Constipation and Enuresis

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Constipation and Enuresis

• Katie Mallam
• Paediatric Update for Primary care
• 9th October 2012

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Constipation Why?

• Common
• Prevalence 5-30
• 1/3 become chronic (gt8 weeks) soiling
• Debilitating
• Social, psychological and educational
  consequences
• Cost
• Longer duration longer, more intensive
  treatment
• Varying advice angry parents

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Constipation NICE

• Standardise approach
• Early treatment
• Reduce consequences and cost
• No need to remember history and examination
  http//guidance.nice.org.uk/CG99/Questionnaire

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Constipation?
2 of ..

Breast fed babies can go up to a week without
opening bowels

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Constipation?
http//www.childhoodconstipation.com/Extra/Documen
ts.aspx
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Constipation?
2 of ..

Breast fed babies can go up to a week without
opening bowels

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Constipation Causes

• Mostly idiopathic
• Rarely
• Hirschsprungs
• Neurological NB lumbosacral abnormalities
• Anorectal malformations
• Hypothyroid
• Coeliac
• Cystic fibrosis (but normally diarrhoea due to
  fat malabsorption)
• Cows milk protein intolerance
• Associations
• Cerebral palsy
• Autism
• Downs syndrome (NB beware hypothyroidism and
  Hirschsprungs)

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Constipation History 1
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Constipation History 2
Faltering growth treat and do coeliac and TFT
(refer)
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Constipation Examination
No PR in primary care NB perianal strep
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Perianal streptococcal infection
Swab Treat infection and constipation
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Constipation Examination
No PR in primary care NB perianal strep
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Constipation Its NICE

• No need to remember history and examination
  http//guidance.nice.org.uk/CG99/Questionnaire

lt 1 year
1 year
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Constipation Actions

• Red (or amber) flags
• Refer paeds
• No red flags
• Reassure
• Explain constipation and treatment (could just do
  briefly and give patient information using
  resources in Explain 2 slide)
• Treat

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Constipation Explain 1

• Rectum gets used to being full normal reflexes
  and power are reduced baggy.
• Reduced sensation and overflow soiling is not
  intentional
• Need to get empty and stay empty for rectum to
  shrink back and recover reflexes and sensation
  takes time

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Constipation Explain 2

• Tameside comprehensive leaflet
• Patient.co.uk very good, can print pdf leaflet
• ERIC lots of info for professionals and
  parents/patients (age banded)
  http//www.eric.org.uk/
• NICE template letter

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Constipation Treat

• Get empty, stay empty!
• Faecal impaction?
• Soiling
• Abdominal mass
• Movicol, movicol, movicol!
• NB different strengths e.g. Paed Plain no taste
• Softeners
• Movicol, Lactulose, Docusate (also squeezes)
• Squeezers
• Senna, sodium picosulphate, bisacodyl
• Doses as per BNFc or NICE

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Constipation Get empty

• Disimpaction
• Aiming for liquid and no more lumps messy
• Review after 1 week
• Movicol
• If not tolerated stimulant laxative /-
  lactulose
• If not worked after 2 weeks add stimulant
  laxative and urgently refer to Paeds
• Enemas and manual evacuation only if all else
  failed

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Constipation Stay empty 1

• Maintenance
• Until rectum no longer stretched and reflexes
  return
• Laxatives do not make bowel lazy may need for
  several years and should be gradually reduced
• Movicol
• If not tolerated stimulant /- lactulose, or
  docusate alone
• If not effective add stimulant

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Constipation Stay empty 2

• Behavioural
• Non-punitive (I say training the subconscious)
• Regular toileting after meals
• Foot support, sit forward (rock and pop!),
  bubbles, books
• Diary and rewards (things under their control)
• NB school (NB ERIC info)
• Use school nurses and HV

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Constipation Stay empty 3

• Fluids

Page 15, NICE Quick Reference Guide
http//www.nice.org.uk/nicemedia/live/12993/48754/
48754.pdf
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Constipation Stay empty 4

• Diet
• High Fibre fruit, veg, high fibre bread,
  wholegrain breakfast cereals, baked beans
• Activity

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Constipation Failed treatment

• Disimpaction has failed if not responded to
  Movicol after 2 weeks
• Urgent referral to Paeds (or Bladder and Bowel
  Specialist Nurse)
• Maintenance has failed
• In those aged lt1 year, if not responded after 4
  weeks
• Refer paeds
• In those aged 1 year, if not responded after 3
  months
• Check no red flags
• If red flags refer paeds
• No red flags refer to the Bladder and Bowel
  Specialist Nurse Service

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Constipation Toolkit

• RED FLAGS, refer paeds
• History and examination questionnaires
  http//guidance.nice.org.uk/CG99/Questionnaire
• Bristol Stool Chart
• EXPLAIN Tameside leaflet
• IMPACTED? GET EMPTY, STAY EMPTY!
• Medical usually Movicol Paed Plain as per BNFc
• Non Medical see Tameside leaflet and fluid rqmts
  on page 15 of NICE http//www.nice.org.uk/nicemedi
  a/live/12993/48754/48754.pdf
• If fails, add stimulant
• Disimpaction failure, refer paeds
• Maintenance failure, refer Bladder and Bowel
  Specialist Nurse

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Enuresis - definitions

• Incontinence
• uncontrollable leakage of urine
• Enuresis
• Incontinence of urine when sleeping usually say
  Nocturnal
• Bedwetting involuntary wetting during sleep
  without any inherent suggestion of frequency of
  bedwetting or pathophysiology (NICE)
• Primary
• Secondary previously dry for 6 months

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Urinary Incontinence History 1

• Secondary (especially recent)
• UTI
• Diabetes (drinking overnight)
• Constipation
• Neurological spine and lower limb exam
• Emotional/behavioural difficulties consider
  psychology

Urine dipstick NB same day referral if suspect
diabetes
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Urinary Incontinence History 2

• Pattern of bedwetting
• Variable volume, gt1 per night could be
  Overactive Bladder
• Daytime symptoms
• Urgency, Frequency gt7/day, Infrequent lt4/day,
  straining, pain
• Consider UTI, Overactive Bladder, Neuro/Uro cause
• Urine dipstick
• If significant, refer to consider
  investigation/treatment of those symptoms first
• Toileting patterns
• NB School
• Fluid intake
• Check not restricting

Diary
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Urinary Incontinence History 3

• Effect on child/YP/family
• Social (sleep-over), self-esteem
• PMHx
• UTI
• Developmental, attention or learning
  difficulties consider specific management

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Urinary Incontinence Examination

• Primary Nocturnal not required according to NICE
• Secondary Nocturnal or Daytime Symptoms
• Genitalia
• Abdomen
• Spine
• Lower limb neuro

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Urinary Incontinence Referral

• RED FLAGS recurrent UTI, Diabetes, examination
  abnormalities
• refer paeds
• No red flags
• Nocturnal only
• refer HV or school nurse
• Day only, or Nocturnal with daytime symptoms
• refer to Bladder and Bowel Specialist Nurse

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Enuresis NICE

• Principles of Care
• Not their fault non-punitive management
• Tailor management to child/YP and parent/carer
• Consider parental support
• Do not exclude lt7y
• Reassure

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Enuresis

• Prevalence

Age lt 2 per week 2 per week
4.5y 21 8
9.5y 8 1.5
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Enuresis NICE

• Principles of Care
• Not their fault non-punitive management
• Tailor management to child/YP and parent/carer
• Consider parental support
• Do not exclude lt7y
• Reassure
• Trial of BASICS
• lt5y encourage toilet training if not done
  already and trial out of nappies at night

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Enuresis Management BASICS!

• Fluids avoid caffeinated (and ?fizzy and
  blackcurrant)
• Regular toileting 4-7/day
• NB double voiding if Overactive Bladder symptoms
• Trial out of nappies/pull-ups offer alternatives
• Reward system for agreed behaviour (not dryness)

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Enuresis Information

• NHS choices concise, for parents
  http//www.nhs.uk/Conditions/Bedwetting/Pages/Intr
  oduction.aspx
• Patient.co.uk concise, for parents
  http//www.patient.co.uk/health/Bedwetting.htm
• ERIC all ages, parents, professionals
  http//www.eric.org.uk/

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Enuresis Alarm

• High long-term success rate (weeks)
• But need commitment and can disrupt sleep
• Contraindications
• lt 1-2 wet nights/week
• Parental distress or negativity (consider
  parental support)
• Need training
• Hence referral to HV/school nurse
• http//www.patient.co.uk/health/Bedwetting-Alarms.
  htm
• Encourage to combine with reward system
• Get up and go to toilet, help change sheets

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Enuresis Desmopressin

• Rapid, short-term results (sleep-over)
• Alarm is inappropriate or undesirable
• Inform them
• many relapse when treatment is withdrawn
• how desmopressin works
• fluid restriction from 1 hour before until 8
  hours after taking desmopressin
• that it should be taken at bedtime
• how to increase the dose if the response to the
  starting dose is not adequate
• that treatment should be continued for 3 months
• that repeated courses can be used
• Stop during sickle cell crises or DV

http//www.medicinesforchildren.org.uk/search-for-
a-leaflet/desmopressin-for-bedwetting/
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Enuresis Other treatments

• Only on advice of specialist
• Anticholinergic with desmopressin
• Oxybutinin
• If
• Not responded to desmo/-alarm
• Daytime symptoms
• Imipramine
• Gradual increase and withdrawal
• Warn re dangers of OD
• http//www.medicinesforchildren.org.uk/search-for-
  a-leaflet/

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Urinary Incontinence Top tips

• Secondary think other causes esp Diabetes
• Examine if Secondary or Daytime
• Refer all?
• Red flags paeds
• Others HV/school nurse/BBSN
• Basics
• Give/direct to information