Toileting: The Assessment and Treatment of Enuresis and Encopresis Emily D. Warnes, Ph.D. EDPS 951

Toileting: The Assessment Toileting: The Assessment and Treatment of Enuresis and Treatment of Enuresis

and Encopresisand Encopresis

Emily D. Warnes, Ph.D.Emily D. Warnes, Ph.D.

EDPS 951EDPS 951

Enuresis: DefinitionEnuresis: Definition

DSM IV definition: DSM IV definition:

““Repeated voiding of urine into bed or Repeated voiding of urine into bed or clothes, whether involuntary or clothes, whether involuntary or intentional” (American Psychiatric intentional” (American Psychiatric Association, 2000, p. 121).Association, 2000, p. 121).

Enuresis: Diagnostic Enuresis: Diagnostic CriteriaCriteria

307.6 Enuresis307.6 Enuresis Repeated voiding of urine into bed or clothesRepeated voiding of urine into bed or clothes Clinically significantClinically significant

Twice per week for at least 3 consecutive monthsTwice per week for at least 3 consecutive months Impairment in daily functioning (e.g., social academic)Impairment in daily functioning (e.g., social academic)

Chronological Age: 5 years (or developmental Chronological Age: 5 years (or developmental equivalent)equivalent)

Behavior is not due exclusively to the direct Behavior is not due exclusively to the direct physiological effect of the following:physiological effect of the following:

Substance (e.g., diuretic)Substance (e.g., diuretic) General Medical Condition (e.g., diabetes. Seizure General Medical Condition (e.g., diabetes. Seizure

disorder)disorder)

Enuresis: DefinitionEnuresis: Definition

Enuresis Types:Enuresis Types: DiurnalDiurnal

Voids occurring during the daytimeVoids occurring during the daytime NocturnalNocturnal

Voids occurring during the nighttimeVoids occurring during the nighttime

Enuresis: PrevalenceEnuresis: Prevalence

Incidence of Nocturnal Enuresis

30

10

3

1

0

5

10

15

20

25

30

35

40

Age in Years

Per

cen

tag

e (%

)

4 6 12 18

Enuresis: Prevalence Enuresis: Prevalence

Who Experiences Nocturnal Enuresis?Who Experiences Nocturnal Enuresis? 5-7 million American children over age 55-7 million American children over age 5 15% spontaneously remit per year15% spontaneously remit per year MalesMales

Estimates range up to 25% at age 6 and 8% at age 12Estimates range up to 25% at age 6 and 8% at age 12 FemalesFemales

Estimates range up to 15% at age 6 and 4% at age 12Estimates range up to 15% at age 6 and 4% at age 12 Approximately 15% to 20% also experience Approximately 15% to 20% also experience

diurnal enuresisdiurnal enuresis

Enuresis: EtiologyEnuresis: Etiology

Familial Factors: Incident RatesFamilial Factors: Incident Rates 77% in children who have both maternal 77% in children who have both maternal

and paternal positive history for NEand paternal positive history for NE 44%, one parent with positive history of NE44%, one parent with positive history of NE 15% , no parental history of NE15% , no parental history of NE


Sleep FactorsSleep Factors Parents of children with NE report Parents of children with NE report

remarkably heavy sleepremarkably heavy sleep Sleep EEG research suggests enuretic Sleep EEG research suggests enuretic

episodes indiscriminately transpire episodes indiscriminately transpire across the nightacross the night

Sleep patterns parallel between children Sleep patterns parallel between children with and without enuresiswith and without enuresis


Biological FactorsBiological Factors Mean bone growth and height less Mean bone growth and height less

developed among children with enuresisdeveloped among children with enuresis Small bladder capacitySmall bladder capacity

Research suggests bladder capacity remains Research suggests bladder capacity remains the same during day and nightthe same during day and night

Increased nocturnal urine outputIncreased nocturnal urine output Differences in production of the antidiuretic Differences in production of the antidiuretic

horomone (ADH)horomone (ADH)


Bio-Behavioral FactorsBio-Behavioral Factors Integration of biological factors and Integration of biological factors and

behavioral learning principles behavioral learning principles AssessmentAssessment TreatmentTreatment

Enuresis: AssessmentEnuresis: Assessment

Medical AssessmentMedical Assessment Rule out significant medical conditionRule out significant medical condition Most often already ruled out by the time Most often already ruled out by the time

you see the kidyou see the kid Behavioral AssessmentBehavioral Assessment

Assess general behavior using a broad-Assess general behavior using a broad-band rating scale (e.g., CBCL or BASC)band rating scale (e.g., CBCL or BASC)


Behavioral Assessment: InterviewBehavioral Assessment: Interview Behavioral or developmental problemsBehavioral or developmental problems Medical conditionsMedical conditions History and current status of problemHistory and current status of problem Family historyFamily history Potty training historyPotty training history


Behavioral Assessment: Interview Behavioral Assessment: Interview Environmental contributors (e.g., when, Environmental contributors (e.g., when,

how much fluid intake, proximity to b-how much fluid intake, proximity to b-room, sleep routine and arrangements)room, sleep routine and arrangements)

Consequences (e.g., how do parents Consequences (e.g., how do parents handle it, how does the child react)handle it, how does the child react)

Child’s feelings and motivation to treatChild’s feelings and motivation to treat


Behavioral Assessment: Recording Behavioral Assessment: Recording Data Data Provide Chart for recording voidsProvide Chart for recording voids Assess time of night, number of voids, Assess time of night, number of voids,

size of void, reactionsize of void, reaction

Enuresis: TreatmentEnuresis: Treatment

Pharmacological Pharmacological Imipramine (Trofanil)Imipramine (Trofanil)

Tricyclic antidepressantTricyclic antidepressant Once medication discontinued, bedwetting Once medication discontinued, bedwetting

resumesresumes Relapse rate varies from 60% to 90%Relapse rate varies from 60% to 90%

Duration of treatment varies without Duration of treatment varies without consensus consensus


Pharmacological Pharmacological Desmopressin Acetate (DDAVP)Desmopressin Acetate (DDAVP)

Analogue of Vasopressin (ADH)Analogue of Vasopressin (ADH) Supports urine concentrationSupports urine concentration Decreases urine volume during nighttimeDecreases urine volume during nighttime

Research findings yield mixed outcomesResearch findings yield mixed outcomes Increased number of dry nightsIncreased number of dry nights Dryness may not maintain once terminate Dryness may not maintain once terminate

DDAVPDDAVP Relapse rate varies from 50% to 95% Relapse rate varies from 50% to 95%


BehavioralBehavioral Moisture Alarm (Bell and Pad)Moisture Alarm (Bell and Pad)

Classical ConditioningClassical Conditioning Full bladderFull bladder VoidsVoids Alarm soundsAlarm sounds AwakeningsAwakenings

Operant ConditioningOperant Conditioning Avoid aversive conditions during night (e.g., Avoid aversive conditions during night (e.g.,

waking up to a wet bed, cleaning up procedures, waking up to a wet bed, cleaning up procedures, changing bed linens)changing bed linens)


Moisture AlarmMoisture Alarm Generally achieve dry nights within 2- 4 Generally achieve dry nights within 2- 4

monthsmonths Research suggests up to 70% successful Research suggests up to 70% successful

outcomesoutcomes High Response EffortHigh Response Effort


Arousal Training –Focus on R+ Arousal Training –Focus on R+ getting upgetting up Awakens Awakens Turns off alarmTurns off alarm Attends the restroom for toilet sitAttends the restroom for toilet sit Reattach enuresis alarmReattach enuresis alarm

EncopresisEncopresis

Encopresis: DefinitionEncopresis: Definition

Involuntary loss of formed, Involuntary loss of formed, semiformed, or liquid stool in semiformed, or liquid stool in inappropriate places, such as inappropriate places, such as underwear, in children older than age underwear, in children older than age 44

Encopresis: Diagnostic Encopresis: Diagnostic CriteriaCriteria

EncopresisEncopresis Repeated passage of feces into inappropriate Repeated passage of feces into inappropriate

places (e.g., clothing or floor)places (e.g., clothing or floor) Clinically significantClinically significant

Once per month for at least 3 monthsOnce per month for at least 3 months Chronological Age: 4 years (or developmental Chronological Age: 4 years (or developmental

equivalent)equivalent) Behavior is not due exclusively to the direct Behavior is not due exclusively to the direct

physiological effect of the following:physiological effect of the following: Substance (e.g., laxatives)Substance (e.g., laxatives) General Medical Condition except constipationGeneral Medical Condition except constipation

Encopresis: Diagnostic Encopresis: Diagnostic CriteriaCriteria

EncopresisEncopresis Code as follows:Code as follows:

797.6 With Constipation and Overflow 797.6 With Constipation and Overflow IncontinenceIncontinence

307.7 Without Constipation and Overflow 307.7 Without Constipation and Overflow IncontinenceIncontinence

Encopresis: PrevalenceEncopresis: Prevalence

1-2% of the child population1-2% of the child population Boys are 3-6 times more likely to Boys are 3-6 times more likely to

have it than girlshave it than girls Mean onset is 7 years oldMean onset is 7 years old 95% of children referred for 95% of children referred for

treatment of encopresis have treatment of encopresis have constipationconstipation

Encopresis: EtiologyEncopresis: Etiology

Little support for genetic basis for the Little support for genetic basis for the disorderdisorder

Little support for emotional and Little support for emotional and behavioral problems associated with behavioral problems associated with encopresisencopresis

More a problem of dysfunction of the More a problem of dysfunction of the bowelbowel

Encopresis: EtiologyEncopresis: Etiology

Rule Out Hirschsprung DiseaseRule Out Hirschsprung Disease Absence of ganglion cells and normal Absence of ganglion cells and normal

peristaltic waves in one segment of the peristaltic waves in one segment of the bowelbowel

Develop a megacolonDevelop a megacolon Risk for impactionRisk for impaction Seepage of liquid stoolSeepage of liquid stool

Encopresis: AssessmentEncopresis: Assessment

Medical AssessmentMedical Assessment Rule out Hirschprung’sRule out Hirschprung’s Any constipating medicationsAny constipating medications Diet (i.e., fiber intake, water)Diet (i.e., fiber intake, water)


Behavioral Assessment: InterviewBehavioral Assessment: Interview Toilet training historyToilet training history Any behavioral or emotional problemsAny behavioral or emotional problems Recent stressful precipitating eventsRecent stressful precipitating events Current status of toileting habits and Current status of toileting habits and

bowel movementsbowel movements


Behavioral Assessment: InterviewBehavioral Assessment: Interview Environmental contributors (e.g., Environmental contributors (e.g.,

routine, diet and exercise)routine, diet and exercise) Consequences (e.g., parental reactions, Consequences (e.g., parental reactions,

child reactions)child reactions) Child motivation for treatmentChild motivation for treatment


Behavioral Assessment: Recording Behavioral Assessment: Recording Data Data Provide Chart for recording bowel Provide Chart for recording bowel

movementsmovements Assess place, number of voids, size and Assess place, number of voids, size and

consistency of void, reactionconsistency of void, reaction Record fiber intake and exerciseRecord fiber intake and exercise

Encopresis: TreatmentEncopresis: Treatment

Combination of medical and Combination of medical and behavioral treatment the most behavioral treatment the most effective approacheffective approach

Medical TreatmentMedical Treatment Clean out the bowelClean out the bowel EnemasEnemas LaxativesLaxatives Increase fiber and exerciseIncrease fiber and exercise Ensure regular bowel movementsEnsure regular bowel movements

Encopresis: TreatmentEncopresis: Treatment

Behavioral TreatmentBehavioral Treatment Scheduled toilet sits Scheduled toilet sits

After meals or suppositories/laxatives After meals or suppositories/laxatives Make relaxingMake relaxing Keep brief (e.g., 5-10 minutes)Keep brief (e.g., 5-10 minutes)

Reinforcers for sits and then poops in Reinforcers for sits and then poops in the toiletthe toilet

Minimize reaction to accidentsMinimize reaction to accidents

Documents

Toileting: The Assessment and Treatment of Enuresis and Encopresis Emily D. Warnes, Ph.D. EDPS 951