Bedwetting and Elimination Problems
- Screening Question: have you repeatedly passed urine or feces onto your clothing, bed, the floor, or another inappropriate location?
- Encopresis: intentional or involuntary voiding of feces at least >1 time/month and occurring >3months in a row. Exclusion; child <4y/o and not due to another physiological mechanism or medical condition. Encopresis can be primary as in the child was never completely trained or secondary, the child was trained for a period before incontinence occurred.
- Enuresis: intentional or involuntary voiding of urine >2 times/week and for at least >3months in a row. Exclusion; child <5y/o and not due to another physiological mechanism or medical condition. Primary enuresis, the child never established control. Secondary enuresis, the child develops incontinence after a 6-12 month period of established control. Nocturnal enuresis (occurring at bedtime) and diurnal enuresis (occurring during daytime).
I wanted to make a few suggestions that have helped me with kids having elimination and bathroom challenges. Like most families and patients, the topic can be embarrassing and very sensitive. Sometimes the family would forget to mention the problem or maybe out of respect for the child they’ll rather not discuss it in the office. However, it’s an important assessment so here’s how you ease into the conversation:
- Ask about hygiene: you can try open-ended questions such as, how well does the child clean? any washing or bathing concerns? any difficulties in the bathroom or in general?… Let’s assume there is a problem and the mother, MM, says yes AM (the 7y/o daughter) needs help with “wiping” and bed wetting off/on more often. She also has an autistic son, TM who’s 13y/o and has been smearing feces on the wall and wears diapers.
- Ask about the duration and any changes in diet or nutrition: the duration is part of the inclusion factors and maybe it’s something simple such as changing the diet. MM reports how AM usually eats junk food and since starting her on aripiprazole, she has been gaining more weight. TM has bathroom challenges since he was younger but is also wetting his diaper more often, also indulging in junk food, and he’s not on any medication.
- Ask if anything has helped in the past and have they discussed these issues with PCP: Maybe the patient was prescribed imipramine or DDAVP in the past or has a medical condition unbeknownst. MM reports neither one of the kids had any prior treatment or additional conditions, and she said it’s usually not this bad. PCP referred them to urology but the family has yet to follow up.
As a psych provider, bedwetting is technically not our scope but yes we may have to make changes to the plan of care based on these issues. Plus, if a patient is on one of our prescribed medication that’s causing issues, YES it’s our job to address it. Let’s discuss the plan of care for MM’s kids:
How to Manage Symptoms & Considerations
- Rule out UTI: so PCPs are usually good at checking things out but if not, encourage the family to ask the PCP to r/o a UTI or you can write a prescription to get labs done. Again, you’re not diagnosing a UTI but ruling it out and making sure the metabolic panel is unremarkable with a kid being on an antipsychotic. Another way to r/o a UTI is to simply ask if there’s any pain after urination or itching. I usually always tell my female patients (young and old) the importance of wiping front to back, making sure clothing isn’t too tight, and only cleaning using soap and water… don’t assume pertinent information is well-known.
- Reassess the medication: this is a med review appointment so we have to reassess the treatment, behavior, and side effects. Maybe MM isn’t aware of how antipsychotics can increase the appetite/weight but correlate the timing to see if it could be the medications versus AM’s 7y/o body simply growing. Monitor height/weight with growth charts to know what’s WNL. Plus see if there’s a chance to the lower dose of the antipsychotic or to ween her off of it due to metabolic risks. You want to make sure the increase of bedwetting or accidents isn’t r/t diabetes or other reasons.
- Encourage healthy eating and activities: for all kids and families, promote healthy living. Sometimes poor bathroom habits and challenges are the results of poor eating and low physical activities. TM has been eating junk food and the mother is unsure if there are constipation problems but agreed to include more fiber in his diet. For children who are special needs and have bathroom challenges, I usually recommend a stool softener and focus on a bathroom schedule. A bathroom schedule helps with proper elimination and reinforces good hygiene habits.
- Try the simple changes and behavioral modifications first: I try to avoid making major changes whether the issue is direct or indirect. Sometimes with a little bit of tweaking, things can get better. TM is having fewer bathroom/wetting incidents since the mother increased his fiber but he’s still occasionally smearing feces on the wall. AM followed up with PCP and didn’t have a UTI but the mother agreed to discontinue the antipsychotic and AM hasn’t been overeating and has fewer issues using the bathroom. TM and AM continue to do therapy related to managing mood and behaviors that can also help issues.
Ongoing Problems with Elimination
- R/O Mood, Behavior Problems: since TM continues to smear feces I would likely start him on a low-dose antipsychotic versus other medications. We have to address this major deviation from normal behavior, regardless of whether this was prior or usual activities. It’s not clear why he thinks it’s okay to behave in this manner and would probably refer for more intensive therapy like ABA. Keep in mind, ABA is usually not readily available so medications may be more helpful to manage issues. This is also a great situation where I can trial trazodone to get anticholinergic effects versus using a TCA that has more risks.
- Mood-Related: sometimes I would prescribe an SSRI if the bathroom issues are related to anxiety, the child feel scared/separation anxiety/PTSD/nightmares, fear of toilets, flushing, or embarrassment/bullying, or too depressed to engage in self-care. If enuresis is truly a primary problem and all other measures didn’t help, I would focus more on behavioral therapeutics and treating the mood.
- Consult Urology: If the bathroom issues continue to get worse I would consider referring to a urologist. AM and TM issues were low-risk and manageable but one of my patients was referred to a urologist that actually recommended using a stool softener and the patient stop having bedwetting issues so I’ve been telling my patients to use them as tolerated. My patient issue was minor but I usually f/u when my patients see other specialists. The urologist was only doing telehealth so the family didn’t think it was beneficial but it wasn’t an issue anymore. Urologists are also referred to r/o structural issues and are a great reference for treatment.
Red Flags: always r/o abuse or trauma, bruising, pain, bleeding, foul-smelling odor/drainage, changes with body/swelling.
Treatments
- Encopresis Management: (non-constipated) avoid stool softeners or laxatives but trial fiber products like Metamucil; (constipated) increase fiber and fluids, stool softeners -starting from once to twice a day as tolerated, toilet sitting BID for 10 minutes. Use incentives.
- Enuresis Management: limit night fluids <1 cup, void by the clock every 2 hours, teach not to wait for the urge to urinate. Medications: Imipramine: a TCA so not first-line or even a drug of choice due to cardiac risks. I would either ask the PCP (r/o cardiac risks) or urologist before starting this medication. Desmopressin (DDAVP): used primarily for nocturnal enuresis, intranasal d/c due to hyponatremia risks. Oxybutynin: useful for controlling daytime enuresis. I also usually first recommend increasing fiber or stool softeners with the initial treatment.
TCA and DDAVP are fine but good luck with coverage! I usually inherit kids taking it already but rarely try to start them on it anymore because of insurance issues. Stool softeners have honestly given me the best results. It can be any OTC brand, parents asked me for something specific but I usually respond with whatever is on sale because supplements can be expensive. FYI guanfacine has induced bedwetting for some of my kids, which resolved after d/cing the dose.
If things continue to be abnormal or difficult, then the family should be referred to the PCP because most kids don’t have major elimination issues as they get older or they’re self-limiting. However, if the child is lactose intolerant or has other bathroom or dietary issues, most PCPs only recommend lifestyle modifications. Overall, keep managing, rule out the red flags, and prioritize the non-pharmacological treatments.
