Elimination

1. Wetting
   1. Definitions
      1. Variations
      2. Problems
      3. Disorders
   2. Key Points
      1. Toilet training
         1. Classification
         2. Epidemiology
         3. Etiology
   3. Clinical Guides
      1. History
      2. Physical Exam
      3. Laboratory
   4. Differential Diagnosis
      1. Primary Enuresis
      2. Secondary Enuresis
   5. Management
      1. Toilet training/Toilet learning
      2. Nocturnal Enuresis
         1. Principles for all wetting treatments
         2. Dryness suggestion technique: First choice intervention
         3. Conditioning alarm: second choice intervention
         4. Pharmacotherapy: Third choice intervention.
         5. Self-hypnosis/Hypnotherapy (See Dryness Suggestion)
         6. Dietary
      3. Diurnal Enuresis
2. Encopresis
   1. Definitions
      1. Variations
      2. Problems
      3. Disorders
   2. Key Points
      1. Toilet Training for Stool
         1. Stool_training
            1. Symptoms
            2. Physical Exam
            3. Encopresis predisposing factors
            4. Prevalence
            5. Etiology
            6. Tests
            7. Psychogenic
            8. Prognosis
   3. Differential Diagnosis
   4. Management
      1. Prevention
      2. Toilet fears
      3. Stool refusal
      4. Encopresis - retentive type
      5. Laxatives
      6. Encopresis - non-retentive type
      7. Outcome Retentive Type
3. Citations
4. Readings for Parents

Comments

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• Toilet training: Learning to use the toilet is a milestone in self-control that affects the social relationship between parent and child. Because parents are often so invested in the results, toilet learning can become a locus of child-parent power struggles and conflict. Toddlers are typically ready to start toilet training by around 24 months, but parents should be encouraged not to push the issue, to avoid resistance and shaming.
  Learning to use the toilet is a milestone in self-control that affects the social relationship between parent and child. Because parents are often so invested in the results, toilet learning can become a locus of child-parent power struggles and conflict. Toddlers are typically ready to start toilet training by around 24 months, but parents should be encouraged not to push the issue, to avoid resistance and shaming.
• Nocturnal: only while sleeping (including naps); usually monosymptomatic
  only while sleeping (including naps); usually monosymptomatic
• Dirunal: while sleeping and awake: May have associated frequency, urgency, dysuria, hesitancy, may have low bladder capacity
  while sleeping and awake: May have associated frequency, urgency, dysuria, hesitancy, may have low bladder capacity
• Primary: never been dry before
  never been dry before
• Secondary: after 6 months of consecutive dryness (more likely to have psychological or organic cause)
  after 6 months of consecutive dryness (more likely to have psychological or organic cause)
• Genetic: bdominant gene (Chromosome 13) with variable penetrance
  bdominant gene (Chromosome 13) with variable penetrance
• Increased in lower SES, stress, institutionalized (esp. secondary): because chaotic social situations--poor voiding habits--problems with daytime control
  because chaotic social situations--poor voiding habits--problems with daytime control
• Occurs in different sleep stages randomly, no EEG differences: since enuresis is outgrown with maturation in sleep patterns that allow the child to recognize a full bladder.
  since enuresis is outgrown with maturation in sleep patterns that allow the child to recognize a full bladder.
• Some lack normal nighttime increase in arginine vasopressin: Seen in some monosymptomatic nocturnal
  Seen in some monosymptomatic nocturnal
• Some have smaller bladder capacity: capacity in ounces= age in years + 2)
  capacity in ounces= age in years + 2)
• Prematurity is risk for diurnal enuresis due to minor neurological damage: Prematurity is one of the most significant risk factors for children with daytime symptoms, also more likely to have comorbid conditions such as ADHD.
  Prematurity is one of the most significant risk factors for children with daytime symptoms, also more likely to have comorbid conditions such as ADHD.
• Constipation can cause enuresis: dilated rectum impinges on bladder making control more difficult.
  dilated rectum impinges on bladder making control more difficult.
• Toilet training can be frustrating and confusing: This is true for both parents and children, not because they lack information, but because of issues or power struggles within the relationship. You can reframe toileting concerns for parents by helping them look for ways to empower their child in other areas, e.g. food, clothing, and play activities. You want to be careful, however, not to simply give advice without finding out how the parents feel about these strategies. Ask such questions as: How do you feel about letting the child be in charge of this process? Are there pressures on you to have him out of diapers? How much power does she have in food, clothing, or sleep choices?
  This is true for both parents and children, not because they lack information, but because of issues or power struggles within the relationship. You can reframe toileting concerns for parents by helping them look for ways to empower their child in other areas, e.g. food, clothing, and play activities. You want to be careful, however, not to simply give advice without finding out how the parents feel about these strategies. Ask such questions as: How do you feel about letting the child be in charge of this process? Are there pressures on you to have him out of diapers? How much power does she have in food, clothing, or sleep choices?
• Strategies for toilet training: Encourage parents to do the following: --wait for signs of readiness to start training, such as signaling before voiding, --deal with accidents with no more than mild disappointment --avoid starting training during periods of major change or high stress, such as the birth of a sibling. When child shows readiness, have him sit on his own special potty in clothes first, then naked after meals. Praise success. Avoid shaming. Keep the potty chair nearby while playing. Have child watch others using the toilet.
  Encourage parents to do the following: --wait for signs of readiness to start training, such as signaling before voiding, --deal with accidents with no more than mild disappointment --avoid starting training during periods of major change or high stress, such as the birth of a sibling. When child shows readiness, have him sit on his own special potty in clothes first, then naked after meals. Praise success. Avoid shaming. Keep the potty chair nearby while playing. Have child watch others using the toilet.
• Toddlers who resist toilet training: Simple techniques can encourage most children over 2 1/2 years who are resisting toileting. Pressure can be removed by returning the child to diapers and offering "big kid"picture underwear as an incentive "when they are ready." Disposable pull off training pants can delay toileting progress. Independent toileting symbolizes growing up and some loss of intimate caregiving. Acknowledging this and helping the parent and child to create alternative intimate moments such as "cuddle time" can allow progress.
  Simple techniques can encourage most children over 2 1/2 years who are resisting toileting. Pressure can be removed by returning the child to diapers and offering "big kid"picture underwear as an incentive "when they are ready." Disposable pull off training pants can delay toileting progress. Independent toileting symbolizes growing up and some loss of intimate caregiving. Acknowledging this and helping the parent and child to create alternative intimate moments such as "cuddle time" can allow progress.
• Fear of the toilet: Educate parents that toileting fears, such as falling into the toilet or losing genitalia, are common at this stage of cognitive development. These fears can result in withholding or toilet refusal. Suggest use of a potty chair or toilet insert or sitting backwards for security. Tell the child that their genitals are "theirs forever. No one took anything away (from girls). No one can take it away (from boys). Girls are made with vagina and boys are made with penises." Suggest exploration of the toilet and its pipes to desensitize fears.
  Educate parents that toileting fears, such as falling into the toilet or losing genitalia, are common at this stage of cognitive development. These fears can result in withholding or toilet refusal. Suggest use of a potty chair or toilet insert or sitting backwards for security. Tell the child that their genitals are "theirs forever. No one took anything away (from girls). No one can take it away (from boys). Girls are made with vagina and boys are made with penises." Suggest exploration of the toilet and its pipes to desensitize fears.
• Takes 3-5 months, inexpensive: Alarm sensor is attached to child's underwear with probe in front of urethra. Buzzer sounds when first wet (Nytone to the wrist and Palco to the shoulder). Keep a daily record of success with or without rewards. Costs about $80. Covered by Medicaid.
  Alarm sensor is attached to child's underwear with probe in front of urethra. Buzzer sounds when first wet (Nytone to the wrist and Palco to the shoulder). Keep a daily record of success with or without rewards. Costs about $80. Covered by Medicaid.
• "Overconditioning": take 16-32 ounces before bedtime - may lead to resumption of wetting - After 14 dry days, stop the alarm and drinking
  take 16-32 ounces before bedtime - may lead to resumption of wetting - After 14 dry days, stop the alarm and drinking
• Self-hypnosis/Hypnotherapy: Child-centered therapy where physiology of bladder-brain connects are explained to child, and child is taught self-hypnosis and visual imaging to respond to a full bladder while sleeping: 68% dry in 9 months -vs.- 24% with Imiprimine.
  Child-centered therapy where physiology of bladder-brain connects are explained to child, and child is taught self-hypnosis and visual imaging to respond to a full bladder while sleeping: 68% dry in 9 months -vs.- 24% with Imiprimine.
• Support, Demystification, Education: dispel misperceptions, avoid shaming, teach epidemiology, physiology, etiology and natural history. Explain to child how urine is made and what the bladder is
  dispel misperceptions, avoid shaming, teach epidemiology, physiology, etiology and natural history. Explain to child how urine is made and what the bladder is
• Bladder dysfunction - small bladder capacity: may respond to bladder stretching exercises, stopping and starting urine flow (give 1 cent per stoop), holding urine for as long as possible. Measure capacity by holding as long as possible and voiding in measuring cup- reward system for 5-10% increase in bladder capacity. Anticholinergic- Oxybutynin 5 mg tid with exercises for 2-3 months, then slowly withdraw
  may respond to bladder stretching exercises, stopping and starting urine flow (give 1 cent per stoop), holding urine for as long as possible. Measure capacity by holding as long as possible and voiding in measuring cup- reward system for 5-10% increase in bladder capacity. Anticholinergic- Oxybutynin 5 mg tid with exercises for 2-3 months, then slowly withdraw
• Stool_training: Learning to use the toilet is a milestone in self-control that affects the social relationship between parent and child. Because parents are often so invested in the results, toilet learning can become a locus of child-parent power struggles and conflict. Toddlers are typically ready to start toilet training by around 24 months, but parents should be encouraged not to push the issue, to avoid resistance and shaming. Some caregivers are squeamish about stool and transmit this to child but do fine with urine.
  Learning to use the toilet is a milestone in self-control that affects the social relationship between parent and child. Because parents are often so invested in the results, toilet learning can become a locus of child-parent power struggles and conflict. Toddlers are typically ready to start toilet training by around 24 months, but parents should be encouraged not to push the issue, to avoid resistance and shaming. Some caregivers are squeamish about stool and transmit this to child but do fine with urine.
• Signs of toilet readiness: Child shows awareness that he is about to urinate or have a bowel movement --Child can stay dry for 2 to 3 hours at a time -- Child can follow simple directions -- Child can pull pants/shorts/underwear up and down -- Child can use a few simple words to indicate wants and needs. -- Child shows interest in other family members' bathroom activities. -- Child has bowel movements on a predictable schedule. -- Child is mostly willing to go along with your requests, i.e. is not in a refusing phase -- Child is not currently undergoing major change or stress (e.g. a new sibling or a household move)
  Child shows awareness that he is about to urinate or have a bowel movement --Child can stay dry for 2 to 3 hours at a time -- Child can follow simple directions -- Child can pull pants/shorts/underwear up and down -- Child can use a few simple words to indicate wants and needs. -- Child shows interest in other family members' bathroom activities. -- Child has bowel movements on a predictable schedule. -- Child is mostly willing to go along with your requests, i.e. is not in a refusing phase -- Child is not currently undergoing major change or stress (e.g. a new sibling or a household move)
• Symptoms: soiling of underwear, sometimes recurrent abdominal pain, sometimes decreased appetite and energy even vomiting in severe cases
  soiling of underwear, sometimes recurrent abdominal pain, sometimes decreased appetite and energy even vomiting in severe cases
• Often begins with withholding after painful stools.: Some have history of inconsistent toilet training, poor limit setting, parental conflict over these.
  Some have history of inconsistent toilet training, poor limit setting, parental conflict over these.
• Presentation is most common in 7-10 year old boys.: Retentive type is characterized by cycles of days without stools followed by a huge painful defecation then more retentive days with overflow soiling. There may be a year or more of constipation before soiling begins.
  Retentive type is characterized by cycles of days without stools followed by a huge painful defecation then more retentive days with overflow soiling. There may be a year or more of constipation before soiling begins.
• Child is often unaware of his own odor: due to saturation of olfactory system
  due to saturation of olfactory system
• states he does not feel the stool coming.: due to decreased sensation in the colon from chronic distention
  due to decreased sensation in the colon from chronic distention
• have often severely punished the child.: watch and listen for belittling or shaming. Often the soiling occurs at 3pm making parents feel it is intentional.
  watch and listen for belittling or shaming. Often the soiling occurs at 3pm making parents feel it is intentional.
• Children may be remarkably unmotivated.: perhaps having given up or accepted soiling as part of their self image.
  perhaps having given up or accepted soiling as part of their self image.
• Enuresis co-occurs in 25% and may be secondary to encopresis.: due stimulation of sacral nerves and pressure by stool mass but coexistence should prompt careful neurological and physical exam to rule out disorders of sacral nerves eg diastematomyelia, tethered cord, anterior placement of anus. Urinary tract infections can be secondary in females due to perineal contamination.
  due stimulation of sacral nerves and pressure by stool mass but coexistence should prompt careful neurological and physical exam to rule out disorders of sacral nerves eg diastematomyelia, tethered cord, anterior placement of anus. Urinary tract infections can be secondary in females due to perineal contamination.
• Encopresis predisposing factors: include personal or family history of constipation and slow gut motility; distractible temperament leading to ignoring inner signals to void; medications that constipate such as narcotics, methylphenidate, antihistamines
  include personal or family history of constipation and slow gut motility; distractible temperament leading to ignoring inner signals to void; medications that constipate such as narcotics, methylphenidate, antihistamines
• Some homes and schools have adverse toileting situations: that can bring on stool withholding and some children find new toilet situations like camp aversive.
  that can bring on stool withholding and some children find new toilet situations like camp aversive.
• A child's schedule may require him to ignore the urge to defecate: (after breakfast hurrying to school; at school waiting until certain times to use the bathroom; school bathrooms that lack privacy and may be a place he fears, especially a new school; after school there may be activities that again that give him insufficient time for the bathroom)
  (after breakfast hurrying to school; at school waiting until certain times to use the bathroom; school bathrooms that lack privacy and may be a place he fears, especially a new school; after school there may be activities that again that give him insufficient time for the bathroom)
• Predisposing factors: personal or family history of constipation and slow gut motility; distractible temperament leading to ignoring inner signals to void; medications that constipate such as narcotics, methylphenidate, antihistamines
  personal or family history of constipation and slow gut motility; distractible temperament leading to ignoring inner signals to void; medications that constipate such as narcotics, methylphenidate, antihistamines
• Symptoms usually include relatively infrequent bowel movements, passage of small hard stools, and pain with defecation.: Ask child, parent may be unaware.
  Ask child, parent may be unaware.
• At all ages, mild transient constipation is most frequently caused by recent dietary changes or a viral illness.: leading to GI dysmotility and/or dehydration
  leading to GI dysmotility and/or dehydration
• Acute or chronic constipation can be caused by medications: anticholinergics, antihistamines, antacids, diuretics, anticonvulsants, narcotics, antidepressants (phenothiazines), iron, lead, mercury, Bismuth
  anticholinergics, antihistamines, antacids, diuretics, anticonvulsants, narcotics, antidepressants (phenothiazines), iron, lead, mercury, Bismuth
• Assessment: Rectal exam for amount of stool in the vault, stool consistency, anal tone, anorectal malformations, fissures, and dermatitis. Neurologic exam should include assessment of hypertonia or hypotonia, anal wink, lower extremity function and inspection of back for clues to spinal cord disorders
  Rectal exam for amount of stool in the vault, stool consistency, anal tone, anorectal malformations, fissures, and dermatitis. Neurologic exam should include assessment of hypertonia or hypotonia, anal wink, lower extremity function and inspection of back for clues to spinal cord disorders
• Lab: Stool for occult blood in all infants and any child with abdominal pain, failure to thrive, diarrhea or FH of cancer or polyps. Transit time if needed.
  Stool for occult blood in all infants and any child with abdominal pain, failure to thrive, diarrhea or FH of cancer or polyps. Transit time if needed.
• Infants: clean out with glycerin pr; no enemas. Maintain with juices with sorbitol eg prune, pear, apple or barley malt extract, corn syrup, lactulose or sorbitol. No mineral oil or stimulant laxatives.
  clean out with glycerin pr; no enemas. Maintain with juices with sorbitol eg prune, pear, apple or barley malt extract, corn syrup, lactulose or sorbitol. No mineral oil or stimulant laxatives.
• Children: clean out: oral, rectal or enemas. Diet whole grains and fruit. Maintain with mineral oil, Mg citrate, lactulose or sorbitol, polyethylene glycol. May need rescue with bowel stimulants eg senna, bisacodyl, cisapride. Biofeedback can help short term constipation.
  clean out: oral, rectal or enemas. Diet whole grains and fruit. Maintain with mineral oil, Mg citrate, lactulose or sorbitol, polyethylene glycol. May need rescue with bowel stimulants eg senna, bisacodyl, cisapride. Biofeedback can help short term constipation.
• A KUB can be helpful to detect stool masses if the history of constipation is not clear.: Manometry and rectal biopsy should be reserved for suspected Hirschprung's or recalcitrant cases. Females should have a urine culture. Barium enemas and sigmoidoscopy are not helpful.
  Manometry and rectal biopsy should be reserved for suspected Hirschprung's or recalcitrant cases. Females should have a urine culture. Barium enemas and sigmoidoscopy are not helpful.
• psychogenic encopresis.: chronic neurotic encopretics with history of neurologic delay, harsh toilet training and distant fathers/neurotic mothers. Increased rates in war orphans
  chronic neurotic encopretics with history of neurologic delay, harsh toilet training and distant fathers/neurotic mothers. Increased rates in war orphans
• Encourage parents to avoid toileting struggles: by: waiting for signs of readiness to start training such as signaling before voiding; deal with accidents with no more than mild disappointment; avoid starting training during periods of high oppositionality, if the child is generally out of control, or close to the birth of a sibling; and time the process for when caregivers are able to respond within seconds for several weeks.
  by: waiting for signs of readiness to start training such as signaling before voiding; deal with accidents with no more than mild disappointment; avoid starting training during periods of high oppositionality, if the child is generally out of control, or close to the birth of a sibling; and time the process for when caregivers are able to respond within seconds for several weeks.
• ask parents if they "are willing " for the child to toilet independently.: The fact that independent toileting symbolizes growing up and some loss of intimate caregiving and loss of control causes some parents and children ambivalence. Acknowledging this and helping the parent and child to create alternative intimate moments such as "cuddle time " can allow progress.
  The fact that independent toileting symbolizes growing up and some loss of intimate caregiving and loss of control causes some parents and children ambivalence. Acknowledging this and helping the parent and child to create alternative intimate moments such as "cuddle time " can allow progress.
• desensitize: For children with no history of toilet trauma: 1. Educate parents about the normality of fears over falling into the toilet or losing genitalia because of cognitive abilities at this age which can result in withholding or toilet refusal. 2. Suggest use of a potty chair or toilet insert or sitting backwards for security 3. Tell boys that "his penis is his forever" no one can ever take it away. When you are big like daddy, your penis will be big too! " 4. Tell children under 4 about the "Poop party " under the house where poops want to go. Act disappointed that his poops don't go to the poop party and ask other family members if theirs do (with coaching for enthusiastic "yes "). 5. Suggest exploration of the toilet and its pipes to desensitize fears for children over 4. For children with toilet trauma: 1. Make a scrapbook about toilets 2. Visit many toilets and discuss 3. Associate sitting on potty chair and later toilet in clothes with calming activity like reading a book or eating candy. Progress to sitting naked; then voiding. 4. Can use 1 M &M for sitting, 2 for urinating, 3 for pooping in toilet. 5. Consider sexual abuse.
  For children with no history of toilet trauma: 1. Educate parents about the normality of fears over falling into the toilet or losing genitalia because of cognitive abilities at this age which can result in withholding or toilet refusal. 2. Suggest use of a potty chair or toilet insert or sitting backwards for security 3. Tell boys that "his penis is his forever" no one can ever take it away. When you are big like daddy, your penis will be big too! " 4. Tell children under 4 about the "Poop party " under the house where poops want to go. Act disappointed that his poops don't go to the poop party and ask other family members if theirs do (with coaching for enthusiastic "yes "). 5. Suggest exploration of the toilet and its pipes to desensitize fears for children over 4. For children with toilet trauma: 1. Make a scrapbook about toilets 2. Visit many toilets and discuss 3. Associate sitting on potty chair and later toilet in clothes with calming activity like reading a book or eating candy. Progress to sitting naked; then voiding. 4. Can use 1 M &M for sitting, 2 for urinating, 3 for pooping in toilet. 5. Consider sexual abuse.
• For generally oppositional children, address general control issues and fears while allowing a diaper nonjudgmentally initially.: Do not use pull-ups as they decrease needed motivation. Inform child that this skill is up to them
  Do not use pull-ups as they decrease needed motivation. Inform child that this skill is up to them
• In persistent cases (>6 months) of stool refusal in a child with obvious control over voids, restrict the child to a playroom without television starting 1/2 hour before expected stools each day until he or she voids in the toilet.: This should only be begun after control issues are handled i.e. address noncompliance first. Takes 3 days once control issues have been handled.
  This should only be begun after control issues are handled i.e. address noncompliance first. Takes 3 days once control issues have been handled.
• : Motivate child and shift control to the child. Ask the child if he wants to fix this problem. Defer treatment a week or two if they don't seem to care. Send the parents out of the room to convey this. Put the child in charge of the sitting and the chart.
  Motivate child and shift control to the child. Ask the child if he wants to fix this problem. Defer treatment a week or two if they don't seem to care. Send the parents out of the room to convey this. Put the child in charge of the sitting and the chart.
• If : If significant constipation, an initial cleanout is essential.Choices: a series of enemas (e.g. twice per day of Adult Fleet's until liquid diarrhea with no lumps) with a bowel stimulant (bisadocyl or senokot both beginning 12 hours before enema); or Mg citrate (will cause cramping) or bisadocyl, followed by a mild stimulant (e.g. senokot granules one teaspoon per day) and/or adequate amounts of mineral oil (e.g. one to two tablespoons two times per day -- adjust if greasy leakage occurs) or Miralax (eg 1 capful bid). For very intrusive parents avoid enemas
  If significant constipation, an initial cleanout is essential.Choices: a series of enemas (e.g. twice per day of Adult Fleet's until liquid diarrhea with no lumps) with a bowel stimulant (bisadocyl or senokot both beginning 12 hours before enema); or Mg citrate (will cause cramping) or bisadocyl, followed by a mild stimulant (e.g. senokot granules one teaspoon per day) and/or adequate amounts of mineral oil (e.g. one to two tablespoons two times per day -- adjust if greasy leakage occurs) or Miralax (eg 1 capful bid). For very intrusive parents avoid enemas
• : Roughage: "p" fruits- pears, peaches, apricots, grapes, prunes, pineapple; raw bran mixed into foods, high fiber cereals and muffins, popcorn, fig newtons
  Roughage: "p" fruits- pears, peaches, apricots, grapes, prunes, pineapple; raw bran mixed into foods, high fiber cereals and muffins, popcorn, fig newtons
• constipating foods.: apple skins, bananas, carrots, rice, cow milk
  apple skins, bananas, carrots, rice, cow milk
• : Provide prolonged laxative use: mineral oil, senokot, Milk of Magnesia, Miralax, Naturcil. May switch types as child starts to refuse them.
  Provide prolonged laxative use: mineral oil, senokot, Milk of Magnesia, Miralax, Naturcil. May switch types as child starts to refuse them.
• Maintain weekly contact with the child: to instill self direction and keep parents out of it checking chart in person or through the mail until clean for 2 weeks then every month until clean for 3 months and then every 3 months.
  to instill self direction and keep parents out of it checking chart in person or through the mail until clean for 2 weeks then every month until clean for 3 months and then every 3 months.
• Assure neurological integrity.: If trained for urine and hides to pass stools this is assured.
  If trained for urine and hides to pass stools this is assured.
• If other oppositional/angry behaviors- manage discipline first.: Likely to need parent-child interaction therapy and/or individual therapy for parent mental illness
  Likely to need parent-child interaction therapy and/or individual therapy for parent mental illness
• Assure neurological integrity: consider spinal cord tumor, tethered cord, diastematomyelia if lacks sensation secondarily
  consider spinal cord tumor, tethered cord, diastematomyelia if lacks sensation secondarily
• Assess for and manage stress: sexual abuse, marital discord/violence, loss of primary caregiver (even sitter), new sibling, child abuse
  sexual abuse, marital discord/violence, loss of primary caregiver (even sitter), new sibling, child abuse