Bowel & Bladder - normal & issues

Question 1

How common is bed wetting and general epidemiological features?

Answer 1

-Very common
-20% 5 yr olds
-5% 10 yr ols
-Higher frequency in boys
-Day time incontinence usually 5-6 years
-Bed wetting usually 7-8 years
Spontaneous remission rate only 15%

Question 2

Aetiology of bed wetting?

Answer 2

High nocturnal urine production
a. Nocturnal ADH production is still elevated in children ??

Small nocturnal functional bladder capacity
a. Overactive bladder, detrusor instability, irritable bladder

Poor arousal from sleep to a full bladder
a. Heavier sleepers than others but not as simple as this – usually they have poorer sleep quality

Question 3

Important features to ask in HOPC for child presenting with bed wetting?

Answer 3

Characterize bed wetting
-Duration of issue, Frequency, Volume

Do they wake during the night with need to void? Do they wake after wetting?

Context - Fluid intake, Intercurrent illness, Sleep history

Monosymptomatic vs. non-monosymptomatic

• Are daytime symptoms present?
• Wetting, jiggling, urgency, frequent passage of small volumes

Differentiate primary vs. secondary cause

• Have they had continuous bed wetting? i.e. no ‘dry periods’
• Previously been dry and recently started bed wetting?

Question for secondary causes
- Constipation, Signs of neurogenic bladder, Signs of diabetes

Psychosocial impact

Is there a significant event coming up where this may be an issue? i.e. school camp, holiday

Question 4

Important PMHx and FHx to ask child presenting with bed wetting?

Answer 4

i. Diabetes
ii. Spinal cord trauma/injury
iii. OSA
iv. Epilepsy
v. Bed wetting or day time incontinence in childhood

Question 5

What are important points when counselling child/parents about bed wetting?

Answer 5

a. Reassure child it is not their fault
b. Explain inherited nature of problem
c. Explain the prevalence – i.e. in a class your size, 2 other kids would be bed wetting also

Question 6

What examinations would you perform for child presenting with bed wetting?

Answer 6

1. Urinalysis
   a. Infection
   b. Glycosuria
2. Back/spine examination
3. Abdominal examination
   ? genital examination

Question 7

What is the management for bed wetting?

Answer 7

Usually don’t treat unless > 7 years
>10 years require urgent attention

Exclude UTI; treat constipation if present
Motivation
a. Child should be involved in plan
b. Can be helpful to make a record chart
c. Positive reinforcement without negativity if bet is wet

Behaviour modification

a. Avoid caffeinated drinks, esp. late at night
b. Avoid nappies/pull ups use
c. Alarms

Symptom minimisation
a. Mattress and bedding protectors

Medications

a. Anticholinergics -Oxybutynin
b. Desmopressin -ADH analogue

Question 8

Clinical features of UTI in infants/young children?

Answer 8

1. Fever
   a. Can be sole feature
2. Non-specific
   a. Lethargy
   b. Irritability
   c. Vomiting
   d. Poor feeding
3. Urine
   a. Offensive odour is not sensitive or specific for UTI

Question 9

Clinical features of UTI in older children?

Answer 9

1. Fever
2. Irritative symptoms dysuria, frequency, urgency, incontinence
3. Haematuria
4. Abdominal pain

Question 10

Diagnosis of UTI?

Answer 10

Clinical diagnosis adequate

Bacterial growth on:

a. MSU, Catheter sample, SPA
d. Clean catch prone to contamination

Screening
a. Full ward test/urine dipstick
b. Useful for screening if low index of suspicion
Should NOT be used if high chance nitrites, leucocytes negative in 50% children with UTI

Question 11

Management of UTI?

Answer 11

Consider admission

a. Very unwell febrile child traffic light system
b. Most children < 6 months (all <1 mth need IV antis)
c. IV antibiotics +/- fluid resuscitation - Gentamycin + Benzylpenicillin

Oral medication if admission not required

a. Trimethoprim or cephalexin
b. 10 day course if < 2 yrs, 7 days if > 2 yrs
3. Consider follow-up investigation

Ultrasound

i. All children <6mo with 1st UTI
ii. Consider in >6mo with 1st UTI

Question 12

Epidemiological features of faecal incontinence?

Answer 12

Boys 3-6 times more than girls

Most common in 7 – 8 yr age range

Question 13

Associations which can result in faecal incontinence?

Answer 13

• Painful or frightening event associated with defecation in early childhood
• Nocturnal enuresis
• Day wetting – irritable bladder
• Limited attention-concentration, learning disability

Question 14

Causes of faecal incontinence?

Answer 14

1. Constipation

Rare:

2. Neurological
3. Congenital/structural
4. Inflammatory
5. Psychogenic

Question 15

Causes of constipation?

Answer 15

Functional causes most common – ignoring urge leading to build up, painful defaecation – avoidance

If < 6 weeks’ alert for organic disease

Less common causes – malabsorptive diseases, cow milk allergy, neurological cause, hypothyroidism, hypocalcaemia

Commonly occurs around time of introduction of solids, toilet training and school entry

Question 16

Important features on history for child presenting with constipation?

Answer 16

Timing of meconium passage

Previous painful or frightening precipitant to opening bowels

Bowel habits - usual and change, timeframe of change, description of stool

Associated features - Straining, Toilet refusal, Hiding while defecating , Crossing legs or other with-holding behaviour, Faecal or urinary incontinence day or night, Pain when defecating

Question 17

Red flags of constipation for organic disease cause?

Answer 17

Weight loss 
Vomiting 
PR bleeding 
Constitutional symptoms
Onset before 1 month
Delayed passage of meconium
Ribbon stools
Abdominal distension and vomiting 
Growth faltering
Protective concerns 
Abnormal neurology lower limbs
Abnormality of anus/buttocks/sacrum

Question 18

Ix for child with constipation?

Answer 18

Ix not recommended unless red flags or persistence despite adequate Rx AXR not recommended

Consider Ix for less common causes if constipation persists despite adequate behaviour modification 
1.	Coeliac antibodies
2.	TFT
3.	FBE, iron studies 
4.	Calcium 
Surgical referral

Question 19

Management of constipation?

Answer 19

1. Educate - Not the child’s fault, Demystify and reassure

1st line = Toileting retraining & behavioural modification - Toilet sits, Posture (Feet should be supported, knees above hips, legs apart and bulge tummy, Chart/reward system for positive reinforcement

Laxatives – may require initial ‘clear out’ and sometimes maintenance laxatives

Remove barriers

2nd line = diet

3rd line = Laxatives

Long-term follow up - at least 6 months

Question 20

What are the laxative options for a constipated child?

Answer 20

Avoid rectal medication in young children

Osmotic laxatives good for clear out but not as good for maintenance (stools too loose)

1st line = osmotic or lubricant laxative

i. Macrogol
ii. Lactulose or sorbitol
iii. Paraffin oil

2nd line = stimulants (if not regular after 2-3 mths)

i. Bisacodyl or Senna
ii. Sodium picosulfate

3rd line (faecal impaction)

i. High dose macrogol for 3 days
ii. Hospital admission