disorder of elimination Flashcards Preview

Paediatrics > disorder of elimination > Flashcards

Flashcards in disorder of elimination Deck (23):

what are the normal ages of acquisition of bowel and bladder control

2 to 3 yrs


how old should a child be when not being toilet trained is concerning

By age 4yr


causes of nocturnal enuresis

occurs in normal children and is due to a delay in the development of the normal sphincter control mechanisms.


Causes of diurnal enuresis

poor bladder sensation or bladder muscle instability


Define secondary enuresis

refers to wetting in a child who had previously been dry and is often associated with psychological stress


Who gets primary nocturnal enuresis

10% in 6yr and 3% are 12yr once a week


Causes of primary nocturnal enuresis

Delayed maturation - often familial
May be reduced ADH production
Reduced bladder awareness
Emotional stress
Polyuria due to DM or renal disease


Causes of secondary enuresis

Emotional upset
threadworm infection


Causes of diurnal enuresis

Neurogenic bladder
congenital abnormality eg ectopic ureter
Severe constipation
Psychogenic due to stress
Sexual abuse - RED FLAG
Physiological urgency


Hx question when asking elimination disorders

Ever been dry, what age, any triggers
FmHx of primary nocturnal enuresis
Sexual abuse
Dysuria, polyuria, systemic upset - UTI?
constipation ?
DM - polyuria polydipsia or wt loss
What has been done by parents at home?
any punishment or criticised the child when wetting. False expectation?
Pattern of bed wetting, running to get to toilet, dribbling.


O/E for bedwetting

evidence with neurological or congenital abnormality
check leg reflexes and perineal sensation
spina bifida occulta eg lipoma or hairy patch over the sacral area.
Palpable faecal mass
Renal disease


Ix for bed wetting

Urine MCS - to exclude UTI
Urine dipstick - exclude glycosuria
Renal USS - ectopic ureter strongly suspected


Mx of bedwetting/daytime wettiing

Enuresis is common- 15% of 5 yr
There is rarely an organic cause
Majority respond to behavioural management
Psychological stress should be considered in secondary enuresis.
no intervention until 7 yr
Behavioural management with star charts and rewards for dry nights
Enuresis alarm
Bladder training - full bladder during day
Avoid caffeinated drinks and fruit juice
Medication - Desmopressin (nasal spray or tb), Oxybutynin - reduces detrusor muscle instability in children with a call bladder capacity and urgency.
Tx any constipation


Differentiated between constipation and Hirschsprung's disease

Onset - after newborn period
Passage of meconium - 48 hr
Soiling - uncommon
Wt gain - poor
Size of bowel motion - thin "rabbit like"
Anal fissure - uncommon
Xray - barium and AXR
Tx - bowel irrational and surgery within the first week of life


tx for Posterior urethral valves

Surgical corection


Causes of UTI in children

UTI in children may indicate congenital renal anomaly
Vesicoureteric reflux (leads to hydronephrosis)
Obstructed urinary systems
- Pelviureteric obstruction
- Urinary stones
- Posterior urethral valves- boys with poor urinary stream
- Duplex kidney with obstructed pole
- Horseshoe kidney (turner's)
Poor hygiene - wet nappies, and wipes back to front in girls
Neuropathic bladder - spinal cord defect can result in impaired continence and infection


Presentation of posterior urethral valves

Poor force of stream in infant boys
Antenatal - bilateral dilated renal helix
abnormal urinary stream
Multiple UTI
Kidney failure


Congenital renal anomalies

Solitary kidney - due to unilateral renal genesis
Ectopic kidney - due to abnormal migration during embryogenesis leads to pelvic or horseshoe kidney.
Multi cystic dysplastic kidney - it is non functioning and usually involutes and disappears by school age.
Autosomal dominant polycystic kidney disease - may cause haematuria, HTN and renal failure.
Autosomal recessive polycystic kidney disease - reduced fluid production antenatal -> Secondary pulmonary hypoplasia. If child survives the neonatal period = end stage renal failure in early childhood.


List urological abnormalities

Predispose to UTI and if severe can lead to renal impairment or failure.
- Pelviureteric obstruction - abnormal tissue or external compression at the point the renal pelvis joins the ureter. 75% improve without surgical intervention
- Posterior urethral valves - 1/10000 male infant. cause = persistence of an embryological fold across urethra causing bladder hypertrophy, bilateral hydronephrosis and renal impairment.
- Hypospadias - mild = no tx, severe = surgical. Advice them not to circumcised.
- Phimosis - Non retractile. only surgery if obstruction problem
- Paraphimosis - foreskin trapped behind the glans causing pain and swelling. usually reducible without surgery.
- Circumcision


vesicoureteric reflux

Retrograde flow of urine into ureters.
Can cause Hydronephrosis and predispose to UTI, pyelonephritis, HTN or end stage renal failure.
Cause is from an abnormally short and straight insertion of the ureters through the wall so that they are not properly occluded during bladder contraction.
Ix - USS for dilation of ureters, renal pelvis and calyces.
Mx - conservative tx - surveillance and ABX for infection. Some may need surgery for breakthrough infection or deteriorating renal function.


Causes of Encopresis

Chronic constipation - retentive encopresis
Hirschsprung disease
Spinal cord lesion
Anorectal malformations


Define Encopresis

Feacal incontinuence in a child >4 yrs at least once a month for 3 months


Define retentive encopresis

Child holds bowel movement, develops constipation, leading to fecal impaction and seepage of soft or liquid stool = overflow incontinence