1. Constipation and Enuresis
Dr. Sussens & Dr Ongosi
GP PLT Event, Nottingham.

2. Introduction
The local constipation pathway was developed by Paediatric gastroenterology in Nottingham.
The development is by consensus of a multidisciplinary team within the hospital, community and general practice.
It is based on national guidelines and local experience.

3. Constipation
Delay and sometimes difficulty/discomfort in passing stools, which may be of a harder consistency.
Constipation can occur soon after birth but usually occurs between the ages of 1- 5 years of age
Common (5% of general paediatric referrals and up to 25% of referrals to Paediatric Gastroenterology)

4. Definitions Soiling Encopresis Withholding
Secondary to long term constipation and caused by involuntary overflow of fluid or semi solid stools around the faecally loaded rectum.
Encopresis
Inappropriate passage of normal stool in inappropriate places, in this situation it is implied that there is normal sensation and control.
Withholding
A subconscious with-holding of stool because of previous pain of constipation or fissure, fear of the toilet or coercive potty training. Common in young children.

5. Primary care management.
Establish idiopathic constipation and exclude underlying causes

6. Two or more symptoms from the following;
Reduced frequency and or consistency of stool
less than three complete stools per week (Bristol Stool Form type 3 or 4)
hard large stools, rabbit droppings (Bristol Stool Form type 1),
Soiling
History
Previous constipation,
Previous or current anal fissure,
Painful bowel movements and bleeding associated with hard stools
Symptoms associated with defecation
Straining,
Bleeding associated with hard stool,
Poor appetite,
Abdominal pain,
Anal pain
Evidence of retentive posturing

7. A careful, detailed history
From the parent/carer and the child where possible.
Delayed passage of meconium
Onset and duration of problem
Normal bowel pattern,
Stool type
Typical diet and fluid intake
History of other illness or medical problems
Toilet/potty training and use

8. History... Any urinary problems Reaction of parents
Family and social history
Management tried to date
Developmental/school progress
Toilet facilities at home and school e.g lack of privacy, cleanliness

9. Examination Overall health Assessment of growth,
Abdominal distension or faecal masses,
Inspection of peri-anal area for fissure, infection, skin disease, ectopic position, anal reflex, etc
Neurological examination.

10. Consider Hirschsprung’s disease or anorectal anomaly if
Delayed passage of meconium,
Constipation in first month of life,
Vomiting,
Failure to thrive
Abdominal distension.

11. Symptoms from birth (or first few weeks of life).
Failure or delay to pass meconium more than 48 hours after birth in term baby
Ribbon Stools’ (more likely in child < 1year)
Gross or chronic abdominal distension and vomiting
Leg weakness or gross motor delay or abnormal reflexes
Poor growth
Bloody diarrhoea
Abnormal lumbosacral /gluteal region or abnormal position of anus
Absent anal wink
Concerns re child maltreatment

12. Investigations Usually none
If other pathology is suspected consider referral.
Coeliac screen, thyroid function, calcium, U&E and creatinine may be useful if an organic problem is suspected.

13. Treatment Explanation of the problem Education
Oral medication to soften and evacuate retained stools
Medicines used include Lactulose, Sodium Picosulphate, Senna, Movicol.
Avoid suppositories.
Clear out if required
Increase dietary fibre and fluids
Toileting issues

14. Treatment Use of Record Charts and reward systems Psychology input
Social Services referral sometimes needed if there is concern about significant harm from abuse or neglect
Regular follow-up
Advice on daily physical activity

15. Medical treatment Faecal impaction
Macrogols (Paediatric movicol) - escalating doses
Add stimulant Laxatives (picosulfate, bisacodyl, senna, docusate) if no response to Paediatric movicol within 2 weeks
Substitute with stimulant laxative + osmotic laxative (lactulose) if macrogols not tolerated.
NB: Inform families that disimpaction can initially increase symptoms of soling and abdominal pain

16. Medical treatment
NO rectal medications or sodium citrate enemas unless failed oral treatment.
NO phosphate enemas unless under hospital supervision and all above have failed
NO manual evacuation under GA unless oral and rectal treatment has failed.
Review all children undergoing disimpaction within 1 week.

17. Maintenance treatment.
First line treatment – Paediatric movicol. (about half of disimpaction dose)
Add stimulant laxative if macrogol doesn’t work
Substitute with stimulant laxative + osmotic laxative (lactulose) if macrogols not tolerated.

18. Referrals To general paediatrics(community or hospital)
Problematic constipation in first 3 months of life
Failure of treatment using protocols for 3 months
Failure of faecal lump to disappear in 3 weeks (following guidelines for clearout)
Persistent rectal bleeding
Failure to thrive
Social/family problems
Toileting problems at school

19. References Nottingham paediatric guidelines Nice guidance may 2010:
Diagnosis and management of idiopathic childhood constipation in primary and secondary care

20. Enuresis Refers to a repeated inability to control urination
Primary enuresis refers to children who have never been successfully trained to control urination.
Secondary enuresis refers to children who have been successfully trained but revert to wetting in a response to some sort of stressful situation or medical condition

21. When is it Enuresis?
Children are generally expected to be dry by a developmental age of 5 years, and historically it has been common practice to consider children for treatment for nocturnal enuresis only when they reach 7 years
The NICE guidance has specific advice for children under 5 years, and has indicated treatment options for children between 5 and 7 years.

22. Daytime incontinence
That is not associated with urinary infection or anatomical abnormalities is less common than nocturnal enuresis
Tends to disappear much earlier than nocturnal enuresis.
Consider
Overactive bladder.
Abnormal voiding habits, the most common being infrequent voiding.
More common in girls than in boys.
Refer to continence service.

23. Nocturnal Enuresis
A widespread and distressing condition that can have a deep impact on a child or young person's behaviour, emotional wellbeing and social life.
Very stressful for the parents or carers.

24. Prevalence The prevalence of bedwetting decreases with age.
Bedwetting less than 2 nights a week
21% at about 4 and a half years
8% at 9 and a half years.
More frequent bedwetting is less common
8% at 4 and a half years
1.5% at 9 and a half years.

25. Guidance Available Local pathway is currently being finalised.
NICE guidance October 2010
The management of bedwetting in children and young people.
Nice guidance is only about nocturnal enuresis but does cover some important areas that are obviously relevant to both conditions.

26. History.. Ask about the presence of daytime symptoms, including:
Daytime frequency (that is, passing urine more than seven times a day)
Daytime urgency
Daytime wetting
Passing urine infrequently (fewer than four times a day)
Abdominal straining or poor urinary stream
Pain passing urine.
pattern of bedwetting i.e. timing, frequency, amount, waking
constipation

27. Haematuria
Straining on urination
Dibbling
Poor flow
Gait disturbance
Poor bowel control
Continuous dampness

28. Assessment and investigation
Is this a presentation of a systemic illness.
Has it started in the last few days or weeks?
Consider UTI/ DM
Are they opening their bowels regularly?
Constipation is a common cause of secondary enuresis
Has there been a recent emotional or behavioural problems
Is there child maltreatment?
UTI – follow NICE CG54
Constipation and soiling – follow NICE CG99
Emotional health problems – refer to CAMHS
Safeguarding issues – refer to Social Care
Daytime symptoms – refer to Specialist Continence Service NUH

29. Drinking Do they drink enough Are drinks being restricted.
Need to drink enough in the day to ‘train the bladder’ to hold decent volumes of urine.
Do not need to restrict input except for last hour or so before bed.
Consider a diary.

30. Examination Blood pressure Examination of the back
Lower limb examination

31. Urinalysis
Do not perform routinely in children and young people with bedwetting, unless any of the following apply:
Bedwetting started in the last few days or weeks
There are daytime symptoms
There are any signs of ill health
There is a history, symptoms or signs suggestive of urinary tract infection
There is a history, symptoms or signs suggestive of diabetes mellitus.

32. Management Patient –centred care
Advice on fluid intake, diet and toileting behaviour.
Trial without nappies/pull ups at night
Reward systems on agreed behaviour rather than dry nights i.e. rewards for;
Drinking recommended levels of fluid during the day
Using the toilet to pass urine before sleep
Engaging in management (for example, taking medication or helping to change sheets).
The new pathways that are being agreed for the city and the county will involve the GP supporting the families through the above management and advice and then if there is no improvement form this, giving a trial of desmopressin and referring on for further management if there is no help from this.

33. Management If no response to initial treatments;
Consider whether or not it is appropriate to offer alarm or drug treatment. This is dependent on
The age of the child or young person,
The frequency of bedwetting
And the motivation and needs of the child or young person and their family.
Usually from the School nurse
Should be offered as the first-line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system, unless:
an alarm is considered undesirable to the child or young person or their parents and carers An alarm is considered inappropriate, particularly if:
bedwetting is very infrequent (that is, less than 1–2 wet beds per week)
the parents or carers are having emotional difficulty coping with the burden of bedwetting
the parents or carers are expressing anger, negativity or blame towards the child or young person.

34. Local pathway City School nursing role under review
Trial of desmopresssin and refer to continence service if no improvement.
(Stephanie Joyner Sherwood Rise H/C)
This is still being worked out, the pathway is still in discussion, but what has been agreed so far is.

35. County… No nurse led continence clinic. Trial of desmopresin.
Refer/discuss with community paediatrician.

36. Drug treatment NICE guidance suggests;
Offer desmopressin to children and young people over 7 years if:
Rapid-onset and/or short-term dryness is a priority or
Alarm is inappropriate or undesirable
Parents/carers with emotional difficulties, anger, blame..

37. If offering desmopressin for bedwetting;
Inform the child or young person and their parents or carers:
That many children and young people, but not all, will experience a reduction in wetness
That many children and young people, but not all, will relapse when treatment is withdrawn
Of the importance of fluid restriction from 1 hour before until 8 hours after taking desmopressin
That it should be taken at bedtime
If appropriate, how to increase the dose if there is an inadequate response to the starting dose
To continue treatment with desmopressin for 3 months
That repeated courses of desmopressin can be used.

38. When to Refer Refer children and young people with bedwetting that;
has not responded to courses of treatment with an alarm and/or desmopressin
For further review and assessment of factors that may be associated with a poor response, such as an overactive bladder, an underlying disease or social and emotional factors.

39. Any Questions?