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

2. 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

3. 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)‏

4. 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

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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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) qhs
Anticholinergic side effects
Law #13 – delivery of good med care is to do as much nothing as possible – do no harm.

13. 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

14. Functional Encopresis Types
Retentive
Continuous
Discontinuous
Toilet phobia

15. 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

16. 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.

17. 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)‏

18. 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”

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

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

21. Physical Exam

22. 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)

23. 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

24. 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

25. 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

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

27. 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

28. Poop Song
OIgXyvzUU&feature=rec-rn

29. 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.

30. 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

31. 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.

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

33. 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

34. 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

35. 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