307.6 Enuresis (not due to a general medical condition)
307.7 Encopresis without constipation and overflow incontinence
787.6 Encopresis with constipation and overflow incontinence
The DSM-IV defines enuresis/encopresis as repeated involuntary (or, much more rarely, intentional) voiding/passage of feces into places not appropriate for that purpose, after attaining the developmental level at which continence is expected. If continence has not been achieved, the condition can be termed “functional” or “primary.” The period of continence necessary to differentiate between primary and secondary enuresis/encopresis is now considered to be 1 year. There does seem to be a significant relationship between enuresis and encopresis, although neither condition can be the direct effect of a general medical condition (e.g., diabetes, spina bifida, seizure activity) to be included in this category.
Numerous psychological interpretations exist speculating on the dynamics of toilet training and the significance of flushing bodily fluids down the toilet. Freudian theory places the fixation at the anal stage of development whereby the child fails to neutralize libidinal urges, and the aggressive impulses are fused with the pleasure of controlling bodily functions. Expulsion of feces or urination and untimed feces or urination or intentionally placing the feces in inappropriate places elicits hostility from parents. Loss of bodily functions leads to loss of self-respect, loss of friends, and feelings of shame and isolation.
Learning to control urination/defecation is a developmental task most likely achieved by age 4 or 5 and requires a mechanically effective anatomy. In some enuretic children, abnormalities in regulation of vasopressor/antidiuretic hormone (ADH) have been evidenced, with ADH regulation being linked to both the dopaminergic and serotonergic systems. A theory of developmental delay suggests there is a common underlying maturational factor that predisposes children to manifest both enuresis and behavioral disturbances. Enuresis and encopresis are normal responses to environmental stresses that occur in certain situations (e.g., when a child is separated from his or her family or is abused). In either case, as the child matures and the environmental stressors are alleviated, normal bodily control is resumed. Children who are hyperactive may have occasional accidents, as they do not attend to the sensory stimuli until it is too late.
Enuresis and its relationship to bladder capacity and urinary tract infections has been explored, as has nocturnal enuresis occurring during deep sleep with no response to arousal signals. In addition, research has been conducted to investigate the physiological basis for encopresis. These studies indicate that the act of bearing down led to decreased anal sphincter control in almost all cases.
Soiling may result from excessive fluid buildup caused by diarrhea, anxiety, or the retention overflow process, whereby leakage occurs around a retentive fecal mass. This mechanism is responsible for 75% of encopretic children.
Genetically, a child is at risk for enuresis if the parent has a history of enuresis after the age of 4. Recent research suggests a genetic mutation on chromosome 13.
As mentioned previously, the parental attitude toward cleanliness and the rigidity with which this behavior is controlled may perpetuate the fear associated with loss of bodily control. Parents often get caught up in the volitional aspects, blaming the child for “acting like a baby.” Further social embarrassment ensues when school personnel target the problem in terms of “the dirty child from a dirty family.” Attempts to deny the problem lead to covert behaviors such as hiding soiled clothing in lockers, under the bed, or in the trash. The child may in fact be using the only weapon available, as in the case of severe neglect and/or sexual assault.
CLIENT ASSESSMENT DATABASE
May/may not be awakened when bed-wetting occurs
Unusual sleep habits, increased incidence of sleepwalking or sleep terror disorders
Expressions of poor self-esteem (e.g., “I am bad”)
Shy, withdrawn, feelings of isolation, shame
Overly anxious around adult figures
Stressors may include family conflicts/change in structure (e.g., divorce, birth of a sibling)
History of delayed or difficult toilet training
Inattention to cues of need for elimination
Episodes of urinary incontinence twice a week for at least 3 consecutive months in child of at least 5 years of age (or equivalent developmental level)
Pattern of diurnal and/or nocturnal enuresis
One episode of soiling per month over a 3-month period in child at least 4 years of age (or equivalent developmental level)
Fecal incontinence; seepage secondary to fecal retention/colorectal loading
Anal self-stimulation may be noted in nocturnal pattern of soiling
Deliberate attempts to hide evidence of soiled clothing
May have developmental (neuromuscular or gross motor) delays
Less than 1/3 of enuretic children have documented emotional disorders (regression is rarely reason for problem)
Acting-out behaviors (e.g., placing feces or defecating in inappropriate places for retaliation)
History/evidence of abuse may be present (condition may be related to abuse and/or the cause of abuse)
Avoidance of sexual activity in older adolescents
Impaired social, academic functioning
Power struggles with family/school to maintain personal hygiene, change bed linens
Reluctance to engage in peer activities; social rejection (body odor)
Uncomfortable spending the night with friends either in own home or away
Usual age of onset 5–7 years, developmental age of at least 4 (encopresis) or 5 (enuresis) years
Prevalence as high as 22% of 5-year-olds, 10% of 10-year-olds
Boys more often affected than girls (3:1)
History of parental enuresis
Bed-wetting suppressed only as long as medication is taken; relapse usually occurring within 3 months
Urinalysis: Rule out UTI.
Electrolytes: Identify imbalance in presence of chronic diarrhea.
Abdominal, Lower GI X-Rays: Evaluate anatomical abnormalities such as anal fissure, obstruction.
Cystometrogram (CMG): Test for bladder capacity when in question.
Detailed Toilet Training History: Baseline continence data clarifying problem and evaluating for secondary vs. primary enuresis/encopresis.
ECG: To provide baseline when starting antidepressant medication.
1. Promote understanding of condition.
2. Identify and support change in parent/child patterns of interaction.
3. Enhance self-esteem.
4. Assist client in achieving continence.
1. Condition/therapy needs are understood.
2. All parties are participating in therapeutic regimen.
3. Achieves as near a normal pattern of bowel/bladder functioning as individually possible.
4. Plan in place to meet needs after discharge.