Elimination Disorders

What are elimination disorders

Disorders involving inappropriate elimination of urine or feces

What are the 2 main elimination disorders

Enuresis / encopresis

When are elimination disorders usually first diagnosed

Childhood or adolescence

Can elimination disorders be voluntary or involuntary

Both

Can enuresis and encopresis occur together

Yes

What is enuresis

Repeated voiding of urine into bed or clothes whether involuntary or intentional

How often must enuresis occur to meet the frequency requirement

At least twice per week

How long must the frequency requirement for enuresis persist

At least 3 consecutive months

Can enuresis be diagnosed without twice weekly wetting

Yes / if clinically significant distress or impairment is present

What minimum age is required for enuresis

At least age 5 or equivalent developmental level

What exclusion applies to enuresis

Urinary incontinence cannot be caused by a substance medication or medical condition

What are the 3 enuresis subtypes

Nocturnal only / diurnal only / nocturnal and diurnal

What is nocturnal only enuresis

Urination occurs only during nighttime sleep

What is another name for nocturnal only enuresis

Monosymptomatic enuresis

What is diurnal only enuresis

Urination occurs during waking hours without nighttime enuresis

What is urge incontinence

Sudden urinary urgency with bladder instability followed by incontinence

What is voiding postponement

Consciously delaying urination until incontinence occurs

What is nocturnal and diurnal enuresis

Urinary incontinence occurs during both sleep and waking hours

What is another name for nocturnal and diurnal enuresis

Nonmonosymptomatic enuresis

What is primary enuresis

Urinary continence was never established

What is secondary enuresis

Urinary incontinence develops after a period of established continence

When does secondary enuresis commonly begin

Between ages 5 and 8 although it can begin later

Does most childhood enuresis persist into adulthood

No / most children become continent by adolescence

What factors may increase risk for enuresis

Developmental delays / neuropsychiatric problems / delayed toileting / psychosocial stress / family history

What mechanisms are associated with nocturnal enuresis

Mismatch between nighttime urine production / bladder capacity / and ability to awaken from sleep

Is nocturnal enuresis associated with genetics

Yes / strong familial influence is reported

Which sex is nocturnal enuresis more common in

Males

Which sex is daytime urinary incontinence more common in

Females

What functional problems can enuresis cause

Low self esteem / peer embarrassment / restricted social activities / caregiver anger or punishment

What medical conditions should be considered before diagnosing enuresis

Neurogenic bladder / structural urinary abnormalities / diabetes / urinary tract infection / seizure disorder

Can medication cause urinary incontinence

Yes / examples include diuretics and antipsychotic medications

Can enuresis still be diagnosed when another medical condition is present

Yes / if incontinence clearly existed before the condition or persists after adequate treatment

What conditions commonly occur with enuresis

Developmental delays / behavioral symptoms / constipation / encopresis / sleep disorders / urinary tract infections

What sleep problems may be associated with nocturnal enuresis

Restless legs / sleepwalking / sleep terrors / heavy snoring / sleep apnea

What is encopresis

Repeated passage of feces into inappropriate places whether involuntary or intentional

How often must encopresis occur

At least once per month

How long must encopresis persist

At least 3 months

What minimum age is required for encopresis

At least age 4 or equivalent developmental level

What exclusion applies to encopresis

Fecal incontinence cannot be caused by a substance or medical condition except through a mechanism involving constipation

What are the 2 encopresis subtypes

With constipation and overflow incontinence / without constipation and overflow incontinence

What defines encopresis with constipation and overflow incontinence

Evidence of constipation is present by history or examination

What does stool often look like in encopresis with overflow

Poorly formed or liquid because stool leaks around retained feces

What commonly causes involuntary encopresis

Constipation / fecal impaction / stool retention followed by overflow

What may cause constipation leading to encopresis

Anxiety about defecation / stool withholding / painful defecation / inadequate fluids / medical conditions / medication effects

What cycle can maintain constipation related encopresis

Painful defecation leads to withholding / withholding worsens constipation / constipation causes more painful defecation and overflow

What often happens after constipation is successfully treated in overflow encopresis

The fecal incontinence resolves

What defines encopresis without constipation and overflow incontinence

Repeated soiling occurs without evidence of constipation

What is stool usually like in encopresis without constipation

Normal form and consistency with intermittent soiling

What behavioral disorders may be associated with deliberate fecal soiling

Oppositional defiant disorder / conduct disorder

Is encopresis with constipation more common than encopresis without constipation

Yes

What emotional consequences can encopresis cause

Shame / embarrassment / low self esteem / social avoidance

Can fecal smearing be accidental

Yes / it may result from attempts to clean or hide involuntary stool

What is primary encopresis

Fecal continence was never established

What is secondary encopresis

Fecal incontinence develops after a period of established continence

What factors may increase risk for encopresis

Inconsistent toilet training / psychosocial stress / painful defecation / anxiety / depression / behavioral disorders

Is encopresis more common in boys or girls after early childhood

Boys

Is extensive testing usually required to diagnose encopresis

No / diagnosis is generally based on history and physical examination

What finding supports encopresis with constipation and overflow incontinence

Fecal impaction on examination or other evidence of retained stool

When should additional medical evaluation be considered for encopresis

When symptoms are refractory or suggest another medical cause

What medical causes of fecal incontinence would argue against encopresis

Chronic diarrhea / spina bifida / anal stenosis or other conditions directly causing fecal incontinence

Can enuresis occur with encopresis

Yes / it is commonly associated

What is other specified elimination disorder

Clinically significant elimination symptoms that do not meet full criteria when the clinician states why

What is an example of other specified elimination disorder

Low frequency enuresis

What is unspecified elimination disorder

Clinically significant elimination symptoms that do not meet full criteria when the clinician does not state why or lacks enough information

What is the highest yield age shortcut for elimination disorders

Enuresis requires developmental age 5 / encopresis requires developmental age 4

What is the highest yield frequency shortcut for elimination disorders

Enuresis = twice weekly for 3 months or significant impairment / encopresis = once monthly for 3 months

What is the highest yield diagnostic shortcut for elimination disorders

Enuresis = inappropriate urine after developmental age 5 / encopresis = inappropriate feces after developmental age 4