Constipation and Enuresis

1. Constipation and Enuresis Dr. Sussens & Dr Ongosi 18.9.12. GP PLT Event, Nottingham.

2. Introduction The local constipation pathway was developed by Paediatric gastroenterology in Nottingham. The development is by consensus of a multidisciplinary team within the hospital, community and general practice. It is based on national guidelines and local experience.

3. Constipation Delay and sometimes difficulty/discomfort in passing stools, which may be of a harder consistency. Constipation can occur soon after birth but usually occurs between the ages of 1- 5 years of age Common (5% of general paediatric referrals and up to 25% of referrals to Paediatric Gastroenterology)

4. Definitions • Soiling Secondary to long term constipation and caused by involuntary overflow of fluid or semi solid stools around the faecally loaded rectum. • Encopresis Inappropriate passage of normal stool in inappropriate places, in this situation it is implied that there is normal sensation and control. • Withholding A subconscious with-holding of stool because of previous pain of constipation or fissure, fear of the toilet or coercive potty training. Common in young children.

5. Primary care management. Establish idiopathic constipation and exclude underlying causes

6. Two or more symptoms from the following; Reduced frequency and or consistency of stool less than three complete stools per week (Bristol Stool Form type 3 or 4) hard large stools, rabbit droppings (Bristol Stool Form type 1), Soiling History Previous constipation, Previous or current anal fissure, Painful bowel movements and bleeding associated with hard stools Symptoms associated with defecation Straining, Bleeding associated with hard stool, Poor appetite, Abdominal pain, Anal pain Evidence of retentive posturing

7. A careful, detailed history • From the parent/carer and the child where possible. • Delayed passage of meconium • Onset and duration of problem • Normal bowel pattern, • Stool type • Typical diet and fluid intake • History of other illness or medical problems • Toilet/potty training and use

8. History... Any urinary problems Reaction of parents Family and social history Management tried to date Developmental/school progress Toilet facilities at home and school e.g lack of privacy, cleanliness

9. Examination Overall health Assessment of growth, Abdominal distension or faecal masses, Inspection of peri-anal area for fissure, infection, skin disease, ectopic position, anal reflex, etc Neurological examination.

10. Consider Hirschsprung’s disease or anorectal anomaly if Delayed passage of meconium, Constipation in first month of life, Vomiting, Failure to thrive Abdominal distension.

11. Symptoms from birth (or first few weeks of life). Failure or delay to pass meconium more than 48 hours after birth in term baby Ribbon Stools’ (more likely in child < 1year) Gross or chronic abdominal distension and vomiting Leg weakness or gross motor delay or abnormal reflexes Poor growth Bloody diarrhoea Abnormal lumbosacral /gluteal region or abnormal position of anus Absent anal wink Concerns re child maltreatment

12. Investigations Usually none If other pathology is suspected consider referral. Coeliac screen, thyroid function, calcium, U&E and creatinine may be useful if an organic problem is suspected.

13. Treatment Explanation of the problem Education Oral medication to soften and evacuate retained stools Medicines used include Lactulose, Sodium Picosulphate, Senna, Movicol. Avoid suppositories. Clear out if required Increase dietary fibre and fluids Toileting issues

14. Treatment Use of Record Charts and reward systems Psychology input Social Services referral sometimes needed if there is concern about significant harm from abuse or neglect Regular follow-up Advice on daily physical activity

15. Medical treatment • Faecal impaction • Macrogols (Paediatric movicol) - escalating doses • Add stimulant Laxatives (picosulfate, bisacodyl, senna, docusate) if no response to Paediatric movicol within 2 weeks • Substitute with stimulant laxative + osmotic laxative (lactulose) if macrogols not tolerated. • NB: Inform families that disimpaction can initially increase symptoms of soling and abdominal pain

16. Medical treatment NO rectal medications or sodium citrate enemas unless failed oral treatment. NO phosphate enemas unless under hospital supervision and all above have failed NO manual evacuation under GA unless oral and rectal treatment has failed. Review all children undergoing disimpaction within 1 week.

17. Maintenance treatment. First line treatment – Paediatric movicol. (about half of disimpaction dose) Add stimulant laxative if macrogol doesn’t work Substitute with stimulant laxative + osmotic laxative (lactulose) if macrogols not tolerated.

18. Referrals To general paediatrics(community or hospital) Problematic constipation in first 3 months of life Failure of treatment using protocols for 3 months Failure of faecal lump to disappear in 3 weeks (following guidelines for clearout) Persistent rectal bleeding Failure to thrive Social/family problems Toileting problems at school

19. References • Nottingham paediatric guidelines • Nice guidance may 2010: • Diagnosis and management of idiopathic childhood constipation in primary and secondary care

20. Enuresis Refers to a repeated inability to control urination Primary enuresis refers to children who have never been successfully trained to control urination. Secondary enuresis refers to children who have been successfully trained but revert to wetting in a response to some sort of stressful situation or medical condition

21. When is it Enuresis? Children are generally expected to be dry by a developmental age of 5 years, and historically it has been common practice to consider children for treatment for nocturnal enuresis only when they reach 7 years The NICE guidance has specific advice for children under 5 years, and has indicated treatment options for children between 5 and 7 years.

22. Daytime incontinence That is not associated with urinary infection or anatomical abnormalities is less common than nocturnal enuresis Tends to disappear much earlier than nocturnal enuresis. Consider Overactive bladder. Abnormal voiding habits, the most common being infrequent voiding. More common in girls than in boys. Refer to continence service.

23. Nocturnal Enuresis A widespread and distressing condition that can have a deep impact on a child or young person's behaviour, emotional wellbeing and social life. Very stressful for the parents or carers.

24. Prevalence The prevalence of bedwetting decreases with age. Bedwetting less than 2 nights a week 21% at about 4 and a half years 8% at 9 and a half years. More frequent bedwetting is less common 8% at 4 and a half years 1.5% at 9 and a half years.

25. Guidance Available Local pathway is currently being finalised. NICE guidance October 2010 The management of bedwetting in children and young people.

26. History.. Ask about the presence of daytime symptoms, including: Daytime frequency (that is, passing urine more than seven times a day) Daytime urgency Daytime wetting Passing urine infrequently (fewer than four times a day) Abdominal straining or poor urinary stream Pain passing urine. pattern of bedwetting i.e. timing, frequency, amount, waking constipation

27. Haematuria • Straining on urination • Dibbling • Poor flow • Gait disturbance • Poor bowel control • Continuous dampness

28. Assessment and investigation Is this a presentation of a systemic illness. Has it started in the last few days or weeks? Consider UTI/ DM Are they opening their bowels regularly? Constipation is a common cause of secondary enuresis Has there been a recent emotional or behavioural problems Is there child maltreatment?

29. Drinking Do they drink enough Are drinks being restricted. Need to drink enough in the day to ‘train the bladder’ to hold decent volumes of urine. Do not need to restrict input except for last hour or so before bed. Consider a diary.

30. Examination • Blood pressure • Examination of the back • Lower limb examination

31. Urinalysis Do not perform routinely in children and young people with bedwetting, unless any of the following apply: Bedwetting started in the last few days or weeks There are daytime symptoms There are any signs of ill health There is a history, symptoms or signs suggestive of urinary tract infection There is a history, symptoms or signs suggestive of diabetes mellitus.

32. Management Patient –centred care Advice on fluid intake, diet and toileting behaviour. Trial without nappies/pull ups at night Reward systems on agreed behaviour rather than dry nights i.e. rewards for; Drinking recommended levels of fluid during the day Using the toilet to pass urine before sleep Engaging in management (for example, taking medication or helping to change sheets).

33. Management If no response to initial treatments; Consider whether or not it is appropriate to offer alarm or drug treatment. This is dependent on The age of the child or young person, The frequency of bedwetting And the motivation and needs of the child or young person and their family.

34. Local pathway City • School nursing role under review • Trial of desmopresssin and refer to continence service if no improvement. (Stephanie Joyner Sherwood Rise H/C)

35. County… • No nurse led continence clinic. • Trial of desmopresin. • Refer/discuss with community paediatrician.

36. Drug treatment • NICE guidance suggests; • Offer desmopressin to children and young people over 7 years if: • Rapid-onset and/or short-term dryness is a priority or • Alarm is inappropriate or undesirable • Parents/carers with emotional difficulties, anger, blame..

37. If offering desmopressin for bedwetting; Inform the child or young person and their parents or carers: That many children and young people, but not all, will experience a reduction in wetness That many children and young people, but not all, will relapse when treatment is withdrawn Of the importance of fluid restriction from 1 hour before until 8 hours after taking desmopressin That it should be taken at bedtime If appropriate, how to increase the dose if there is an inadequate response to the starting dose To continue treatment with desmopressin for 3 months That repeated courses of desmopressin can be used.

38. When to Refer Refer children and young people with bedwetting that; has not responded to courses of treatment with an alarm and/or desmopressin For further review and assessment of factors that may be associated with a poor response, such as an overactive bladder, an underlying disease or social and emotional factors.

39. Any Questions?