Elimination disorders are characterized by the inappropriate voiding of urine or feces in places other than a toilet. These conditions are typically seen in children who have developed past the age where they should have achieved full bladder and bowel control. While occasional accidents are a normal part of early childhood, elimination disorders become a clinical concern when these behaviors persist and occur regularly. The conditions can cause significant distress for the child and family, potentially impacting self-esteem and social functioning.
Defining Elimination Disorders and Key Characteristics
Elimination disorders are defined by the repeated passage of urine or feces into clothing or other inappropriate locations, whether the act is voluntary or involuntary. Diagnosis is not applied until a child reaches a minimum developmental age, ensuring the behavior is not merely a delay in typical development. The minimum age for Enuresis (inappropriate urination) is typically five years, and for Encopresis (inappropriate defecation) it is four years.
The behavior must demonstrate a certain frequency and duration, such as occurring at least twice a week for three consecutive months, or causing clinically significant distress. Diagnosis also requires that the behavior not be due exclusively to the physiological effects of a substance or another general medical condition, except for constipation’s role in Encopresis.
The Two Primary Forms
The two main forms of elimination disorders are Enuresis and Encopresis, which are differentiated by the type of waste involved. Enuresis refers to the repeated involuntary or intentional voiding of urine into bedding or clothes. This condition is often referred to as bedwetting when it occurs during sleep, which is the most common presentation.
Enuresis is categorized as nocturnal (nighttime) or diurnal (daytime). It is also distinguished as primary or secondary based on the child’s history of dryness. Primary enuresis occurs when the child has never achieved a consistent period of dryness lasting at least six months. Secondary enuresis is diagnosed when wetting recurs after the child has been reliably dry for a minimum of six months, often following a stressful life event.
Encopresis is the repeated passage of feces into inappropriate places, such as clothing or the floor, and is also known as fecal incontinence or soiling. The large majority of encopresis cases are associated with chronic constipation, leading to a specific mechanism called overflow incontinence.
In overflow incontinence, hard, impacted stool accumulates in the rectum, causing it to stretch and lose sensitivity. Softer or liquid stool then leaks around this blockage and out of the anus. A smaller number of cases, referred to as encopresis without constipation, are typically associated with psychological or behavioral issues rather than a physical blockage.
Underlying Factors and Potential Causes
The causes of elimination disorders involve a combination of physiological and psychological factors. For encopresis, the primary initiating factor is chronic constipation, accounting for up to 95% of cases. This constipation starts a cycle where painful bowel movements cause the child to intentionally withhold stool to avoid discomfort. The chronic withholding causes the colon and rectum to become distended, which impairs the nerves that signal the need to defecate.
For enuresis, physiological factors include an imbalance between the amount of urine produced at night and the functional capacity of the bladder. Many children with enuresis also have a sleep arousal disorder, meaning they do not wake up in response to the sensation of a full bladder.
Environmental and psychological factors also contribute. Life changes, such as the birth of a sibling or starting a new school, can trigger secondary enuresis or encopresis. Inadequate or overly harsh toilet training methods can create fear or anxiety around using the toilet, leading to intentional withholding behavior. Dietary factors, such as low fiber and fluid intake, also contribute to chronic constipation.
Diagnosis and Management Approaches
Diagnosis begins with a medical history and physical examination to rule out other medical conditions, such as diabetes or urinary tract infections. The provider gathers information about the frequency, timing, and nature of the accidents, including whether soiling is accompanied by constipation symptoms. Understanding the specific subtype of the disorder is paramount, as it dictates the most effective treatment strategy.
Management is typically multi-pronged, combining medical and behavioral interventions. For encopresis, the initial step involves clearing impacted stool through a disimpaction protocol, often using laxatives or enemas. This is followed by long-term maintenance therapy using stool softeners and dietary changes to increase fiber and fluid intake.
For enuresis, the use of a moisture alarm (bedwetting alarm) is highly effective, conditioning the child to wake up in response to wetting. Scheduled toilet sitting, positive reinforcement, and avoiding punishment are employed for both conditions to help the child regain control. In some cases of enuresis, specific medications like desmopressin can be used to decrease nighttime urine production, often alongside behavioral therapies.