TIS

Enuresis/Encopresis
• At 2-4 yr of age child is developmentally ready to being toilet training.
• To achieve conscious bladder control several conditions must be present:
- Awareness of bladder filling
- Cortical inhibition of reflex bladder contractions
- Ability to consciously tighten external sphincter to prevent incontinence
- Normal bladder growth
- Motivation to stay dry
• Girls acquire bladder control before boys
• Bowel control is achieved before bladder control
Nocturnal Enuresis: Facts
• Involuntary voiding at night after 5 yrs. of age.
• 60% of these kids are boys, family history is positive in 50%.
• If one parent has +ve history each child has a 44% risk of the same, if
both parents have a +ve history risk in each child increases to 77%.
• 20% of 5 yr. olds are affected by it. It ceases spontaneously in 15%.
Nocturnal Enuresis: Definitions
• Primary :
- the child never achieved nocturnal control
• Secondary:
- The child achieved dry nights at least for a few months ( 6 months according to
AAFP) but now has enuresis.
• Monosymptomatic:
- only has nighttime bed wetting
• Non-monosymptomatic:
- Daytime lower urinary tract symptoms, Daytime incontinence, holding
maneuvers.
Encopresis
• Bowel continence is expected to occur by the age of 4 years.
• Encopresis is the repeated passage of feces into inappropriate places (usually the
underpants) at least once a month for 3 consecutive months
Types of Encopresis?
• Retentive: with constipation & overflow incontinence
• Non retentive: no evidence of fecal retention with 1 or more episode /week in
the previous 2 months in a child >4 yrs of age.
Case 1
• The mother of a five-year-old boy is concerned about his nightly bed-
wetting. How will you evaluate?
 History
• Has there ever been a period of nighttime dryness? • No
• Is the child bothered by enuresis? • Yes

• Has any therapy been tried? • No

• Once every night
• What is the frequency of enuresis?
• Early, usual 2 hours after he has slept
• When during the night does it occur?
• Soaked diapers mostly
• Amount? – soakage of diapers
• No morning void is small
• Does the child have a large first morning void despite the enuresis?
• Likes to have juice with dinner, occasionally soda with evening snack
• Daytime drinking habits?
• No daytime symptoms
• Does the child have daytime symptoms?
• h/o UTI? • None
• h/o Constipation? • Yes, on and off. Mother ensures he takes good hydration esp in the evenings
when she comes back from work ensures he has hydrated well.
• h/o Weight loss?
• No but hasn’t really gained weight either.
• Snoring at night or daytime sleepiness
• No snoring or daytime sleepiness
• Developmental history?
• Age appropriate
• Psychosocial history • Parents feel he is a naughty kid, teacher recently called a meeting to discuss
his classroom behavior, advised to cut down his screentime. He is not
aggressive but mother feels he tends to have a hard time following
instructions.
Examination
• Anthropometry • Normal
• HEENT • No Enlarged tonsils
• CNS • Gait normal, no sensory deficit, DTRs and tone
normal in lower limbs
• Abd
• No palpable bladder or fecal mass
• Genitilia • Not circumcised, no hypospadias
• Rectum • No fecal soiling of garments, anal tone normal
• Back • No dimple or tuft of hair
Differentials
• Monosymptomatic primary enuresis • UTI
• Constipation
• Attention deficit/hyperactivity
disorder
Plan
After 18:00 restrict fluids to less Other pharmacologic options:
than 2 oz Anticholinergic: -
Avoid sugar and caffeine after 4 Oxybutynin or tolterodine
pm TCA:
- Imipramine
Case 2
Mother of a 5 year old boy shows concerns about her son soiling his
underpants. She is expecting her second child and has been aggressive
with toilet training.
How will counsel the mother about her child’s complaint?
• First explain how constipation is the cause in majority of the cases and establish
whether in her son’s case this is retentive vs non retentive.
• Ensure Soft, well formed stools: dietary change, then stool softeners and
laxatives.
• Address toilet refusal behavior: Positive toilet sits strategy i.e associate bathroom
trips with enjoyable activities and parent-child interactions. Short sits (30 secs)
progress gradually.
• Schedule prompted sits – after meals to take advantage of gastrocolic reflex.
• Reassure mother and explain that aggressive reaction will be counter productive.
Thank you