Module 6 – Elimination Disorders

3rd edition as of August 2022

Module Overview

In Module 6, we will discuss matters related to elimination disorders to include their clinical presentation, prevalence, comorbidity, etiology, assessment, and treatment options. Our discussion will include enuresis and encopresis. Be sure you refer to Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain psychopathology (Module 2), and descriptions of the various therapies (Module 3).

Module Outline

• 6.1. Clinical Presentation and DSM-5-TR Criteria
• 6.2. Prevalence and Comorbidity
• 6.3. Etiology
• 6.4. Assessment and Treatment

Module Learning Outcomes

• Describe the presentation of enuresis.
• Describe the presentation of encopresis.
• Describe the prevalence of enuresis and encopresis.
• Describe the etiology of enuresis and encopresis.
• Describe how enuresis and encopresis are assessed, diagnosed, and treated.

6.1. Clinical Presentation and DSM-5-TR Criteria

Section Learning Objectives

• Describe the presentation and associated features of enuresis.
• Describe the presentation and associated features of encopresis.

6.1.1. Enuresis

Enuresis is the repeated voiding of urine into bed or clothes and can be involuntary or intentional. It has occurred at least two times per week for the past three consecutive months. The child must also be at least five years of age. Mental health professionals can specify whether the enuresis is nocturnal only (i.e., urinary incontinence only while sleeping), diurnal only (i.e., urinary incontinence only while awake), or nocturnal and diurnal (i.e., both while asleep and awake; APA, 2022). The nocturnal only type is most common and occurs during the first one-third of the night. Diurnal enuresis most commonly occurs in the early afternoon on school days or after coming home from school. The degree of impairment is a function of, “…the limitation on the child’s social activities (e.g., ineligibility for sleep-away camp) or its effect on the child’s self-esteem, the degree of social ostracism by peers, and the anger, punishment, and rejection on the part of caregivers” (APA, 2022, pg. 401).

6.1.2. Encopresis

Encopresis is defined as the repeated passage of feces into inappropriate places such as clothing or onto the floor, whether involuntary or intentional. There has been at least one such event each month for the past three months, and the individual must be at least four years of age. Mental health professionals will specify whether encopresis is with or without constipation and overflow incontinence (APA, 2022). The child often feels ashamed and may wish to avoid situations, such as going to camp, that might lead to embarrassment. Encopresis is associated with, “a significant decrease in health-related quality of life and family functioning, particularly in older children” (APA, 2022, pg. 404). When the incontinence is clearly deliberate, oppositional defiant disorder or conduct disorder may also be present.

6.2. Prevalence and Comorbidity

Section Learning Objectives

• Describe the prevalence of encopresis and enuresis.
• Describe comorbid disorders of encopresis and enuresis.

6.2.1. Enuresis

Daytime incontinence has a prevalence between 3.2% and 9.0% in children aged 7 years, from 1.1.% to 4.2% in youth ages 11-13 years, and from 1.2% to 3.0% in adolescents ages 15-17 years of age. Nocturnal enuresis is more common in males than females.

Most children with enuresis do not have a comorbid mental disorder. That said, the prevalence of comorbid behavioral and developmental symptoms does appear to be higher in children with both diurnal and nocturnal enuresis than those without incontinence.

6.2.2. Encopresis

Most children older than four years of age diagnosed with encopresis have the subtype “with constipation and overflow incontinence.” The disorder affects 1% to 4% of children in high-income countries, while in some Asian countries a prevalence rate of 2% to 8% has been reported. It also affects children aged 4-6 years more than children aged 10-12 years. Encopresis is also higher among children who were low-income youth or were abused or neglected early. The gender ratio appears to be about equal in children younger than 5 years but is more common in boys than in girls among older children.

Enuresis is often reported in children with encopresis, especially in children not presenting with constipation and overflow incontinence.

6.3. Etiology

Section Learning Objectives

• Describe the biological/genetic basis/causes of elimination disorders.
• Describe environmental/psychosocial causes of elimination disorders.

6.3.1. Biological/Genetic

      6.3.1.1. Enuresis. Because medical conditions can explain urinary incontinence, careful consideration for specific bladder conditions or medical conditions that can impact urinary continence (e.g., neurogenic bladder or untreated diabetes) must be made. Additionally, nocturnal enuresis has been associated with a mismatch between nocturnal urine production, nocturnal bladder storage capacity, and the ability to arouse from sleep (APA, 2022).

Finally, there appears to be a heritability factor in enuresis, with children being anywhere from 3.6 (for enuretic mothers) to 10.1 times (for enuretic fathers) more likely to develop enuresis if their parents had enuresis themselves in childhood (APA, 2022; von Gontard et al., 2011).

     6.3.1.2. Encopresis. Similar to enuresis, fecal incontinence can be caused by other medical conditions. For example, spina bifida and chronic diarrhea can lead to fecal incontinence. Because of this, a medical examination and/or consideration for specific medical conditions must be considered. This is because encopresis is not diagnosed if incontinence is explained better by a medical condition.

6.3.2. Environmental/Psychological  

Ineffective toilet training procedures, or toilet-training procedures that occur later than necessary, may contribute to enuresis and encopresis. Moreover, high levels of stress may also impact these disorders. Additionally, if a child experiences chronic constipation, and experiences painful bowel movements, they may become extremely fearful of defecating and avoid doing so. This perpetuates concerns with encopresis. Thus, they may avoid defecating for long enough that they can physically no longer do so, resulting in accidents. The DSM also notes that for encopresis, “…anxiety, depression, behavioral disorders, psychological stressors (e.g., bullying, poor school performance), and lower socioeconomic status” (APA, 2022, pg. 404) may contribute to the development of fecal incontinence.

6.4. Assessment and Treatment

Section Learning Objectives

• Describe how elimination disorders are assessed and diagnosed.
• Describe treatment options for elimination disorders.

6.4.1. General Assessment of Elimination Disorders

Similar to feeding-related disorders, assessments focus on parent/caregiver reports during interviews, as well as a thorough medical examination, to rule out medical conditions causing the elimination concerns. Utilizing a voiding diary may help parents recognize when and how frequently accidents occur. They may be asked to note the volume of waste/urine and frequency of accidents in addition to successful occurrences of voiding in the toilet. (Reiner & Kratochvil, 2008).

6.4.2. Treatment of Enuresis

The use of urine alarm therapy is helpful. The basic principal behind this therapy is that an alarm activates when moisture is detected. These systems often utilize a pad that is placed on a child’s mattress, although some more advanced systems may be incorporated into clothing.  For examples of these alarms, you can check out https://www.pottymd.com. The alarm will either vibrate or sound (or both) when it becomes wet. This awakens the child to prompt them to go to the bathroom. The idea is, eventually, behavioral conditioning occurs, and the child slowly begins to awaken on their own to use the bathroom (Shepard, Poler, & Grabman, 2017). The alarm system is often utilized for several months, typically a minimum of 3 (Reiner & Kratochvil, 2008). This method can be used independently; however, it is often combined with dry bed training as well (Shepard, Poler, & Grabman, 2017).

Dry bed training utilizes several strategies. For example, scheduling wakeup times throughout the night to check for dryness and/or go to the bathroom may be implemented. If an accident occurs, overcorrection may be used. Overcorrection requires that a child become responsible for changing sheets, changing clothes, etc. when an accident occurs, rather than the parent doing it for them. Combining dry-bed training with urine alarm therapy is more effective than only utilizing urine alarm therapy (Shepard, Poler, & Grabman, 2017).

Some children may simply hold their urine for so long that accidents occur. This may be especially true for diurnal enuresis. As such, a small watch that reminds a child to go to the bathroom at a set frequency may be used.

6.4.3. Treatment of Encopresis

Treatment for encopresis may incorporate biofeedback. The goal is to teach the individual to recognize their own muscular movements by using probes that send signals to the individual physically or visually. This may help the child learn to relax and contract anal muscles, further allowing them to control bowel movements. Another option may include enhanced toilet training which teaches and trains individuals to relax and contract muscles through the use of simple strategies such as breathing exercises, relaxation, etc. (Shepard, Poler, & Grabman, 2017).

6.4.4. General Treatment Considerations

For many of the interventions discussed, use of rewards can be very helpful when implementing the behavioral therapies. It is imperative to stress that punishment and shame should not occur when a child has an accident.

Some medicinal interventions may be utilized. For example, desmopressin, imipramine, oxybutynin, tolterodine, and propantheline (Reiner & Kratochvil, 2008) or nortriptyline (Ghanizadeh & Haghighat, 2012) may be useful. However, when medication is withdrawn, chance of encopresis or enuresis reoccurring is high (Ghanizadeh & Haghighat, 2012).

Dietary supplementation may also be helpful and necessary, particularly with encopresis. For example, naturally increasing fiber in a child’s diet or introducing polyethylene glycol-3350 (over-the-counter laxative) may prove helpful (Reiner & Kratochvil, 2008).

Module Recap

In this module, we learned about enuresis and encopresis. We discussed the various symptoms of these elimination disorders. We then discussed the prevalence of elimination disorders and identified potential comorbid disorders. We then looked at the etiology of elimination disorders. Finally, we discussed the process of assessing and treating these disorders. This concludes our discussion of disorders in infancy and early childhood.

Our next module starts our discussion of developmental delays and motor disorders. We will start by reviewing intellectual development disorder (intellectual disability) and specific learning disorder.

3rd edition