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Nocturnal enuresis + daytime urinary symptoms
Work on behavioral techniques x 3 months
Nocturnal enuresis + Constipation
Treat constipation with behavioral techniques + laxatives /dietary changes x 1-3 months
Treat nocturnal enuresis
Nocturnal enuresis only
FIGURE 12.1. Treatment algorithm.
References
1.Neveus T, von Gontard A. The standardization of terminology of lower urinary tract function in children and adolescents: Report from the standardisation commitee of the international children’s continence society. J Urol. 2006;176:314-324.
2.Hjalmas K, Arnold T, et al. Nocturnal enuresis: an international evidence-based management strategy. J Urol. 2004;171:2545-2561.
3.Feehan M, McGee R, Stanton W, Silva PA. A six year follow up of childhood enuresis: prevalence in adolescence and consequences for mental health. J Paediatr Child Health. 1990;26:75-79.
4.Schmitt BD. Nocturnal enuresis. Pediatr Rev. 1997;18:183-191.
5.Culbert TP, Banez GA. Wetting the bed: Integrative approaches to nocturnal enuresis. Explore. 2008;4:215-220.
6.Mercer R. Seven Steps to Nighttime Dryness: A Practical Guide for Parents of Children with Bedwetting. Ashton: Brookeville Media LLC; 2004.
7.Wolfish NM. Sleep/arousal and enuresis subtypes. J Urol. 2001;166:2444-2447.
8.Neveus T. Enuretic sleep: deep, disturbed or just wet? Pediatr Nephrol. 2008;23:1201-1202.
9.Maizels M et al. Getting to Dry: How to Help Your Child Overcome Bedwetting. Boston: The Harvard Common Press; 1999.
10.Glazener CMA et al. Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2009:1-108.
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11.Moffatt MEK, Harlos S, Kirshen AJ, et al. Desmopressin acetate and nocturnal enuresis: how much do we know? Pediatrics. 1993;92:420.
12.Mercer R. Dry at night: Treating nocturnal enuresis. Adv Nurse Pract. 2003;11:26-32.
13.Robson WL. Evaluation and management of enuresis. N Engl J Med. 2009;360(14):1429-1436.
Chapter 13
Disorders of Elimination:
Constipation
J. Christopher Austin
Key Points
››The majority of children who present with urinary tract infections and problems with daytime and nighttime incontinence will have associated bowel symptoms such as constipation and encopresis.
››In children presenting with the complaint of constipation up to 2/3 will also have associated symptoms of bladder dysfunction.
››About 95% of patients with constipation have functional constipation and will respond to therapy with behavior modification (timed evacuation after meals) and laxative therapy.
››The treatment of constipation will improve or cure some children with daytime incontinence and recurrent urinary tract infections.
13.1 Introduction
Constipation is commonly seen in pediatric patients. It is a frequent complaint seen by pediatric gastroenterologists as well as primary care providers. Constipation is very relevant to pediatric urology patients as it is seen frequently in
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patients presenting with urinary tract infections and/or voiding dysfunction. Dysfunctional elimination is the combination of bowel and bladder dysfunction that was initially described in patients with recurrent urinary tract infections and vesicoureteral reflux. It is important to seek out symptoms of bowel dysfunction in patients seen with urinary complaints and vice versa. The treatment of constipation is an integral part of the treatment regimen in children with voiding dysfunction. Encopresis, or fecal incontinence associated with constipation and chronic fecal impaction may also be present in patients with voiding dysfunction and recurrent urinary tract infections. In children with constipation an organic cause should be sought out during the evaluation including neurologic, endocrine, or anatomic causes. In 95% of patients no etiology is found and they are classified as having functional constipation.
13.2 Definition of Constipation
There are multiple definitions of constipation. For research studies the Rome definition is often used, however, for clinical practice this is too restrictive. For simplicity constipation can be defined as symptoms lasting for more than 2 weeks of infrequent (less than 3 per week), delay or difficulty in having bowel movements, large hard or painful bowel movements, or fecal soiling (encopresis). Given the relatively benign nature of the treatment of constipation with stool softeners or laxatives treating patients with bowel or urinary complaints should be considered when the diagnosis is suspected.
13.3 Evaluation
The first step in evaluating a child with constipation is a thorough elimination history. This should include whether the child passed meconium within 48 h of birth, the frequency, size and consistency of bowel movements. The presence of