Constipation and Enuresis
Katie Mallam
Paediatric Update for Primary care
9th October 2012
Constipation – Why?
• Common
– Prevalence 5-30%
– 1/3 become chronic (>8 weeks) = soiling
• Debilitating
– Social, psychological and educational consequences
• Cost
– Longer duration = longer, more intensive treatment
• Varying advice = angry parents
Constipation – NICE
• Standardise approach
• Early treatment
– Reduce consequences and cost
• No need to remember history and examination:
http://guidance.nice.org.uk/CG99/Questionnaire
Constipation?
2 of ……..
*
* Breast fed babies can
go up to a week
without opening
bowels
Constipation?
http://www.childhoodconstipation.com/Extra/Documents.aspx
Constipation?
2 of ……..
*
* Breast fed babies can
go up to a week
without opening
bowels
Constipation – Causes
• Mostly idiopathic
• Rarely
–
–
–
–
–
–
–
Hirschsprung’s
Neurological NB lumbosacral abnormalities
Anorectal malformations
Hypothyroid
Coeliac
Cystic fibrosis (but normally diarrhoea due to fat malabsorption)
Cow’s milk protein intolerance
• Associations
– Cerebral palsy
– Autism
– Down’s syndrome (NB beware hypothyroidism and Hirschsprung’s)
Constipation – History 1
Constipation – History 2
Faltering growth = treat
and do coeliac and
TFT (refer)
Constipation – Examination
No PR in primary care
NB perianal strep
Perianal streptococcal infection
Swab
Treat infection and constipation
Constipation – Examination
No PR in primary care
NB perianal strep
Constipation – It’s NICE
• No need to remember history and examination:
http://guidance.nice.org.uk/CG99/Questionnaire
< 1 year
≥ 1 year
Constipation – Actions
• Red (or amber) flags
 Refer paeds
• No red flags
 Reassure
 Explain constipation and treatment (could just do briefly and
give patient information using resources in ‘Explain 2’ slide)
 Treat
Constipation – Explain 1
-Rectum gets used to being full: normal reflexes and power are reduced =
‘baggy’.
-Reduced sensation and overflow: soiling is not intentional
-Need to ‘get empty and stay empty’ for rectum to shrink back and recover
reflexes and sensation: takes time
Constipation – Explain 2
• Tameside = comprehensive leaflet
• Patient.co.uk = very good, can print pdf leaflet
• ERIC = lots of info for professionals and parents/patients (age
banded)
http://www.eric.org.uk/
• NICE ‘template letter’
Constipation – Treat
• Get empty, stay empty!
• Faecal impaction?
– Soiling
– Abdominal mass
• Movicol, movicol, movicol!
– NB different strengths e.g. Paed Plain = no taste
• ‘Softeners’
– Movicol, Lactulose, Docusate (also squeezes)
• ‘Squeezers’
– Senna, sodium picosulphate, bisacodyl
• Doses as per BNFc or NICE
Constipation – Get empty
• Disimpaction
– Aiming for liquid and no more lumps = messy
– Review after 1 week
 Movicol
 If not tolerated = stimulant laxative +/- lactulose
 If not worked after 2 weeks = add stimulant laxative and urgently
refer to Paeds
• Enemas and manual evacuation only if all else failed
Constipation – Stay empty 1
• Maintenance
– Until rectum no longer stretched and reflexes return
– Laxatives do not make bowel lazy: may need for several years
and should be gradually reduced
 Movicol
 If not tolerated = stimulant +/- lactulose, or docusate alone
 If not effective = add stimulant
Constipation – Stay empty 2
• Behavioural
– Non-punitive (I say ‘training the subconscious’)
– Regular toileting after meals
– Foot support, sit forward (rock and pop!), bubbles, books
– Diary and rewards (things under their control)
– NB school (NB ERIC info)
– Use school nurses and HV
Constipation – Stay empty 3
• Fluids
Page 15, NICE Quick Reference Guide
http://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf
Constipation – Stay empty 4
• Diet
– High Fibre = fruit, veg, high fibre bread, wholegrain
breakfast cereals, baked beans
• Activity
Constipation – Failed treatment
• Disimpaction has failed if not responded to Movicol after
2 weeks:
 Urgent referral to Paeds (or Bladder and Bowel Specialist Nurse)
• Maintenance has failed:
– In those aged <1 year, if not responded after 4 weeks
 Refer paeds
– In those aged ≥ 1 year, if not responded after 3 months
 Check no red flags
 If red flags = refer paeds
 No red flags = refer to the Bladder and Bowel Specialist Nurse
Service
Constipation Toolkit
• RED FLAGS, refer paeds
– History and examination questionnaires
http://guidance.nice.org.uk/CG99/Questionnaire
– Bristol Stool Chart
• EXPLAIN: Tameside leaflet
• IMPACTED? GET EMPTY, STAY EMPTY!
– Medical: usually Movicol Paed Plain as per BNFc
– Non Medical: see Tameside leaflet and fluid rqmts on page 15 of NICE
http://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf
• If fails, add stimulant
– Disimpaction failure, refer paeds
– Maintenance failure, refer Bladder and Bowel Specialist Nurse
Enuresis - definitions
• Incontinence
– uncontrollable leakage of urine
• Enuresis
– Incontinence of urine when sleeping: usually say Nocturnal
– Bedwetting: ‘involuntary wetting during sleep without any
inherent suggestion of frequency of bedwetting or
pathophysiology’ (NICE)
• Primary
• Secondary = previously dry for ≥ 6 months
Urinary Incontinence – History 1
• Secondary (especially recent):
– UTI
– Diabetes (drinking overnight)
Urine dipstick
NB same day referral if
suspect diabetes
– Constipation
– Neurological: spine and lower limb exam
– Emotional/behavioural difficulties: consider psychology
Urinary Incontinence – History 2
• Pattern of bedwetting
– Variable volume, >1 per night: could be Overactive Bladder
• Daytime symptoms
–
–
–
–
Urgency, Frequency >7/day, Infrequent <4/day, straining, pain
Consider UTI, Overactive Bladder, Neuro/Uro cause
Urine dipstick
If significant, refer to consider investigation/treatment of those
symptoms first
• Toileting patterns
– NB School
• Fluid intake
– Check not restricting
Diary
Urinary Incontinence – History 3
• Effect on child/YP/family
– Social (sleep-over), self-esteem
• PMHx:
– UTI
– Developmental, attention or learning difficulties: consider specific
management
Urinary Incontinence – Examination
• Primary Nocturnal: not required according to NICE
• Secondary Nocturnal or Daytime Symptoms:
–
–
–
–
Genitalia
Abdomen
Spine
Lower limb neuro
Urinary Incontinence – Referral
• RED FLAGS = recurrent UTI, Diabetes, examination
abnormalities:
 refer paeds
• No red flags
– Nocturnal only:
 refer HV or school nurse
– Day only, or Nocturnal with daytime symptoms:
 refer to Bladder and Bowel Specialist Nurse
Enuresis – NICE
• Principles of Care
– Not their fault: non-punitive management
– Tailor management to child/YP and parent/carer
– Consider parental support
– Do not exclude <7y
• Reassure
Enuresis
• Prevalence
Age
< 2 per week
≥ 2 per week
4.5y
21%
8%
9.5y
8%
1.5%
Enuresis – NICE
• Principles of Care
– Not their fault: non-punitive management
– Tailor management to child/YP and parent/carer
– Consider parental support
– Do not exclude <7y
• Reassure
• Trial of BASICS
• <5y: encourage toilet training if not done already and trial out of
nappies at night
Enuresis – Management BASICS!
• Fluids: avoid caffeinated (and ?fizzy and blackcurrant)
•
•
•
•
Regular toileting 4-7/day
NB double voiding if Overactive Bladder symptoms
Trial out of nappies/pull-ups: offer alternatives
Reward system: for agreed behaviour (not dryness)
Enuresis – Information
• NHS choices: concise, for parents
http://www.nhs.uk/Conditions/Bedwetting/Pages/Introduc
tion.aspx
• Patient.co.uk: concise, for parents
http://www.patient.co.uk/health/Bedwetting.htm
• ERIC: all ages, parents, professionals
http://www.eric.org.uk/
Enuresis – Alarm
• High long-term success rate (weeks)
• But need commitment and can disrupt sleep
• Contraindications:
– < 1-2 wet nights/week
– Parental distress or negativity (consider parental support)
• Need training
– Hence referral to HV/school nurse
– http://www.patient.co.uk/health/Bedwetting-Alarms.htm
• Encourage to combine with reward system
– Get up and go to toilet, help change sheets
Enuresis – Desmopressin
• Rapid, short-term results (sleep-over)
• Alarm is inappropriate or undesirable
• Inform them:
– many relapse when treatment is withdrawn
– how desmopressin works
– fluid restriction from 1 hour before until 8 hours after taking
desmopressin
– that it should be taken at bedtime
– how to increase the dose if the response to the starting dose is not
adequate
– that treatment should be continued for 3 months
– that repeated courses can be used
– Stop during sickle cell crises or D&V
http://www.medicinesforchildren.org.uk/search-for-a-leaflet/desmopressin-forbedwetting/
Enuresis – Other treatments
• Only on advice of specialist
• Anticholinergic with desmopressin
– Oxybutinin
– If:
• Not responded to desmo+/-alarm
• Daytime symptoms
• Imipramine
– Gradual increase and withdrawal
– Warn re dangers of OD
• http://www.medicinesforchildren.org.uk/search-for-aleaflet/
Urinary Incontinence – Top tips
• Secondary: think other causes esp Diabetes
• Examine if Secondary or Daytime
• Refer all?
– Red flags = paeds
– Others = HV/school nurse/BBSN
• Basics
• Give/direct to information