F98.0; F98.1
DESCRIPTION
Enuresis and encopresis involve the inappropriate elimination of urine or faeces in childhood or adolescence. These disorders are based on developmental age (not chronological age) and may be voluntary or involuntary.
ENURESIS
F98.0
DESCRIPTION
Enuresis is bedwetting after the age or developmental level of 5 years. Primary monosymptomatic (nocturnal) enuresis refers to incontinence during sleep only. It is of great importance to differentiate between monosymptomatic enuresis and enuresis with associated bladder dysfunction during daytime, as they are distinct conditions with different treatment modalities.
Enuresis is a benign condition with a 15% spontaneous annual resolution rate. Intervention must carry no risk or have minimal side effects. The cure rate of “treatment” should be significantly greater than the spontaneous cure rate before it can be considered effective.
DIAGNOSTIC CRITERIA (DSM 5)
- Enuresis involves the repeated voiding of urine into bed or clothing, whether involuntary or intentional.
- Occurs more than twice per week for 3 months or causes significant distress or impairment in social or academic functioning.
- Chronological or mental age of 5 years.
- Exclude medical illness, medication or substance usage.
- Classified as nocturnal, diurnal or both.
GENERAL AND SUPPORTIVE MEASURES
- Assess type of enuresis e.g. primary nocturnal enuresis (mono-symptomatic).
- Take a thorough history, including a family history of elimination disorders, aspects of toilet training, trauma, abuse, anxiety and current medications use e.g. SSRI’s, risperidone, or diuretics.
- Perform medical examination and investigations (e.g. urine test strip) to exclude UTI, constipation, obstructive sleep apnoea, diabetes mellitus, diabetes insipidus, neurological and structural abnormalities.
- If sexual abuse is suspected refer to a social worker.
- Secondary enuresis may benefit from psychotherapy in cases where trauma is suspected or parent-child conflict appears to be prominent.
- Primary mono-symptomatic enuresis has a high rate of spontaneous resolution (about 15% per year).
- Management of primary nocturnal enuresis may involve one or a combination of interventions. Education and motivational therapies are usually tried initially. More active intervention is warranted as the child gets older, social pressures increase and self-esteem is affected.
- General education and advice about bedwetting should be provided to all children and families of children with mono-symptomatic enuresis. It is important to emphasize that enuresis is not the child's fault; provide practical suggestions to reduce the impact of bedwetting; encourage regular voiding during the day and just before going to bed; and provide guidelines about the timing and type of fluid intake.
- Motivational therapy (e.g. a star chart) is usually the first intervention for younger children (between five and seven years) who do not wet the bed every night and are mature enough to accept some responsibility for treatment. If motivational therapy fails to lead to improvement after three to six months, active interventions may be warranted.
- Address the manner in which the enuresis is managed at home. The parents should not be punitive but reward when the child remains dry. The child should assist in cleaning up the wet bedding or clothing.
- Ensure the child drinks 6-8 glasses of water daily.
- Ensure regular voiding 5-6 times per day.
- No diapers/nappies as these may lower self-esteem.
- Bladder training and lifting can also be used.
- Enuresis alarms are the most effective long-term therapy and have few adverse effects. They can be expensive and require a long-term commitment (usually three to four months).
- Bell and pad system is effective but only use in children > 7 years and who are well motivated.
MEDICATION TREATMENT
If general measures have failed after 6 months, consult with a specialist for consideration of desmopressin which is supported only for: short term use in low esteemed patient with enuresis:
- Desmopressin, oral, 200–400 mcg at night for 3 months. (Specialist consultation).
- Adverse effects include fluid retention, hyponatraemia and cerebral oedema.
REFERRAL
- Suspected underlying systemic illness or chronic kidney disease.
- Persistent enuresis in a child > 7 years.
- Referral to psychiatry for secondary enuresis, or for primary enuresis in a child > 7 years where basic measures fail and general medical disorders has been excluded.
ENCOPRESIS
F98.1
DESCRIPTION
When the passage of faeces is involuntary, there is usually constipation, impaction and retention with subsequent overflow. The constipation may develop due to psychological reasons e.g. anxiety around defaecation that leads to avoidant behaviour or physiological reasons e.g. paradoxical contraction of external sphincter. Deliberate encopresis may be part of a disruptive behaviour disorder e.g. oppositional defiant disorder. Constipation can lead to enuresis, urinary reflux and chronic UTI’s.
DIAGNOSTIC CRITERIA (DSM 5)
Involves the involuntary or intentional, repeated passage of faeces into inappropriate places. This occurs at least once each month for 3 months. The chronological or mental age of the child is at least 4 years. Substances, medications and medical illnesses need to be excluded. Encopresis is specified as either with or without constipation and overflow incontinence.
GENERAL AND SUPPORTIVE MEASURES
- History to include medical and psychological factors.
- Assess type of encopresis.
- Medical examination and investigations e.g. urine test strip.
- Refer to paediatrician for further work-up as needed.
- Treat constipation with diet and exercise.
- For the retentive subtype – educate child and parent about bowel function and use laxatives if necessary.
- Management requires educational, psychological and behavioural approaches e.g. timed daily intervals on the toilet with rewards.