Eliminative Disorders: Enuresis and Encopresis

1. Eliminative Disorders: Enuresis and Encopresis James H. Johnson, Ph.D. University of Florida

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). • Thirteen to 33% of children will have some degree of nighttime wetting at five years of age (Brown et al,. 2008). • By age 10 only 3% of males and 2 % of females will still wet the bed. • By late adolescence this figure will drop to 1% of males and less than 1% of females (Mellon & Houts, 2006) • Boys wet the bed more frequently than do girls. • About 80 percent of children with enuresis wet the bed only at night. • Only about 3% wet during the day (Peterson, et al., 2003)

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. Concordance rates for identical and fraternal twins are 68% and 36% respectively (Bakwin, 1973)

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 EEG’s 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 (ADH) concentrates and reduces the volume of urine produced by the kidneys, thus decreasing the amount of urine stored by the bladder. • There is some evidence that children with nocturnal enuresis may have a deficiency in ADH and thus 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 - 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 70 % 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 (Fritz, Rockney, et al., 2004)

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/enuresisalarms.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 sometimes 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 1.5 and 3% of 4 to 5 -year-olds. • Boys are 6 times more likely to have this condition than girls (Brown, et al., 2008)

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 Hirschsprung’s 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 child’s 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