The most widely used conditioning therapy for nocturnal enuresis is the enuresis alarm. Enuresis alarms have an initial success rate of 70% with a relapse rate of 10%. The alarm is worn on the wrist or clipped onto the pajama and has a probe that is placed in the underpants or pajamas in front of the urethra. The alarm sounds when the first drop of urine contacts the probe. The child is instructed to get up and finish voiding in the bathroom when the alarm sounds. After 3 to 5 months, 70% of children are dry through the night.
Pharmacotherapy for nighttime enuresis includes desmopressin acetate and, rarely, tricyclic antidepressants. Desmopressin decreases urine production and has proved to be safe in the treatment of enuresis. The oral medication is started at 0.2 mg per dose (one dose at bedtime) and on subsequent nights is increased to 0.4 mg and then to 0.6 mg if needed. This treatment must be considered symptomatic, not curative, and has a relapse rate of 90% when the medication is discontinued. Imipramine, now rarely used for enuresis, reduces the frequency of nighttime wetting. The initial success rate is 50%. Imipramine is effective during treatment only, with a relapse rate of 90% on discontinuation of the medication. The most important contraindication is risk of overdose (associated with fatal cardiac arrhythmia).
The psychological consequences can be severe. Families can minimize the impact on the child’s self-esteem by avoiding punitive approaches and ensuring that the child is competent to handle issues of their own comfort, hygiene, and aesthetics.
Appropriate anticipatory guidance to educate parents that bed-wetting is common in early childhood helps alleviate considerable anxiety.
Constipation is decreased frequency of bowel movementsusually associated with a hard stool consistency. The occurrence of pain at defecation frequently accompanies constipation. Although underlying gastrointestinal, endocrinologic,or neurologic disorders can cause constipation, functional constipation implies that there is no identifiable causativeorganic condition. Encopresis is the regular, voluntary orinvoluntary passage of feces into a place other than the toilet after 4 years of age. Encopresis without constipation isuncommon and may be a symptom of oppositional defiantdisorder or other psychiatric illness. Soiling is the involuntarypassage of stool and often is associated with fecal impaction.The normal frequency of bowel movements declines betweenbirth and 4 years of age, beginning with greater than fourstools per day to approximately one per day.
The etiology of functional constipation and soiling includes a low-fiber diet, slow gastrointestinal transit time for neurologic or genetic reasons, and chronic withholding of bowel movements, usually because of past painful defecation experiences. Approximately 95% of children referred to a subspecialist for encopresis have no other underlying pathologic condition.
In U.S. studies, 16% to 37% of children experience constipation between 5 and 12 years of age. Constipation with overflow soiling occurs in 1% to 2% of preschool children and 4% of school-age children. The incidence of constipation and soiling is equal in preschool girls and boys, whereas there is a male predominance during school age.
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The presenting complaint for constipation with soiling is typically a complaint of uncontrolled defecation in the underwear. Parents may report that the child has diarrhea because of soiling of liquid stool. Soiling may be frequent or continuous. On further questioning, the clinician learns that the child is passing large-caliber bowel movements that may occasionally block the toilet. Children younger than 3 years of age often present with painful defecation, impaction, and withholding. The history should include a complete review of systems for gastrointestinal, endocrine, and neurologic disorders and a developmental and psychosocial history.