Journal of the American Academy of Child & Adolescent Psychiatry
COLUMNS: PSYCHOPHARMACOLOGY PERSPECTIVESPharmacotherapy in the Management of Voiding and Storage Disorders, Including Enuresis and Encopresis
Section snippets
Key Points
- 1.
Appropriate clinical management of disorders of bladder or rectal function requires a standardized terminology based on pathophysiological etiology.
- 2.
Recognition that these are disorders either of voiding or of storage functions, not just of elimination, improves clinical acumen and treatment decision making.
- 3.
Daytime incontinence is clinically distinct from nighttime incontinence, implying different etiologies as well as different treatment interventions.
- 4.
A voiding diary is indicated in cases of
NEUROBIOLOGY AND TERMINOLOGY FOR BLADDER AND ANORECTAL DYSFUNCTIONS
Child and adolescent psychiatrists are uniquely positioned to manage disorders of bladder and rectum, including enuresis and encopresis. Such disorders-whether primary complaints or comorbid with other disorders-typically account for about 40% of all pediatric urology office visits, with reported prevalence rates of 2% to 7% in school-age children for daytime incontinence.1 These disorders are amenable to therapeutic interventions. Still, confusion about etiology as well as about clinical
Initial Patient Contact
The clinical history should include toilet training, fluid intake, any holding maneuvers (posturing), and frequency of voiding, defecating, daytime incontinence, and enuresis. A voiding diary is indispensable for proper diagnosis and can be completed by parents in the 2 weeks after the initial visit (Table 1). If indicated, an estimate of BC and of nocturia can be made from the diary. Enuretic urine volumes can be estimated by measuring the weight of the diapers or bedclothes, typically by
ANORECTAL VOIDING AND/OR STORAGE DYSFUNCTIONS
Because bladder function has been more extensively researched than anorectal function, interventions are often aimed at LUT dysfunctions only. In addition, children and their parents often fail to recognize the child's symptoms of anorectal dysfunction. Still, anorectal voiding and/or storage dysfunctions are such frequent comorbid conditions,2,5,7, and so often are side effects of psychotropic medications, that a bowel protocol as an intervention (Fig. 2) should nearly always accompany
Enuresis
For enuresis, intervention targets include sleep arousal, nocturnal urine production, or the balance between bladder filling and spontaneous micturition (Fig. 3).5,7,8,2 For example, alarm systems are aimed at enuresis but do not deal with the often comorbid problem of constipation. They are the most successful treatment and the only chance for cure of enuresis.3,5,12, Nevertheless, it is unclear whether they target nocturnal arousal specifically or in combination with aspects of bladder tone,
FINAL THOUGHTS
The complexity of voiding and/or storage dysfunctions of bladder and rectum highlight possibilities of overdiagnosis or underdiagnosis as well as possible miscommunication with patients or parents. Still, an understanding of the standardized terminology and basic science of continence/incontinence greatly enhances clinical effectiveness. Web site information plus written instructions on bladder and bowel treatment protocols greatly enhance parent-patient compliance. Novel treatments based on
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Cited by (19)
Prevalence of enuresis and its association with attention-deficit/ hyperactivity disorder among U.S. children: Results from a nationally representative study
2009, Journal of the American Academy of Child and Adolescent PsychiatryCitation Excerpt :Future developmental epidemiological studies are needed to better understand the comorbidity between enuresis and other psychiatric disorders and the possible role of enuresis in the development or nonresolution of other disorders. Treatment targets for enuresis include arousal, nocturnal urine production, and abnormalities in urine storage/voiding.48 Management of enuresis includes maintaining a voiding diary, addressing the often comorbid constipation, alarms, and medications (imipramine and desmopressin).48
Encopresis
2023, Chronic Disease and Disability: The Pediatric Gastrointestinal Tract, Second Edition. Overview with Perspectives of History, Nutrition and Behavioral PediatricsEnuresis: Current concepts and conundrums
2022, Behavioral Pediatrics II: Neuropsychiatry, Sexuality and Eating Disorders. Fifth EditionEncopresis
2022, Behavioral Pediatrics II: Neuropsychiatry, Sexuality and Eating Disorders. Fifth EditionEncopresis in an Adolescent Treated by Imipramine: A Case Report
2022, Bahrain Medical BulletinA case of the giggles: Diagnosis and management of giggle incontinence
2018, Canadian Family Physician
Psychopharmacology Perspectives aims to discuss practical approaches to everyday issues in pediatric pharmacotherapy. The discussions may address aspects of clinical care related to psychopharmacology for which we do not have adequate applicable controlled trials. Given the need to address symptoms in youths with often complex, severe, and comorbid disorders, recommendations are likely to be off-label from the perspective of the U.S. Food and Drug Administration. We fully appreciate that for virtually all disorders, medication is only one aspect of comprehensive care. This column focuses primarily on psychopharmacological management. Although it is important that clinicians address psychosocial issues in the evaluation and treatment of their patients, such discussion is beyond the specific scope of this feature. These are not meant to be practice guidelines, but rather examples of the thought process that may go into pharmacotherapy decision making.
Disclosure: The author reports no conflicts of interest.