Midnight Laundry Enuresis, Encopresis and Diarrhea Tory Davis, PA-C

Enuresis Urinary incontinence in child who should be continent 5-6 years (or developmental equivalent) or older Not caused by medication or medical condition Peeing in clothes or in the bed Involuntary or intentional

Enuresis Primary enuresis Secondary enuresis has never had a sustained period of dryness. 90% nocturnal Secondary enuresis has had a sustained period of bladder control (6-12 months)‏

Primary Enuresis Boys 3x girls Most become continent by adolescence, even without intervention FHx , esp father Likely maturational delay of: sleep/wake mechanisms development of bladder capacity and urethral sphincter control

Primary Enuresis 1 14 2-3 12 3-5 10 7 7-8 8 15 5 Occasional daytime wetting Nocturnal enuresis (%)‏ Age in years

Daytime Enuresis More common in : Boys = Girls Kids with hyperactivity Timid/shy kids Boys = Girls 60-80% also have nocturnal wetting

Secondary Enuresis Onset after child has had sustained period of continence Often follows a stressful event Loss, new sibling, family discord, move, new school, abuse

Differential UTI *MC Distal urethritis (bubble bath)‏ Neurological disorders- congenital or acquired Congenital anomalies (spina bifida)‏ Seizure disorders Diabetes (mellitus or insipidus)‏ Structural abnormalities of the urinary tract (urethral cyst, urethral duplication, obstruction)‏ 1. Need to r/o

Diagnosis Take a good history Do a good physical Observe child’s urinary stream Straining, dribbling, stress incontinence? Urinalysis and urine culture what’s going on in family; potty training hx; 4. To r/o UTI. May not have dysuria

Treatment Emphasize that noc wetting is likely developmental lag NOT acting out, etc Patient understanding and encouragement Spontaneous cure ~15%/year Avoidance of punitive measures Encourage child participation 5. Get them involved

Treatment Counseling Bladder training Potty pager/ alarm Child has active role: keeps calendar, helps with the midnight laundry, talk to the PA Positive reinforcement, remove guilt/blame Bladder training Hold urine longer during day, limit fluids after dinner, practice start/stop urine flow on toilet, pee just before bed. Helpful ~40% Potty pager/ alarm 3. Can be effective. Insurance covers – usually before drugs

Meds DDAVP (desmopressin acetate) intranasal qhs. Complete remission during tx 50%, high relapse on discontinuation. Good for special events (camp, sleepovers) and as “bridge” Imipramine (TCA) 25-50 qhs Anticholinergic side effects Law #13 – delivery of good med care is to do as much nothing as possible – do no harm.

Encopresis Fecal incontinence in child who should be continent. 4 years (or developmental equivalent) or older Not due to medication or medical condition Involuntary (usually) or intentional 1-1.5% of school-aged kiddos, very rare in adolescence Boys 4x girls

Functional Encopresis Types Retentive Continuous Discontinuous Toilet phobia

Retentive Encopresis *MC Psychogenic Megacolon Child withholds BMs  constipation  fecal impaction seepage of liquid feces (Type 7!) around impaction and out onto skivvies. Marked constipation Painful defecation Retention reduced sensory feedback Rectal wall stretch causes  contractile strength Harder stools due to increased water absorption Then what happens…? 1. Bristol stool chart

Continuous Encopresis Children who have never gained primary control of bowel function. Poop in underwear. Doesn’t care. No regard for social norms. Typically lacks bowel/potty training Often family social/intellectual disadvantage The encopresis is the least of your worries with this child 3. No one tries potty training. 4. This is usually least of concerns about social upbringing.

Discontinuous Encopresis Hx of normal bowel control for extended period Like secondary enuresis, usually in response to stressful event Sometimes voluntary follow-through (smearing, etc)‏

Etiologic considerations Inefficient motility Medical management for (perceived?) bowel disorder Painful defecation (fissures, etc)‏ Surgical hx (imperforate anus)‏ Unrealistic parental expectation 2. Parents think kids are constipated – wide range of “nl”

Consequences Fear Shame Isolation Depression Can depend on caregiver rxn. Need to attend to these other factors during tx

History Bowel pattern since birth Age of onset of problems/symptoms Management attempt and effects Associations (ie with stressors)‏

Physical Exam

Management (Levine) Counseling Phase Demystify: Review colon function Normal and abnormal Draw a picture Show imaging Remove blame Explain treatment plan Emphasize intestinal muscle building Talk about it with them. Make it okay Focused on retentive (the most common)

Inpatient Catharsis When? What? Severe retention Poor outlook for home compliance What? Saline enemas bid 3-7 days Bisacodyl suppositories bid 3-7 days Sit on toilet 15 min pc Sometimes need to get them in and clear everything out. 2.3 – try to reset gastrocolic reflex

Outpatient Catharsis Mild: Senna daily x 1-2 weeks Moderate-Severe: 3 day cycles Day 1: Fleet’s enema bid Day 2: Bisacodyl suppository BID Day 3: Bisacodyl suppository once Follow-up x-ray to confirm catharsis

Maintenance Sit on toilet bid x 10 min, after meals 2 T mineral oil po bid x 4-6 months MVI supplement Eat fiber! Oral laxative (senna) q day or qod x 1 month Read Anna Karinina ?? Reward- sticker chart, etc 2.1 – worried about malabsorption 3. Like a dry sponge – needs to have water with it to make it work

Follow-Up q 1-2 months Check compliance Monitor for relapse Document progress

Thoughts on Potty Teaching Teach your parents well… Readiness signals: dry periods, interest in toilet,wants to be changed when wet, can follow directions No power struggles Respect child’s autonomy Applaud child’s success Accidents happen

Poop Song http://www.youtube.com/watch?v=P- OIgXyvzUU&feature=rec-rn

Acute Diarrhea Gastroenteritis Infectious Food poisoning Antibiotic-associated Overfeeding Great Ddx chart in Nelson text Need to get a definition of what that means for them.

Acute diarrhea Complete history Physical Exam Include day care, travel, animal contact, foods, antibiotics Physical Exam Stool- check for WBCs and occult blood If neg, think viral If pos- r/o (or in) bacterial cause, then consider IBD 1.1 – who else has it? 2. Sore belly, rash etc

Acute diarrhea management Cure initiating event Correct dehydration and e-lyte deficits Manage complications from mucosal injury NO Imodium, Lomotil, paragoric, etc 2. Do it slowly. 4. don’t want to stop it. Usually happens for a good reason – need to get it out.

Chronic Diarrhea Post-infectious secondary lactase deficiency Cow’s milk intolerance Toddler’s diarrhea Celiac disease CF IBS IBD Giardiasis Laxative abuse AIDS enteropathy

Toddler’s Diarrhea- MC Chronic diarrhea in infants Nonspecific diarrhea of infancy 6m-3y onset, duration >3 weeks Painless First stool of the day formed, become increasingly liquid thru day Exacerbated by teething, infections, also by fruit juices with unabsorbable sugars that increase diarrhea

Toddler’s diarrhea Motility disorder with rapid transit Positive FHx for IBS Dx: r/o infectious causes Tx: high fat, high fiber, low sugar diet

Cow’s Milk Intolerance Infants <1year old Stools contain WBCs, eosiniphils Even in breast-fed babes whose mom’s drink cow milk Diarrhea, vomiting, mucus in stools FTT Assoc with atopy, rhinitis, eczema Dx: Stool studies, CBC Tx: alimentum, nutramagen (not soy) or nursing mom avoid milk