Constipation and Enuresis

Katie Mallam

Paediatric Update for Primary care9th October 2012

Constipation – Why?

• Common– Prevalence 5-30%– 1/3 become chronic (>8 weeks) = soiling

• Debilitating– Social, psychological and educational consequences

• Cost– Longer duration = longer, more intensive treatment

• Varying advice = angry parents

• Standardise approach• Early treatment

– Reduce consequences and cost

• No need to remember history and examination: http://guidance.nice.org.uk/CG99/Questionnaire

Constipation – NICE

Constipation?

2 of ……..

Breast fed babies can go up to a week without opening

bowels

*

*

Constipation?

http://www.childhoodconstipation.com/Extra/Documents.aspx

Constipation?

2 of ……..

Breast fed babies can go up to a week without opening

bowels

*

*

• Mostly idiopathic

• Rarely– Hirschsprung’s– Neurological NB lumbosacral abnormalities– Anorectal malformations– Hypothyroid– Coeliac– Cystic fibrosis (but normally diarrhoea due to fat malabsorption)– Cow’s milk protein intolerance

• Associations– Cerebral palsy– Autism– Down’s syndrome (NB beware hypothyroidism and Hirschsprung’s)

Constipation – Causes

Constipation – History 1

Constipation – History 2

Faltering growth = treat and do coeliac and

TFT (refer)

Constipation – Examination

No PR in primary care

NB perianal strep

Perianal streptococcal infection

Swab

Treat infection and constipation

Constipation – Examination

No PR in primary care

NB perianal strep

• No need to remember history and examination: http://guidance.nice.org.uk/CG99/Questionnaire

Constipation – It’s NICE

Microsoft Word Document

Microsoft Word Document

< 1 year ≥ 1 year

• Red (or amber) flagsRefer paeds

• No red flagsReassureExplain constipation and treatment (could just do briefly and

give patient information using resources in ‘Explain 2’ slide)Treat

Constipation – Actions

Constipation – Explain 1

-Rectum gets used to being full: normal reflexes and power are reduced = ‘baggy’.

-Reduced sensation and overflow: soiling is not intentional

-Need to ‘get empty and stay empty’ for rectum to shrink back and recover reflexes and sensation: takes time

• Tameside = comprehensive leaflet

• Patient.co.uk = very good, can print pdf leaflet

• ERIC = lots of info for professionals and parents/patients (age banded) http://www.eric.org.uk/

• NICE ‘template letter’

Constipation – Explain 2

• Get empty, stay empty!

• Faecal impaction?– Soiling– Abdominal mass

• Movicol, movicol, movicol!– NB different strengths e.g. Paed Plain = no taste

• ‘Softeners’– Movicol, Lactulose, Docusate (also squeezes)

• ‘Squeezers’– Senna, sodium picosulphate, bisacodyl

• Doses as per BNFc or NICE

Constipation – Treat

• Disimpaction– Aiming for liquid and no more lumps = messy– Review after 1 week

Movicol If not tolerated = stimulant laxative +/- lactulose If not worked after 2 weeks = add stimulant laxative and urgently

refer to Paeds

• Enemas and manual evacuation only if all else failed

Constipation – Get empty

• Maintenance– Until rectum no longer stretched and reflexes return– Laxatives do not make bowel lazy: may need for several years

and should be gradually reduced

Movicol If not tolerated = stimulant +/- lactulose, or docusate alone If not effective = add stimulant

Constipation – Stay empty 1

• Behavioural– Non-punitive (I say ‘training the subconscious’)

– Regular toileting after meals

– Foot support, sit forward (rock and pop!), bubbles, books

– Diary and rewards (things under their control)

– NB school (NB ERIC info)

– Use school nurses and HV

Constipation – Stay empty 2

Constipation – Stay empty 3

• Fluids

Page 15, NICE Quick Reference Guide http://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf

• Diet– High Fibre = fruit, veg, high fibre bread, wholegrain

breakfast cereals, baked beans

• Activity

Constipation – Stay empty 4

• Disimpaction has failed if not responded to Movicol after 2 weeks: Urgent referral to Paeds (or Bladder and Bowel Specialist Nurse)

• Maintenance has failed:– In those aged <1 year, if not responded after 4 weeks

Refer paeds

– In those aged ≥ 1 year, if not responded after 3 months Check no red flags If red flags = refer paeds No red flags = refer to the Bladder and Bowel Specialist Nurse

Service

Constipation – Failed treatment

• RED FLAGS, refer paeds– History and examination questionnaires

http://guidance.nice.org.uk/CG99/Questionnaire

– Bristol Stool Chart

• EXPLAIN: Tameside leaflet

• IMPACTED? GET EMPTY, STAY EMPTY!– Medical: usually Movicol Paed Plain as per BNFc– Non Medical: see Tameside leaflet and fluid rqmts on page 15 of NICE

http://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf

• If fails, add stimulant– Disimpaction failure, refer paeds– Maintenance failure, refer Bladder and Bowel Specialist Nurse

Constipation Toolkit

• Incontinence– uncontrollable leakage of urine

• Enuresis– Incontinence of urine when sleeping: usually say Nocturnal– Bedwetting: ‘involuntary wetting during sleep without any

inherent suggestion of frequency of bedwetting or pathophysiology’ (NICE)

• Primary• Secondary = previously dry for ≥ 6 months

Enuresis - definitions

• Secondary (especially recent):

– UTI– Diabetes (drinking overnight)

– Constipation– Neurological: spine and lower limb exam

– Emotional/behavioural difficulties: consider psychology

Urinary Incontinence – History 1

Urine dipstick

NB same day referral if suspect diabetes

• Pattern of bedwetting– Variable volume, >1 per night: could be Overactive Bladder

• Daytime symptoms– Urgency, Frequency >7/day, Infrequent <4/day, straining, pain– Consider UTI, Overactive Bladder, Neuro/Uro cause– Urine dipstick– If significant, refer to consider investigation/treatment of those

symptoms first

• Toileting patterns– NB School

• Fluid intake– Check not restricting

Urinary Incontinence – History 2

Diary

• Effect on child/YP/family– Social (sleep-over), self-esteem

• PMHx:– UTI– Developmental, attention or learning difficulties: consider specific

management

Urinary Incontinence – History 3

• Primary Nocturnal: not required according to NICE

• Secondary Nocturnal or Daytime Symptoms:– Genitalia– Abdomen– Spine– Lower limb neuro

Urinary Incontinence – Examination

• RED FLAGS = recurrent UTI, Diabetes, examination abnormalities: refer paeds

• No red flags– Nocturnal only:

refer HV or school nurse

– Day only, or Nocturnal with daytime symptoms: refer to Bladder and Bowel Specialist Nurse

Urinary Incontinence – Referral

• Principles of Care– Not their fault: non-punitive management

– Tailor management to child/YP and parent/carer

– Consider parental support

– Do not exclude <7y• Reassure

Enuresis – NICE

Enuresis

• Prevalence

Age < 2 per week ≥ 2 per week

4.5y 21% 8%

9.5y 8% 1.5%

• Principles of Care– Not their fault: non-punitive management

– Tailor management to child/YP and parent/carer

– Consider parental support

– Do not exclude <7y• Reassure

• Trial of BASICS

• <5y: encourage toilet training if not done already and trial out of nappies at night

Enuresis – NICE

Enuresis – Management BASICS!

• Fluids: avoid caffeinated (and ?fizzy and blackcurrant)

• Regular toileting 4-7/day• NB double voiding if Overactive Bladder symptoms• Trial out of nappies/pull-ups: offer alternatives• Reward system: for agreed behaviour (not dryness)

• NHS choices: concise, for parents http://www.nhs.uk/Conditions/Bedwetting/Pages/Introduction.aspx

• Patient.co.uk: concise, for parents http://www.patient.co.uk/health/Bedwetting.htm

• ERIC: all ages, parents, professionals http://www.eric.org.uk/

Enuresis – Information

• High long-term success rate (weeks)

• But need commitment and can disrupt sleep

• Contraindications:– < 1-2 wet nights/week– Parental distress or negativity (consider parental support)

• Need training– Hence referral to HV/school nurse– http://www.patient.co.uk/health/Bedwetting-Alarms.htm

• Encourage to combine with reward system– Get up and go to toilet, help change sheets

Enuresis – Alarm

Enuresis – Desmopressin

• Rapid, short-term results (sleep-over)• Alarm is inappropriate or undesirable• Inform them:

– many relapse when treatment is withdrawn

– how desmopressin works

– fluid restriction from 1 hour before until 8 hours after taking desmopressin

– that it should be taken at bedtime

– how to increase the dose if the response to the starting dose is not adequate

– that treatment should be continued for 3 months

– that repeated courses can be used

– Stop during sickle cell crises or D&V

http://www.medicinesforchildren.org.uk/search-for-a-leaflet/desmopressin-for-bedwetting/

• Only on advice of specialist

• Anticholinergic with desmopressin– Oxybutinin– If:

• Not responded to desmo+/-alarm• Daytime symptoms

• Imipramine– Gradual increase and withdrawal– Warn re dangers of OD

• http://www.medicinesforchildren.org.uk/search-for-a-leaflet/

Enuresis – Other treatments

• Secondary: think other causes esp Diabetes

• Examine if Secondary or Daytime

• Refer all?– Red flags = paeds– Others = HV/school nurse/BBSN

• Basics

• Give/direct to information

Urinary Incontinence – Top tips