- Psychosocial and behavioral treatment
- stimulant Medications:
- Short-acting , intermediate-acting , and long- acting methylphenidate and long – acting dextroamphetamine are widely used
- Non stimulant medications , including tricyclic antidepressants , may be helpful for children who have not responded to stimulant medication .
Control of elimination
- Definition: urinary incontinence in a child who is considered adequately mature to have achieved continence
- Diurnal(day time): dryness is expected in the U.S. by age 4 years
- Nocturnal(night time): dryness is expected by age 6 years
- Primary: incontinence in a child who has never achieved dryness
- Secondary: incontinence in child who has been dry for at least 6 months.
- Multiple possible etiologic factor
- Primary enuresis often is associated with a family history delayed acquisition of bladder control
- Genetic etiology and familial groups with autosomal dominant phenotypic pattern of nocturnal enuresis have been identified
- Although most children with enuresis do not have a psychiatric disorders , stressful life events can trigger loss of bladder control
- Sleep physiology may play a roll in the etiology of nocturnal enuresis with a high arousal threshold commonly noted.
- In a subgroup enuretic children , nocturnal polyuria relates to a lack of a nocturnal Vasopressin peak.
- Malformation of the detrusor muscle: involuntary contractions even when the bladder contains small amounts of urine
- Chronic constipation with a large dilated distal colon which impinges on the bladder
- How often does wetting occur?
- Does it occur during the day , night or both?
- Are there any associated conditions with wetting episodes(bad dreams , caffeinated drinks or exhausting day)?
- Has the child hade a period of dryness in the past?
- Stressful event (family move , birth , or death of a family member)?
- A review of systems should include a developmental history and detailed information about the neurologic , urinary and gastrointestinal systems(including patterns of defecation)
- A history of sleep patterns also is important
- A family history often reveals that one of both parents had enuresis as children
- Child developmental patterns
- Special attention is paid to the abdominal , neurologic and genital examination.
- A rectal examination is recommended if the child has chronic constipation
- The lumbosacral spine should be examined for signs of spinal dysraphism
- For most children the only laboratory test is a clean catch urinalysis to look for chronic urinary tract infection , renal disease and diabetes mellitus.
-Treatment of organic causes like: UTIs , diabetes mellitus , sleep disorder , urologic abnormalities and chronic constipation
- Conditioning therapy:
- Enuresis alarm (an alarm that rings when the child wets)success rate 70%
- Is 2nd – line treatment(desmopressin acetate , imipramine)
- Is the passage of feces into inappropriate places after a chronological age of 4 years
- Encopresis with constipation
- Encopresis without constipation
- May persist from infancy(primary) , or may appear after successful toilet training(secondary)
- The first consideration in managing encopresis is assessment of fecal retention
- A positive finding on rectal examination is sufficient to document fecal retention(chronic constipation)
- A negative finding requires X-ray of abdomen
- Sometimes there is an abnormal anal sphincter function which needs an electromyography
- Secondary encopresis is associated with high levels of psychosocial and conduct disorders
- The standard treatment begins with clearance of impacted fecal material and short – term use of mineral oil or laxative to prevent further constipation
- Behavioral treatment with regular post prandial toilet sitting and adaption of a high – fiber diet