Elimination Disorders

What are Elimination Disorders?

Elimination disorders occur in children who have problems going to the bathroom — both defecating and urinating. Although it is not uncommon for young children to have occasional “accidents,” there may be a problem if this behavior occurs repeatedly for longer than three months, particularly in children older than 5 years.

Types of Elimination Disorders

Elimination disorders are broadly categorized into enuresis and encopresis.

Enuresis

This disorder is more commonly known as bedwetting. Children with this condition are unable to control their urine. This usually results in frequent or irregular release on their beds or elsewhere.

In households made up of young children, especially boys—2enuresis is a common occurrence. Around 20% of five-year-olds live with this condition. This number goes down to 5%-10% in seven-year-olds. Bedwetting is however more common in the latter age group.2

Enuresis may occur in two forms:2

1. Nocturnal only: Urine is released at night time during sleep
2. Diurnal only: Urine incontinence happens during waking hours

Despite taking place during waking hours, diurnal enuresis is involuntary. A child may pass urine where they feel an increased urge to pee.2

Other times, this urination is the result of pressure on the abdomen. When children delay urination while in public spaces, this may worsen their chances of involuntary expulsion. Unplanned urination may also take place when laughing.2

Encopresis

As a benchmark, encopresis occurs in children no younger than four years old. This condition is characterized by children passing stool in inappropriate locations like their underwear.

This condition may be voluntary or involuntary, and is a common occurrence in male children.3

About 4.1% of children between five to six years of age will defecate in unsuitable locations. In 11- to 12-year-olds, this number drops to 1.6%.

Encopresis usually takes place in daytime. This condition may be observed in children that have received, and those that are lacking toilet training.

The disorder is observed in two forms:

1. Constipation-related encopresis: In this case, constipation causes stool to be hard and painful to pass. This pain can prevent a child from going to the toilet, leading to greater difficulty in releasing the stool. The strain caused by the feces can weaken colon nerves. This can cause liquid or softer stool to leak around the yet-to-be passed stool. The child may also lose control of bowel movements.
2. Non-retentive fecal incontinence: this occurs when a child soils their clothing or other inappropriate items without signs of constipation. This child will have bowel movements in unsuitable places or times.

Signs and Symptoms of Elimination Disorders

There are notable characteristics of elimination disorders. In either case, the following distinguishing traits are present:

Enuresis

• Repeated bedwetting despite toilet training. This is known as primary enuresis.
• Bedwetting after at least six months of dryness. Otherwise termed secondary enuresis.
• Bedwetting must be frequent for at least two weeks over three consecutive months.

Encopresis

• Stool or liquid stool leakage on underwear
• Constipation
• Straining when stooling
• Dry or hard stool
• Avoiding bowel movements
• Encopretic incidents taking place for at least three months

Causes of Elimination Disorders

Enuresis

There is no precise cause of enuresis. Different factors are however linked to bedwetting, or passing urine in inappropriate places.

For instance, constipation may increase pressure on the bladder, leading to an increased urge to urinate.2 Deep sleepers who are not easily aroused may also be at higher risk of enuresis.

Where the bladder suffers a delay in maturity, this can affect its capacity to hold urine. Likewise, levels of vasopressin—a hormone that promotes water retention in the kidneys—may decrease. This can impact the chances of holding urine in.

Encopresis

This condition may result from constipation. A low-fiber diet and poor hydration. Even stress over potty training can contribute to this condition.

Risk factors of encopresis include a low socioeconomic background, fear of using unhygienic toilets, living in a war-torn area, or child hospitalization for another condition. Other contributing factors are bullying and behavioral problems like depression or social anxiety. Poor performance in school could also be a factor.

Treatment of Elimination Disorders

Enuresis Treatment

There are non-pharmaceutical and pharmaceutical measures available for managing this condition.

Non-Pharmaceutical Management of Enuresis

• Bell and pad method: This requires a child to wear a device to sleep. This device contains a sensor that makes a noise when wet to stimulate the child to wake up. The bell and pad method intends to stop the stream, allowing urine to be passed in the toilet instead.
• Dry Bed Training: This is another option which combines the bell and pad with behavior treatment for the child with parental support.
• Nighttime awakenings: Here, children are woken up at regular hours during the night. This is useful where alarms do not work to alert a child to use the toilet. However, this can lead to sleep problems in the child due to disrupted sleep.
• Limiting fluid intake: Children prone to bedwetting can be assisted by restricting their fluid intake before bedtime.
• Bladder training: Under this technique, children are taught to hold their urine for longer periods of time. This is useful for diurnal and nocturnal enuresis.
• Motivational therapy: The child and their caregivers may receive this therapy to boost morale before beginning any of the methods listed above.

Pharmaceutical Management of Enuresis

Children may be given anti-diuretic hormones (ADH) like desmopressin to manage urine production. Other options include imipramine—a tricyclic antidepressant that helps to relax the bladder, preventing enuretic episodes.

It should be noted that pharmaceutical measures produce higher relapse rates compared to the bell and pad method.

Encopresis Treatment

To manage this condition, a pediatrician may give the affected child a laxative, an enema, or medication to soften the stool.

Parents can also assist with good bowel habits by planning bathroom time after meals. They may also praise their children for using the toilet. This can encourage regular toilet usage and may prevent excrement on clothing.