Wetting and Soiling

Question 1

What is the definition of enuresis?

Answer 1

• Wetting while asleep after 5 years (wetting during day is daytime incontinence)

Question 2

What is the difference between primary and secondary enuresis? What tends to cause the latter?

Answer 2

• Primary (never having been dry continuously for at least 6 months)
• Secondary (having relapsed after a period of at least 6 months dryness)
  
  • Usually not an organic cause. Suspect UTI, sexual abuse, DM, epilepsy, neurogenic bladder

Question 3

How is primary enuresis managed?

Answer 3

• Start treating from 7 years old. Urgent over 10 years
• Reassurance - not their fault. Inherited. Prevalent
• Alarms - (70% success rate) 8-12 week use. Alarm when bed is wet, probably work through classical conditioning
• Second-line - desmopressin (ADH analogue) if polyuric, anticholinergics if bladder capacity small. Generally only for school camps etc.

Question 4

How is constipation defined in children?

Answer 4

• Best assessed with degree of difficulty passing stool rather than frequency
• In previous 8 weeks - 2 or more of:
  
  • < 3 bowel motions
  • 1 episode of faecal incontinence
  • Large stools in rectum or on abdo exam
  • Passing of stools so large toilet is obstructed
  • Retentive/withholding posturing
  • Painful defecation
• Most causes are functional, but consider rarer organic causes as well

Question 5

How is faecal incontinence defined in children? How does is commonly arise? How is it managed?

Answer 5

• Involuntary, repeated defecations into clothes in a child > 4
• More common in boys around 7-8
• Pathogenesis - anismus/withholding leading to chronic stretching and rectal hyposensitivity. Intermittent relaxation of EAS leads to leakage
• Mx - toileting program (maximise emptying, enhance sensation, facilitate timing), laxatives for initial clear-out, posture assistance (knees above hips, legs apart, bulge tummy). Remove barriers and add rewards.
  
  • Medications - lubricants, stimulants, stool softeners, osmotic laxative