Elimination disorders are disorders that concern the elimination of feces or urine from the body. The causes of these disorders may be medical or psychiatric.
The American Psychiatric Association recognizes two elimination disorders, encopresis and enuresis . Encopresis is an elimination disorder that involves repeatedly having bowel movements in inappropriate places after the age when bowel control is normally expected. Encopresis is also called fecal incontinence. Enuresis, more commonly called bed-wetting, is an elimination disorder that involves release of urine into bedding, clothing, or other inappropriate places. Both of these disorders can occur during the day (diurnal) or at night (nocturnal). They may be voluntary or involuntary. Encopresis and enuresis may occur together, although most often they occur separately.
Elimination disorders may be caused by a physical condition, a side effect of a drug, or a psychiatric disorder. It is much more common for elimination disorders to be caused by medical conditions than psychiatric ones. In most cases in which the cause is medical, the soiling is unintentional. When the causes are psychiatric, the soiling may be intentional, but it is not always so.
Medical causes of encopresis are usually related to chronic constipation. As hard feces build up in the large intestine, the bowel is stretched out of shape. This allows liquid feces behind the hard stool to involuntarily leak out and stain clothing. Other medical causes of encopresis include malformations of the bowel and side effects of medication. Laxatives (medications that relieve constipation), drugs that kill some of the good bacteria in the intestines, and drugs that increase contractions in the intestines can all cause involuntary encopresis. Pediatricians or family physicians treat almost all cases of encopresis having medical causes. In cases of prolonged involuntary soiling, children may develop feelings of shame and embarrassment, leading to low self-esteem.
Psychiatric causes of encopresis are not as clear. A few children may experience encopresis because of fear of the toilet or because their toilet training was either overly pressured or irregular and incomplete. Older children may soil intentionally, sometimes smearing the feces on wall or clothing or hiding feces around the house. Children who show this pattern of soiling behavior often have clinical behavior problems such as conduct disorder or oppositional defiant disorder . About one-quarter of children who soil intentionally also have enuresis.
Enuresis also has both medical and psychiatric causes. Primary enuresis occurs when a child has never established bladder control. Medical causes of primary enuresis are often related to malformations of the urinary system, developmental delays, and hormonal imbalances that affect the ability to concentrate urine. There appears to be a genetic component to primary enuresis, since the condition tends to run in families. Primary enuresis may also be caused by psychological stressors such as family instability or erratic toilet training.
Secondary enuresis occurs when a child has established good bladder control for a substantial period, then begins wetting again. Involuntary secondary enuresis is thought to be brought on by life stresses. For example, it is common for young children to begin wetting the bed after moving to a new house or having a new sibling enter the family. Voluntary enuresis is not common. Like voluntary encopresis, it is associated with psychiatric conditions such as conduct disorder and oppositional defiant disorder.
Treatment and prognosis
Most children outgrow their elimination disorders successfully by the time they are teens, with the exception of those children whose elimination disorders are symptoms of other psychiatric disturbances.
Encopresis is treated with stool softeners or laxatives and by instituting regular bowel evacuation patterns. Enuresis is treated by behavior modification including changing nighttime toileting habits. The least expensive and most effective method is by having the child sleep on a special pad that sets off an alarm when the pad becomes wet. This wakes the child and allows him to finish relieving in the toilet. Eventually he awakes without assistance before wetting. Drugs can also help in the treatment of enuresis, although relapse is common after they are stopped. Secondary enuresis caused by stress is treated by resolving the stress. Psychotherapy is usually not needed, although it may be helpful to children who develop feelings of shame associated with their elimination disorders. Adults can help children avoid shame and embarrassment by treating elimination accidents mater-of-factly and kindly.
Children with voluntary elimination disorders are treated for the diagnosed psychiatric problem associated with the elimination disorder using behavior modification, drugs, and other psychiatric interventions.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington DC: American Psychiatric Association, 2000.
Hales, Robert E., Stuart C. Yudofsky, and John A. Talbot. The American Psychiatric Press Textbook of Psychiatry. 3rd ed. Washington, DC: American Psychiatric Press, 2000.
Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.
Kuhn, Bret R., Bethany A. Marcus, and Sheryl L. Pitner. "Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal." American Family Physician 58 (April 15, 1999): 8-18.
Mikkelsen, Edwin J. "Enuresis and Encopresis: Ten Years of Progress." Journal of the American Academy of Child and Adolescent Psychiatry 40 (October 2001):1146-1159.
American Academy of Child and Adolescent Psychiatry. P. O. Box 96106, Washington, D.C. 20090. (800) 333-7636. <www.aacap.org> .
Tish Davidson, A.M.