry nights.
• While there are studies supporting the
  effectiveness of dry-bed training, this approach
  often elicits strong emotional responses on the
  part of the parent and child, with temper
  tantrums and parental upset being common side
  effects.
• This, along with some findings that treatment is
  not successful without the simultaneous use of an
  alarm apparatus, has led some to question whether
  this approach is indeed preferable to the bell
  and pad.
• Modeling A case example

24
Effectiveness of Traditional Psychotherapy

• Some attempts have been made to assess the
  effectiveness of traditional psychotherapy in
  enuresis.
• Here, it can be noted that an early study by
  DeLeon Mandell (l966) compared response to
  treatment in 5 to 14 year-old-children who were
  assigned to a bell and pad group, a psychotherapy
  condition or a no treatment control group.
• Improvement rates of 86.3, 18.2 and 11.1 percent
  were found for these three groups, respectively.
  Such results clearly question the effectiveness
  of psychotherapy in treating most cases of
  enuresis.

25
Encopresis

• Encopresis involves soiling, which occurs past
  the age where control over defecation is
  expected.
• The conditions occurs in somewhere between 1 and
  5 of 5-year-olds.
• Boys are 6 times more likely to have this
  condition than girls.

26
DSM IV Criteria

• Repeated passage of feces into inappropriate
  places, whether involuntary or intentional. 
• At least one event a month for at least 3
  months. 
• Chronological age is at least 4 years. 
• The behavior is not due exclusively to the direct
  physiological effects of a substance or a general
  medical condition except through a mechanism
  involving constipation.
• TWO TYPES
• With Constipation and Overflow Incontinence
• Without Constipation and Overflow Incontinence

27
Forms of Encopresis

• As with enuresis, encopresis can take various
  forms.
• The most common distinctions (in addition to
  those in DSM IV), are
• Between the continuous type (analogous to primary
  enuresis) where the child has never become toilet
  trained, and
• The discontinuous type (analogous to secondary
  enuresis) where the child has initially been
  toilet trained and has subsequently become
  incontinent.

28
Contributors to Encopresis

• First, it must be acknowledged that we do not
  know for sure what the cause of encopresis is.
• Historically, it has been suggested that
  continuous encopresis is associated with a lax
  approach to toilet training.
• The assumption here, is that the overly casual
  approach to toileting may result in the child
  failing to learn appropriate toileting skills as
  well as having little motivation to be trained.

29
Contributors to Encopresis

• The discontinuous type has been seen as more
  likely a result of rigid and stress inducing
  approaches to training.
• It has been suggested that coercive approaches
  may result in the child developing excessive
  anxiety over toileting, fears of the toilet, and
  conflicts with parents over toileting.
• It is noteworthy that such harsh approaches may
  result in a child attempting to withhold feces
  (to avoid punishment), which might lead to
  constipation which often precedes the development
  of encopresis.

30
The Role of Constipation

• Encopresis is a problem that children can develop
  due to chronic constipation.
• With constipation, children have fewer bowel
  movements, and the bowel movements they do have
  are often hard, dry, difficult to pass and
  painful.
• Once a child becomes constipated, he/she may
  avoid using the bathroom to avoid discomfort that
  comes from passing a hard stool or from the pain
  that may result from secondary anal fissures.
• At this point the stool can become impacted in
  the distended colon and unable to be evacuated ?.
  

31
The Role of Impaction

• As the rectum/intestine become enlarged due to
  the impaction (Megacolon), the child may adapt to
  the sensations of fullness in the rectum, and be
  unaware of the need to defecate - due to this
  loss of bowel tone.
• Soiling may occur as the anal sphincter (the
  muscle at the end of the digestive tract) loses
  its strength and feces (usually in liquid form)
  leaks around the impacted stool and is gradually
  expelled without the child's awareness.
• Such factors may contribute to encopresis without
  any other physiological disorder to account for
  soiling .

32
Assessment for Encopresis

• In all cases it is necessary for the child to
  have a thorough physical work up to rule out
  physical factors.
• Assessment for megacolon.
• Assessment for Hirschsprungs disease
• Assessment for other health problems that may
  cause chronic constipation (which often precedes
  the soiling.
• diabetes,
• hypothyroidism,
• inflammatory bowel disease.

33
Encopresis Assessment

• The assessment may involve not only a physical
  examination but also lab tests.
• Abdominal x-rays to evaluate the amount of stool
  in the large intestine
• Barium enemas to test for intestinal obstruction,
  strictures (narrow areas of the intestine), and
  other abnormalities.

34
Treatment of Encopresis

• In the case of children with impaction, the
  initial stage of treatment involves attempts to
  remove the impacted stool. This is usually
  accomplished through the use of enemas,
  prescribed by the physician.
• The physician will likely also prescribe
  medications that are designed to help the childs
  bowel movements remain soft.
• This is to prevent a recurrence of the impaction.
• The physician may also make recommendations
  regarding diet (e.g., fluids, high fiber, low
  dairy) that are aimed at increasing the
  likelihood of large soft stools.
• http//www.keepkidshealthy.com/welcome/conditions/
  encopresis.html

35
Treatment of Encopresis Cont.

• While a variety of treatment approaches have been
  employed with encopresis, behavioral methods
  appear to have the greatest success.
• These approaches have typically been of the
  operant variety where the child is positively
  reinforced for setting on the commode and for
  defecating, for having clean underpants, and
  where mild punishment may be used with soiling.
• Extinction procedures have also been employed,
  whereby there is an attempt to remove the
  reinforcers that typically follow soiling
  episodes.

36
Behavioral Intervention with Encopresis

• Most often a combination of operant procedures
  is employed.
• In some instances these procedures have been
  supplemented by the use of suppositories to
  stimulate bowel movements which can then be
  rewarded.
• Although there are few examples of well
  controlled research in this area, the research
  that is available has provided reasonably strong
  support for a behavioral approach to treatment.
  (Case Example).
• http//www.aafp.org/afp/990415ap/2171.html