Enuresis

Enuresis is characterized by repeated voiding of urine into the bed or clothing in youth at least 5 years of age, chronologically or developmentally (APA, 2013). For children to meet criteria for enuresis, such voiding, whether involuntary or intentional, must occur twice a week for at least 3 months or result in clinically significant distress or functional impairment. Additionally, this behavior cannot be attributed to a medication side effect or a general medical condition (e.g., diabetes, spina bifida, epilepsy). Subtypes are identified as nocturnal only (nighttime bedwetting), diurnal only (wetting during the day), and nocturnal and diurnal. Limitations of the existing criteria have been reviewed in the literature and primarily focus on poorly defined criteria, which are too broad, yield subjective interpretation, or are restrictive to the extent that they result in the exclusion of children who would otherwise need intervention (von Gontard, 2012). It is hypothesized that different underlying etiological pathways exist for diurnal and nocturnal enuresis. Based on the greater medical comorbidities and physiological abnormalities observed in children with diurnal enuresis compared to those who experience nighttime wetting, this chapter focuses primarily on nocturnal enuresis (Järvelin et al., 1991; Rushton, 1995).

Enuresis and subclinical bedwetting are common problems experienced by school-age children. Estimates from a large, longitudinal study indicate that at least 20% of first graders experience occasional bedwetting, while 4% wet the bed at least twice a week (Butler et al., 2008). Approximately 10% of school-age children experience nighttime bedwetting compared to the 2% to 3% who experience daytime wetting (McGrath, Mellon, & Murphy, 2000; von Gontard & Nevéus, 2006). Enuresis is more common in boys than girls, with rates of 9% and 7% in 7- and 9-year-old boys as compared to 6% and 3% in 7- and 9-year-old girls (Byrd, Weitzman, Lanphear, & Auinger, 1996). Early literature suggests that prevalence rates steadily decline as children get older; by adolescence, only approximately 1% to 2% experience enuresis (Feehan, McGee, Stanton, & Silva, 1990; Glazener & Evans, 2004).

Nocturnal enuresis is most commonly conceptualized within a biobehavioral framework, given the strong physiological underpinnings of the problem and the associated behavioral approaches to treatment (Houts, 1991). Specifically, it is characterized by the child’s voiding of urine while asleep despite continence during the day (van Gool, Nieuwenhuis, ten Doeschate, Messer, & de Jong, 1999). A minority of these children, approximately 5% to 10%, experience a comorbid dysfunction in daytime urinary abilities (e.g., increased urgency and frequency), and approximately one third of children with nocturnal enuresis experience comorbid constipation (McGrath, Caldwell, & Jones, 2007; Schmitt, 1997). The etiology of enuresis is quite varied, which ultimately reflects the heterogeneous nature of the disorder (McGrath et al., 2000). Many children with nocturnal enuresis exhibit a maturational delay that affects their ability to detect a full bladder overnight (Campbell, Cox, & Borowitz, 2009). Functional bladder capacity may be diminished, production of vasopressin may be decreased, or there may be excessive fluid intake before bedtime, all of which may cause a release of large amounts of urine and exacerbate the child’s difficulties with urine retention while asleep (Devitt et al., 1999; Norfolk & Wooton, 2012; Yeung et al., 2002). Evidence of heritability of nocturnal enuresis is strong, as 77% of youth with enuresis have a first-degree relative with a history of the condition (von Gontard, Schaumburg, Hollmann, Eiberg, & Rittig, 2001). Although children with nocturnal enuresis commonly are considered heavy sleepers, this notion likely stems from anecdotal report, as little empirical evidence exists (Nevéus, Stenberg, Läckgren, Tuvemo, & Hetta, 1999).

Psychosocial implications of enuresis have garnered much attention in the literature, but findings are inconsistent. It is estimated that upward of 20% to 30% of children with nocturnal enuresis evidence behavioral difficulties. Although this is 2 to 4 times higher than children without voiding problems, it is comparable to children with other chronic illnesses (Hirasing, van Leerdam, Bolk-Bennink, & Bosch, 1997; Liu, Sun, Uchiyama, & Okawa, 2000). However, inconsistencies across studies as well as the use of small convenience samples have precluded the identification of a definitive relationship between nocturnal enuresis and psychological problems (Wolfe-Christensen, Veenstra, Kovacevic, Elder, & Lakshmanan, 2012). Overall, given the involuntary nature of nocturnal enuresis, bedwetting is not considered a function of psychological disturbance. Rather, emotional and/or behavioral problems may result from the stigma, stress, and embarrassment associated with the child’s bedwetting. For example, early literature suggests that the emotional difficulties seen in children with nocturnal enuresis are not the cause of the condition but rather the result of negative parental response to the child’s bedwetting (Sharf & Jennings, 1988). Additionally, early studies on self-esteem indicate that bedwetting can have negative emotional effects, as youth’s self-esteem improved with treatment, but there is no evidence to support a causal relationship in the opposite direction (Hägglöf, Andrén, Bergström, Marklund, & Wendelius, 1997; Moffatt, Kato, & Pless, 1987; Panides & Ziller, 1981). Although some studies report no increase in psychological problems for children with enuresis, others have demonstrated elevated rates of clinically significant internalizing, externalizing, and attentional problems in this population based on parent report (De Bruyne et al., 2009; Friman, Handwerk, Swearer, McGinnis, & Warzak, 1998; Hirasing et al., 1997; Joinson, Heron, Emond, & Butler, 2007).

Encopresis

Encopresis is a common problem among school-age children, affecting between 1.5% and 7.5% of youth between 6 and 12 years of age and accounting for upward of 25% of visits to a pediatric gastroenterologist and 3% to 6% of psychiatry referrals (Doleys, 1983; Levine, 1975; Olatawura, 1973). The condition is characterized by repeated defecation in inappropriate places (such as in clothing or on the floor), with episodes occurring at least once a month for 3 months (APA, 2013). For children to meet criteria for encopresis, they must be at least 4 years of age, and the behavior must not be exclusively attributed to medications or a general medical condition other than constipation. The diagnosis has two identified subtypes to indicate whether the fecal soiling is a result of constipation: with constipation and overflow incontinence and without constipation and overflow incontinence (APA, 2013).

The majority of children with encopresis have an early history of chronic constipation, typically developing before 3 years of age (Partin, Hamill, Fischel, & Partin, 1992). The underlying pathophysiology of childhood constipation is based on many factors and is somewhat elusive as no specific organic cause can be identified in upward of 90% of young patients (Loening-Baucke, 1993). Characteristics of chronic constipation include infrequent bowel movements (e.g., fewer than three per week), fecal incontinence, active stool withholding, and passage of stools that are large in diameter and hard in consistency. Stool withholding occurs in nearly all (89%–100%) children with chronic constipation and in only 13% of those without (Partin et al., 1992; Taubman, 1997). With such large, hard, and difficult-to-pass stools, children often develop fearful reactions to defecation. As a result, progressive stool retention is common. In fact, children and their parents have identified fear of pain associated with defecation as a very prominent factor in the child’s constipation and active withholding (Bernard-Bonnin, Haley, Bélanger, & Nadeau, 1993; Partin et al., 1992). However, with increased stool retention, defecation then becomes even more difficult as stools get progressively larger and more difficult and painful to evacuate (Rasquin et al., 2006).

In addition to pain associated with defecation, active stool retention may also result from a child’s fears around toileting, including aversions to public or unfamiliar bathrooms (Benninga, Voskuijl & Taminiau, 2004; Borowitz et al., 2003; Iacono et al., 1998). Stool-specific toileting avoidance, where the child willingly urinates but refuses to defecate in the toilet, occurs in approximately 80% of children with chronic constipation (Taubman, 1997). This behavior also occurs in approximately 20% of children without constipation who are in the toilet training process, often persisting beyond 4 years of age and requiring intervention in 25% of them (Blum, Taubman, & Nemeth, 2004; Taubman, 1997).

Regardless of the etiology, chronic stool retention can result in physical discomfort for the child, including abdominal pain, loss of appetite, early satiety, nausea, and vomiting. In some cases, chronic constipation paired with long-term withholding may lead to acquired megacolon, or the stretching of the rectum walls to accommodate a large amount of retained stool, which ultimately reduces rectal muscle tone, diminishes the child’s ability to feel the urge to defecate, and increases the threshold of detection of this urge (Campbell et al., 2009; Voskuijl et al., 2006). The child may then experience overflow fecal incontinence, where fecal matter leaks around a retained mass of stool and into the child’s underwear. Such fecal incontinence typically occurs during the day, often multiple times a day, but only rarely occurs overnight, and mostly in cases of severe fecal impaction (Benninga et al., 1996). Overflow incontinence typically improves following a thorough cleanout of the bowel, and if successful cleanout is maintained for several months, defecation sensation and muscle tone often return to normal (Callaghan, 1964; van Dijk, Benninga, Grootenhuis, Nieuwenhuizen, & Last, 2007).

Abnormal defecation dynamics typically develop concurrently with stool retentive behaviors and are present in an estimated 45% to 70% of children with chronic constipation as well as in those with encopresis (Loening-Baucke & Cruikshank, 1986; van der Plas et al., 1996; Weber, Ducrotte, Touchais, Roussignol, & Denis, 1987). Paradoxical contraction of the external anal sphincter (EAS) muscle, or failure to relax the EAS, is commonly associated with chronic constipation. It is hypothesized that paradoxical contraction of the EAS develops in response to painful defecation or out of the child’s attempts to control bowel movements during the toilet training process (McGrath et al., 2000). Regardless of whether the pattern was initiated as a response to fear or avoidance of pain associated with defecation or used maladaptively as a regulatory function, it becomes a conditioned response that contributes to the development or further maintenance of the child’s chronic constipation.

Psychosocial consequences related to chronic constipation and encopresis remain understudied. Parenting stress associated with the child’s fecal incontinence is commonly reported in clinical settings, largely stemming from the child’s dishonesty about the occurrence of fecal accidents and the parental burden of frequent laundering of soiled clothing (Cox et al., 2003). In fact, many parents assume that the child’s laziness, carelessness, or willfulness is the primary cause of the child’s incontinence (Fishman, Rappaport, Schonwald, & Nurko, 2003). However, upon understanding the physiological factors that are involved in encopresis, they often experience feelings of guilt for taking an authoritarian (i.e., blaming or punishing) approach with the child (Campbell et al., 2009). Children with encopresis, particularly those who are older, may be teased and labeled by peers as “dirty” or “stinky.” This name-calling can persist even after the fecal incontinence resolves and can result in rejection and social isolation. Ongoing teasing and rejection, whether by peers or by parents, can be devastating for the child and may result in poor self-esteem, hostility, or continued fecal soiling as a result of learned helplessness (Campbell et al., 2009). There is some evidence that perceived quality of life is lower for children with chronic constipation compared to that of healthy children and those with other chronic medical conditions (e.g., inflammatory bowel disease, gastroesophogeal reflux disease) (Youssef, Langseder, Verga, Mones, & Rosh, 2005).