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Elimination Disorders
May 3, 2012Napatia Tronshaw, MDChild and Adolescent FellowUniversity of Illinois at ChicagoInstitute of Juvenile Research
Normal Development
Toddler Phase (18 months- 3 years)
Bowel Continence
Bladder Continence
Enuresis Nocturnal Enuresis
MonosymptomaticPolysymptomatic
Diurnal Enuresis
Primary Enuresis
Secondary Enuresis
Types of Enuresis Regressive 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
Prevalence 30% of US children achieve continence by age 2
5-10% of 5 year olds meet criteria for nocturnal enuresis
15% of enuretic children have spontaneous resolution of symptoms each year
2-3% of 12 year olds meet criteria for nocturnal enuresis
1% of 18 year olds still have enuretic symptoms
Diagnostic CriteriaDiagnostic criteria for 307.6 Enuresis
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 (occupa tional), 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 OnlyDiurnal OnlyNocturnal and Diurnal
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
Physical Exam Neurological Exam
Throat and Neck Exam
Skin Exam
Abdominal Exam
Routine Blood Draw
UA
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
Non-Pharmacological Interventions
Education
Advice
Bell and Pad
Non-Pharmacological Interventions
Bladder-Volume Alarm
Star Chart System
Nightlifting
Timed Night Awakening
Bladder Training Exercises/Overlearning
Pharmacological Interventions
Desmopressin
Imipraminine
Oxybutynin
TCAs, SSRIs & Psychostimulants
NSAIDs
Additional Treatments Cognitive Behavioral Therapy
Psychodynamic Psychotherapy
Biofeedback
Acupuncture
Encopresis Primary Encopresis
Secondary Encopresis
Retentive Encopresis
Nonretentive 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
Diagnostic Criteria
Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether voluntary or unintentional
At least one such event a month for at least 3 months
Chronological age of at least 4 years (or equivalent developmental level)
The behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation.
Diagnostic Criteria The DSM-IV recognizes two subtypes with constipation
and overflow incontinence, and without constipation and overflow incontinence. In the subtype with constipation, the feces are usually poorly formed and leakage is continuous, and occurs both during sleep and waking hours.
In the type without constipation, 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
Etiology Delay in Maturation
Underlying Medical Condition
Psychological/Behavioral
Constipation
Primary Retentive Encopresis
Delayed Physical Maturation
Inappropriate Toilet Training
Retentive Encopresis Represents 80-95% of cases
Infrequent Bowel Movements
Large Stools
Painful Defecation
Secondary Encopresis Birth of sibling
Parental Divorce
Abuse
ODD or CD
MR/Autism/ Psychosis/RAD
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
Physical Exam Abdominal pain/distention Height/Weight Neurological Exam Skin Exam Rectal Exam Abdominal XRAY Stool Collection Blood Testing Rectal Biopsy/Barium Enema
Treatment Advice/Education
Nonpharmacological
Pharmacological Intervention
Advice/Education Dietary Changes (foods high in fiber)
Increase Fluid Intake
Make Toilet Training Non-Threatening
Make Toilet Accessible
Regular Bathroom Times
Nonpharmacological CBT
Psychodynamic Psychotherapy
Biofeedback
Acupuncture
Pharmacological Laxatives
Suppositories
Enemas
Mineral Oil
Stool Softeners