Elimination disorders are present in children that urinate or defecate in places other than the toilet. This condition is diagnosed in children between the ages of 7 and 12. Elimination disorders primarily fall under enuresis, where urine is passed outside the toilet. Encopresis is the passage of feces on bed or outside the toilet. In other cases, it is possible to experience both disorders at the same time. To help with overcome elimination disorders, we’ll examine possible treatment methods to encourage normal waste disposable.
Enuresis or bed wetting is defined as involuntary (or even intentional) micturition in children 5 years of age or older, when normal bladder control is acquired. Bladder control is normally acquired by the age of 3 years. If it is not acquired than it is abnormal. When bed wetting occurs repeatedly, it is called as “enuresis.”
Types of Enuresis
Enuresis may be divided into following types:
- Primary enuresis- Primary enuresis refers to the condition in which children have never been successfully trained to control urination. It may be delay in maturation of sphincter control.
- Secondary enuresis- Secondary enuresis refers to condition in which children have been successfully trained, but revert to bed wetting in response to some stress. It may be due to parent-child maladjustment.
Subtypes may be divided on the basis of time of bed wetting.
- Nocturnal enuresis- Nocturnal enuresis means bedwetting during night.
- Diurnal enuresis- Diurnal enuresis bedwetting during day time.
- Mixed enuresis- Mixed enuresis includes a combination of both nocturnal and diurnal type.
Causes of Enuresis
- Genetics- Heredity as a causative factor of primary nocturnal enuresis has also been strongly suggested by the identification of a genetic marker associated with the disorder. This seems to suggest the existence of a major dominant gene for primary nocturnal enuresis. Genetic research shows that bed wetting is associated with genes on chromosomes 13q and 12q.
- Inappropriate toilet training- If toilet training is started very early, it produces stress on the child. So, age at which toilet training is started has an important impact on child.
- Emotional factors- Emotional and psychological disturbance due to death in family, sexual abuse, scolding, extreme bullying and feeling of rejected create internal emotional imbalance in the child which may lead to secondary enuresis.
- Secretion of Antidiuretic Hormone– It has been found that humans show both diurnal and nocturnal variations in the secretion of antidiuretic hormone, when assessed over a 24-hour period. Normal increases in the secretion of antidiuretic hormone are typically found in response to extended periods of sleep. During this period, the bladder does not empty.
- Neurological developmental delay- This is the most common cause of bed wetting. Bed wetting may be due to delay in nervous system’s ability to process feeling of full bladder.
- Anatomic factors- In cases of primary enuresis, anatomic abnormalities are not usually found. Findings from some studies, however, have suggested that functional bladder capacity may be reduced in patients with nocturnal enuresis. These findings have been disputed by other research which have not found abnormalities in bladder function or size when only nocturnal enuresis cases were considered. While some parents report a small bladder capacity in children with enuresis, this condition usually is accompanied by daytime symptoms.
For management, it is essential to assess the home conditions of the child, his/her socio-economic status and family conditions. Explore the child-parent relationships.
- Reassure the child and parents.
- Build the child’s self confidence.
- Parents are advised not to criticize the child for bed-wetting.
- The child should not be given any liquids like tea or milk after 5pm in the evening.
- The child should be made habit to pass urine before going to bed.
- The child is trained o hold the urine for longer time. This may be done by making the child drink large quantity of water during day and leads him o delay emptying bladder as long as possible.
- Motivational therapy– Convince parents that the child wants to be dry and child is encouraged to assume responsibility for his enuresis and actively participate in treatment. Move from blame for wet nights to praise for dry nights. A dry morning should receive positive recognition and should receive lavish words of praise from everyone in family.
- Bed-wetting alarms therapy- Physicians frequently suggests bed-wetting alarms, which produce a loud tone on sensing moisture. This helps the child to wake at sensation of full bladder.
- Multidimensional behavioral therapy- Full spectrum home training and Scharf’s Comprehensive Treatment Program.
- Pharmacotherapy- In very resistant cases tricyclic antidepressants such as amitriptyline, imipramine are given orally, at night for 2 months. Desmopressin, which is a synthetic replacement for antidiuretic hormone (ADH), is also given as it reduces urine production during sleep.
Encopresis is involuntary fecal soiling in children who passed the age of toilet training. Encopresis happens to children ages 4 and older who have already been toilet trained.
Causes of Encopresis
- It is rarely can be caused by any congenital defect.
- In majority of cases it develops as a result of chronic constipation.
- When a child is constipated, he or she has fewer bowel movements than normal. Bowel movements can then become hard, dry, and difficult to pass.
- If child may avoid going to the bathroom because it hurts. Then stool becomes impacted in the rectum and the large intestine (colon). The stool can’t move forward and rectum and intestine become enlarged.
- Over time, liquid stool can start to leak around the hard, dry, impacted stool. This soils your child’s clothing.
Management can be divided into 3 parts-
- Medical and behavior therapy
The management of encopresis focuses on following principles:
- Empty the colon of stool.
- Establish regular, soft and painless bowel movement.
- Promote regular bowel habits.
Medical and Behavior Therapy
The management of encopresis focuses on following therapies:
- Administer enema, as it creates pressure within the rectum and gives the child an urge to pass stool.
- Suppositories and laxatives can also be used to promote bowel evacuation.
- Establish a regular toilet routine. The child should be made to sit in toilet for 5-10 minutes after breakfast and again after dinner everyday.
The management of encopresis focuses on following techniques:
- Behavioral techniques- Offer age appropriate positive reinforcement for developing regular toilet habits.
- Training techniques- Children are taught how to use their abdominal, pelvic and anal sphincter muscles which they have so often used to retain stool. Children may respond to teaching about appropriate use of muscles and other physical responses during defecation.