1. Constipation and Enuresis
Katie Mallam
Paediatric Update for Primary care
9th October 2012

2. Constipation – Why? Common Debilitating Cost
Prevalence 5-30%
1/3 become chronic (>8 weeks) = soiling
Debilitating
Social, psychological and educational consequences
Cost
Longer duration = longer, more intensive treatment
Varying advice = angry parents

3. Constipation – NICE Standardise approach Early treatment
Reduce consequences and cost
No need to remember history and examination:

4. Breast fed babies can go up to a week without opening bowels
Constipation?
2 of …….. * *
Breast fed babies can go up to a week without opening bowels

5. Constipation?

6. Breast fed babies can go up to a week without opening bowels
Constipation?
2 of …….. * *
Breast fed babies can go up to a week without opening bowels

7. Constipation – Causes Mostly idiopathic Rarely Associations
Hirschsprung’s
Neurological NB lumbosacral abnormalities
Anorectal malformations
Hypothyroid
Coeliac
Cystic fibrosis (but normally diarrhoea due to fat malabsorption)
Cow’s milk protein intolerance
Associations
Cerebral palsy
Autism
Down’s syndrome (NB beware hypothyroidism and Hirschsprung’s)
Hirschspruung’s:
Missing parasympathetic ganglion cells from segment of bowel. Therefore can’t relax or peristalse. Presentation depends on length of effected segment.
Beware enterocolitis
Associated with Down’s, central hypoventilation, deafness, waardenburg’s
Lumbosacral ?sacral agenesis, spina bifida occulta, cord tethering

8. Constipation – History 1

9. Faltering growth = treat and do coeliac and TFT (refer)
Constipation – History 2
Faltering growth = treat and do coeliac and TFT (refer)

10. Constipation – Examination
No PR in primary care
NB perianal strep
Anal atresia
Anal wink = reflex contraction of external anal sphincter = S2-4

11. Perianal streptococcal infection
Swab
Treat infection and constipation

12. Constipation – Examination
No PR in primary care
NB perianal strep
Anal atresia
Anal wink = reflex contraction of external anal sphincter = S2-4

13. Constipation – It’s NICE
No need to remember history and examination:
< 1 year
≥ 1 year

14. Constipation – Actions
Red (or amber) flags
Refer paeds
No red flags
Reassure
Explain constipation and treatment (could just do briefly and give patient information using resources in ‘Explain 2’ slide)
Treat

15. Constipation – Explain 1
Normally, stools build up in the lowest part of the bowel.
When stools accumulate, they start to pass into the rectum (the last part of the bowel) which stretches. This sends nerve messages to the brain, telling you that you need to empty your bowels.
If the stool is not passed out then more stools from higher up also reach the rectum.
Eventually, large hard stools may build up in the rectum.
The rectum may then stretch and enlarge (dilate) much more than normal, to cope with the excessive amount of stools.
A very large stool may develop and get stuck (impacted) in an enlarged rectum.
If the rectum remains enlarged then the normal sensation of needing the toilet is reduced. The power to pass out a large stool is also reduced (the rectum becomes 'floppy').
More stools build up in the colon behind the impacted stool in the rectum.
The lowest part of an impacted stool lies just above the anus. Some of this stool liquefies (becomes runny) and leaks out of the anus. This soils the child's pants or bedclothes. Also, some softer, more liquid stools from higher up the colon may bypass around the impacted hard stool. This also leaks out and soils the pants or bedclothes and can be mistaken for diarrhoea. The child has no control of this leaking and soiling.
When a stool is eventually passed, because the rectum is distended and weakened, it simply fills up fairly quickly again with more hard stool from the backlog behind.
Rectum gets used to being full: normal reflexes and power are reduced = ‘baggy’.
Reduced sensation and overflow: soiling is not intentional
Need to ‘get empty and stay empty’ for rectum to shrink back and recover reflexes and sensation: takes time

16. Constipation – Explain 2
Tameside = comprehensive leaflet
Patient.co.uk = very good, can print pdf leaflet
ERIC = lots of info for professionals and parents/patients (age banded)
NICE ‘template letter’

17. Constipation – Treat Get empty, stay empty! Faecal impaction?
Soiling
Abdominal mass
Movicol, movicol, movicol!
NB different strengths e.g. Paed Plain = no taste
‘Softeners’
Movicol, Lactulose, Docusate (also squeezes)
‘Squeezers’
Senna, sodium picosulphate, bisacodyl
Doses as per BNFc or NICE

18. Constipation – Get empty
Disimpaction
Aiming for liquid and no more lumps = messy
Review after 1 week
Movicol
If not tolerated = stimulant laxative +/- lactulose
If not worked after 2 weeks = add stimulant laxative and urgently refer to Paeds
Enemas and manual evacuation only if all else failed

19. Constipation – Stay empty 1
Maintenance
Until rectum no longer stretched and reflexes return
Laxatives do not make bowel lazy: may need for several years and should be gradually reduced
Movicol
If not tolerated = stimulant +/- lactulose, or docusate alone
If not effective = add stimulant

20. Constipation – Stay empty 2
Behavioural
Non-punitive (I say ‘training the subconscious’)
Regular toileting after meals
Foot support, sit forward (rock and pop!), bubbles, books
Diary and rewards (things under their control)
NB school (NB ERIC info)
Use school nurses and HV

21. Constipation – Stay empty 3
Fluids
Page 15, NICE Quick Reference Guide

22. Constipation – Stay empty 4
Diet
High Fibre = fruit, veg, high fibre bread, wholegrain breakfast cereals, baked beans
Activity

23. Constipation – Failed treatment
Disimpaction has failed if not responded to Movicol after 2 weeks:
Urgent referral to Paeds (or Bladder and Bowel Specialist Nurse)
Maintenance has failed:
In those aged <1 year, if not responded after 4 weeks
Refer paeds
In those aged ≥ 1 year, if not responded after 3 months
Check no red flags
If red flags = refer paeds
No red flags = refer to the Bladder and Bowel Specialist Nurse Service

24. Constipation Toolkit RED FLAGS, refer paeds EXPLAIN: Tameside leaflet
History and examination questionnaires
Bristol Stool Chart
EXPLAIN: Tameside leaflet
IMPACTED? GET EMPTY, STAY EMPTY!
Medical: usually Movicol Paed Plain as per BNFc
Non Medical: see Tameside leaflet and fluid rqmts on page 15 of NICE
If fails, add stimulant
Disimpaction failure, refer paeds
Maintenance failure, refer Bladder and Bowel Specialist Nurse

25. Enuresis - definitions
Incontinence
uncontrollable leakage of urine
Enuresis
Incontinence of urine when sleeping: usually say Nocturnal
Bedwetting: ‘involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology’ (NICE)
Primary
Secondary = previously dry for ≥ 6 months

26. Urinary Incontinence – History 1
Secondary (especially recent):
UTI
Diabetes (drinking overnight)
Constipation
Neurological: spine and lower limb exam
Emotional/behavioural difficulties: consider psychology
Urine dipstick
NB same day referral if suspect diabetes

27. Urinary Incontinence – History 2
Pattern of bedwetting
Variable volume, >1 per night: could be Overactive Bladder
Daytime symptoms
Urgency, Frequency >7/day, Infrequent <4/day, straining, pain
Consider UTI, Overactive Bladder, Neuro/Uro cause
Urine dipstick
If significant, refer to consider investigation/treatment of those symptoms first
Toileting patterns
NB School
Fluid intake
Check not restricting
Diary

28. Urinary Incontinence – History 3
Effect on child/YP/family
Social (sleep-over), self-esteem
PMHx:
UTI
Developmental, attention or learning difficulties: consider specific management

29. Urinary Incontinence – Examination
Primary Nocturnal: not required according to NICE
Secondary Nocturnal or Daytime Symptoms:
Genitalia
Abdomen
Spine
Lower limb neuro

30. Urinary Incontinence – Referral
RED FLAGS = recurrent UTI, Diabetes, examination abnormalities:
refer paeds
No red flags
Nocturnal only:
refer HV or school nurse
Day only, or Nocturnal with daytime symptoms:
refer to Bladder and Bowel Specialist Nurse

31. Enuresis – NICE Principles of Care
Not their fault: non-punitive management
Tailor management to child/YP and parent/carer
Consider parental support
Do not exclude <7y
Reassure

32. Enuresis Prevalence Age < 2 per week ≥ 2 per week 4.5y 21% 8% 9.5y
1.5%

33. Enuresis – NICE Principles of Care
Not their fault: non-punitive management
Tailor management to child/YP and parent/carer
Consider parental support
Do not exclude <7y
Reassure
Trial of BASICS
<5y: encourage toilet training if not done already and trial out of nappies at night

34. Enuresis – Management BASICS!
Fluids: avoid caffeinated (and ?fizzy and blackcurrant)
Regular toileting 4-7/day
NB double voiding if Overactive Bladder symptoms
Trial out of nappies/pull-ups: offer alternatives
Reward system: for agreed behaviour (not dryness)

35. Enuresis – Information
NHS choices: concise, for parents
Patient.co.uk: concise, for parents
ERIC: all ages, parents, professionals

36. Enuresis – Alarm High long-term success rate (weeks)
But need commitment and can disrupt sleep
Contraindications:
< 1-2 wet nights/week
Parental distress or negativity (consider parental support)
Need training
Hence referral to HV/school nurse
Encourage to combine with reward system
Get up and go to toilet, help change sheets

38. Enuresis – Desmopressin
Rapid, short-term results (sleep-over)
Alarm is inappropriate or undesirable
Inform them:
many relapse when treatment is withdrawn
how desmopressin works
fluid restriction from 1 hour before until 8 hours after taking desmopressin
that it should be taken at bedtime
how to increase the dose if the response to the starting dose is not adequate
that treatment should be continued for 3 months
that repeated courses can be used
Stop during sickle cell crises or D&V

40. Enuresis – Other treatments
Only on advice of specialist
Anticholinergic with desmopressin
Oxybutinin
If:
Not responded to desmo+/-alarm
Daytime symptoms
Imipramine
Gradual increase and withdrawal
Warn re dangers of OD

41. Urinary Incontinence – Top tips
Secondary: think other causes esp Diabetes
Examine if Secondary or Daytime
Refer all?
Red flags = paeds
Others = HV/school nurse/BBSN
Basics
Give/direct to information