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Essentials of Diagnosis
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DSM-IV-TR Diagnostic Criteria
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Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional.
At least one such event a month for at least 3 months.
Chronological age is at least 4 years (or equivalent developmental level).
The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.
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(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 Washington, DC: American Psychiatric Association.)
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General Considerations
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A Scandinavian population study revealed a prevalence of 1.5% among children aged 7–8 years. The sex ratio was 3.4:1 in favor of boys. A British study found a prevalence of about 1.5% among children aged 10–11 years, with a sex ratio of 4.3:1 in favor of boys.
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The etiology of encopresis is multifactorial. Normal continence and voiding requires the following sequence of neuromuscular events: (1) sensitivity to rectal fullness, (2) constriction of the external anal sphincter, puborectalis, and internal anal sphincter, (3) rectal contraction waves, (4) increase of intra-abdominal pressure following contraction of the diaphragm and abdominal muscles, and (5) relaxation of the sphincters.
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Children with encopresis exhibit abnormal anorectal dynamics, such as a weak internal sphincter, or a failure of the external sphincter to relax in concert with rectal contraction waves and abdominal straining. There are two types of encopresis: (1) with constipation and overflow incontinence and (2) without constipation and overflow incontinence.
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Toilet training involves the learning of the appropriate place and time for defecation; sensitivity to rectal fullness; and the sequential coordination of withholding, finding the right place, adopting the appropriate posture, relaxing the sphincters, and increasing intra-abdominal pressure. Most children are capable of learning the sequence by 18–24 months of age, however, learning may be interrupted by several antecedent conditions or concurrent events. Particularly important are the parent's attunement to the infant's signals and the parent's capacity to introduce the child to the toilet calmly; offer praise and encouragement for a favorable result; and avoid discouragement, coercion, or punishment for failures.
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A significant number of children who experience fecal retention were constipated in the first year of life. In other children, physiologic constipation has followed an attack of diarrhea. The preliminary constipation causes painful defecation, in some cases with anal fissure, which precipitates withholding. A pattern of withholding, fecal retention, and involuntary overflow may be created if withholding coincides with faulty toilet training (e.g., with coercion, harsh criticism, or physical punishment) or if the parent is emotionally unavailable or poorly attuned to the child (e.g., as a result of depression). Thus an initially physiologic condition disrupts the mother-child relationship, and psychogenic retention culminates in abnormal anorectal dynamics, megacolon, rectal insensitivity, and leakage or involuntary voiding.
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A small number of children, with severe behavioral disturbance, often from neglectful or rejecting homes exhibit no retention and constipation but deliberately defecate in closets or other inappropriate places. Two other nonretentive groups of encopretics are associated with (1) an apparent insensitivity to rectal fullness and the involuntary passage of feces or (2) the passage of (often liquid) feces when emotionally aroused by anxiety, fear, or laughter.
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The degree to which encopresis is associated with psychopathology in the parent or child is disputed. Enuresis, oppositional-defiant behavior, tantrums, school refusal, fire setting, and developmental immaturities have been described as concomitants, although it is uncertain to what degree these symptoms are primary or secondary to the encopresis.
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Although children with some genetically determined forms of mental retardation, such as Fragile-X syndrome, are at greater risk for encopresis, this vulnerability is likely to be more related to their level of intellectual disability than a specific syndrome.
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Some younger children who deliberately soil in inappropriate places do so at a time of stress or family change, for example after the birth of a sibling. Others, as described earlier in this chapter, do so in reaction to severe neglect or rejection, as in psychosocial dwarfism. A second group appears to lose sphincter control when emotionally aroused. These are often highly strung children exposed to emotional stress, for example, after a change of school.
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The most serious cases are associated with constipation, retention, megarectum, megacolon, and the involuntary passage of small amounts of stool, together with liquefaction, fecal leakage, and virtually constant soiling, or the intermittent involuntary passage of large stools. Children with extreme megacolon can become disabled with abdominal distension, anorexia, and loss of weight.
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Differential Diagnosis
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The following causes of incontinence or constipation should be distinguished from encopresis: Hirschsprung's disease, anal stenosis, and endocrine disorder. However, the combination of soiling; constipation; a ballooned, loaded rectum; and a loaded colon occurs only in encopresis.
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The clinician should evaluate the child for other developmental problems or psychiatric disorders (e.g., mental retardation, learning problems, disruptive behavior disorder, anxiety disorder).
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If the child has a loaded colon and rectum, it is likely that his or her rectum is insensitive to distension. Thus the colon should be washed out, and laxatives and stool softeners used until fecal masses can no longer be palpated and the child is passing regular stools of normal consistency. In severe cases, hospitalization is required.
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Parents should be educated to administer a behavioral program. Coercion, punishment, and criticism should be avoided. It is ill-advised, for example, to punish the child by making him or her clean soiled clothes. The child should be asked to sit briefly on the toilet at the same time twice per day: after breakfast and after school. All tension should be removed from the toileting experience. The child may be read to or may read to himself or herself. The parent should make no comment if no bowel movement is passed; in contrast, the parent should praise and offer individualized reward to the child if toileting is successful. Star charts are useful both as a record and for reinforcement (see discussion on “Treatment” in Section “Enuresis”).
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Depressed or compulsive parents often find it difficult to institute a consistent, gentle program of this type and may need treatment in their own right. Fathers should be involved in order to provide support and to cooperate in instituting the behavioral program. Marital problems may need attention.
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The child may require individual psychotherapy for associated anxiety disorder, disruptive behavior disorder, or other psychopathology. Because the possibility of relapse is high, treatment is often needed for one or more years, with a combination of laxatives, stool softeners, a high-fiber diet, parental education, parental behavior management, individual psychotherapy, and when necessary, psychiatric help for the parents. The results of this regimen are good, particularly in younger children. Success rates of 50–90% have been reported. Imipramine has been prescribed to treat encopresis, but no controlled studies of its effectiveness are available.
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Complications/Adverse Outcomes of Treatment
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Treatment complications are rare. Most children will improve with time and through the use of relatively innocuous interventions.
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Most cases of encopresis resolve by adolescence. A small minority of encopretic individuals remain incontinent as adults.
Brazzelli M,Griffiths P: Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev 2001;(4):CD002240.
Hersov L: Encopresis. In: Rutter M,Taylor E,Hersov L (eds).Child and Adolescent Psychiatry, 3rd edn. Oxford, UK: Blackwell Scientific, 1994, pp. 520–528.
Mikkelson EJ: Modern approaches to enuresis and encopresis. In: Lewis M (ed).Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd edn. Philadelphia: Lippincott Williams & Wilkins, 2002, pp. 700–710.
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Enuresis (Not Due to a General Medical Condition)
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Essentials of Diagnosis
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DSM-IV-TR Diagnostic Criteria
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Repeated voiding of urine into bed or clothes (whether involuntary or intentional).
The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
Chronological age is at least 5 years (or equivalent developmental level).
The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder).
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(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 Washington, DC: American Psychiatric Association.)
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General Considerations
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The sex ratio is equal until 5 years of age, after which males predominate (2:1 at 11 years of age). Boys are more likely to develop secondary enuresis. Scandinavian and New Zealand population studies have found the prevalence of enuresis at 7 and 8 years of age to be 9.8% and 7.4%, respectively. In the United States bedwetting is more common in African-Americans and Asian immigrants than among other populations. Most enuretic children achieve continence by puberty. Approximately 3% of childhood enuretics are still incontinent at 20 years of age.
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The cause of enuresis is unknown. One study has found an abnormality in circadian rhythms: Enuretics did not reduce the output of urine at night, as do normal children over 12 months of age. Enuretics have low functional bladder volume, a finding that correlates with behavioral disturbance, suggesting a common etiologic factor. Indeed, enuresis correlates with other maturational delays, particularly in language, speech, motor skills, and social development. An association has been noted between the tendency to sleep for long periods each day, between 1 and 2 years of age, and later enuresis, but the significance of this finding is uncertain. Bedwetting occurs at any stage of sleep, and no abnormalities of sleep architecture have been identified.
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Primary enuresis refers to enuresis without a period of continence. Secondary enuresis is enuresis after a period of normal bladder control. Two general population studies found that if toilet training is delayed until after 18 months, the prevalence of enuresis increases. Secondary enuresis, but not primary enuresis, is associated with psychosocial stressors. Secondary enuresis is more likely to be associated with behavioral disturbance. About 50% of enuretic children between 7 and 12 years of age have had a previous period of continence.
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A genetic factor may be involved in enuresis. Bedwetting runs in families and is significantly more common in monozygotic than dizygotic twins.
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Differential Diagnosis
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Urinalysis, microurine, and urine culture should be ordered routinely. If daytime enuresis is present, if the patient has a history of urinary tract infections or other urinary symptoms (e.g., dysuria, urinary frequency, dribbling), or if the patient's urine grows bacteria, further urologic examinations are required in order to rule out urinary tract infection, bladder neck obstruction, urethral valves, or other structural abnormalities. Epilepsy, diabetes mellitus, diabetes insipidus, and spina bifida should be excluded by history, physical examination, and urinalysis.
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The child is given a star to add to a calendar for each dry night. The star chart alone results in a cure for a minority of enuretic children. It also provides useful records of baseline and the child's progress.
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Surgical Treatment & Retention Control Training
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The efficacy of radical surgical treatments such as urethral dilatation, bladder neck repair, cystoplasty, or division of the sacral nerves has not been demonstrated. Bladder training, which involves the retention of urine for longer and longer periods of time, is no longer used.
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Psychopharmacologic Interventions
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Heterocyclic antidepressants reduce the frequency of bedwetting in about 80% of patients and suppress it entirely in about 30%. However, most patients will relapse within about 3 months of withdrawal from the drug. The effective nighttime dosage is usually 1–2.5 mg/kg and occasionally as much as 3.5 mg/kg. This treatment essentially aims to suppress wetting while waiting for maturation in bladder control. The drug should be tapered and discontinued every 3 months and titrated back to a therapeutic level if enuresis recurs. The neuropharmacologic basis of the antienuretic effect is unknown.
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The synthetic antidiuretic desmopressin acetate (desamine-d-arginine vasopressin) is an antienuretic. It may be administered intranasally or orally. Desamine-d-arginine vasopressin may operate by reducing urine volume below that which triggers bladder contraction. As with antidepressant therapy, relapse is common following withdrawal.
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Sympathomimetic (e.g., ephedrine) and anticholinergic (e.g., belladonna) drugs are ineffective in treating enuresis.
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Psychotherapeutic Interventions
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The alarm-and-pad technique (in which an alarm is triggered when the first drop of urine onto a pad closes an electrical circuit) has a 75–80% rate of cure and a 30% relapse rate. It is the most effective treatment available for both primary and secondary enuresis. Children with daytime enuresis, behavioral problems, and a lack of motivation may be resistant to behavioral treatment. Optimal improvement requires at least 6–8 weeks of treatment. For maximum benefit, the alarm-and-pad technique may be combined with antidepressant or antidiuretic medication and a star chart.
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If behavioral treatment is clearly the most effective method, why is it not the standard? Probably because it is cumbersome, lengthy, embarrassing, and requires good motivation. It is reasonable to begin treating enuresis with drugs and to move to behavioral treatment if medication is ineffective.
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Complications/Adverse Outcomes of Treatment
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Treatment complications are rare. Most children will improve with time.
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Most cases of enuresis remit between 5 and 7 years of age or 12 and 15 years of age. A minority of cases continue into adulthood.
Glazener CM,Evans JH,Peto RE: Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2005;(2):CD002911.
Mikkelson EJ: Modern approaches to enuresis and encopresis. In: Lewis M (ed)Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd edn. Lippincott Williams & Wilkins, 2002, pp. 700–710.