Elimination Disorders in Children and Adolescents

Elimination disorders involve the inappropriate elimination of urine or feces by individuals who are beyond toilet-training age. For children who experience these disorders, including ongoing difficulties with bladder or bowel control, daily life can become challenging. Though identifying the cause of elimination disorders may seem daunting, the conditions are well-understood by medical professionals. Treatments also tend to be successful, putting both hope and help well within reach.

What is an Elimination Disorder?

Typically first diagnosed during childhood or adolescence, elimination disorders include enuresis (i.e., urine incontinence, which is often associated with bed-wetting) and encopresis (i.e., fecal incontinence) ^[1].

These challenges can show up in different ways. For example, trouble with urine control (enuresis) might happen at night (bed-wetting) or during the day. Difficulties with bowel control (encopresis) might occur with constipation causing overflow accidents, or they could happen without constipation. While kids usually deal with either urine or stool accidents, some might experience challenges with both at the same time ^[1].

While these conditions might feel isolating, they’re actually quite common in young children. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a key diagnostic tool for healthcare practitioners, enuresis affects between 5 to 10% of 5-year-olds and 3 to 5% of 10-year-olds ^[2]. By age 15, only 1 to 2% of children with enuresis continue to wet the bed ^[1].

Encopresis is less prevalent, affecting approximately 1% of 5-year-olds, with males showing a higher likelihood of developing the condition ^[2]. Understanding these statistics helps normalize these conditions and encourages families to seek appropriate medical support rather than viewing them as behavioral issues.

Types of Elimination Disorders 

Children who experience elimination disorders may face challenges with either bladder control, bowel control, or both. Identifying the specific type of elimination disorder helps guide effective treatment and support children through their recovery journey.

Enuresis (Bed-wetting): The condition of enuresis (en-nyr-EE-sis) occurs when children repeatedly void urine in inappropriate places, such as in their clothing or bed. Primary enuresis occurs when a child has never achieved consistent dryness, while secondary enuresis develops after a period of successful bladder control ^[3].

Encopresis (Soiling): The condition of encopresis (en-ko-PREE-sis) involves the repeated passage of stool in inappropriate places, generally after four years of age. This condition frequently develops as a result of chronic constipation, though other factors can contribute to it. When a child becomes constipated, stool can become impacted in the colon, leading to involuntary leakage of liquid or soft stool around the impacted mass. This soiling often occurs without the child’s awareness or control ^[4].

Cause of Elimination Disorders

The root causes of elimination disorders can be complex. However, understanding them can help families feel more empowered in seeking treatment. 

Causes of Enuresis 

Bed-wetting often runs in families. If a parent experienced bed-wetting as a child, his or her child is more likely to face similar challenges. Along with genetics, the following issues can also play a role in developing enuresis ^[5]:

• Bladder and Nerve Development: Some children have a smaller bladder capacity, preventing them from holding their urine during the night. Additionally, the connection between bladder signals and brain awareness may still be developing, leading to overnight incontinence, particularly in deep sleepers.
• Natural Body Chemistry: The body produces less urine overnight thanks to anti-diuretic hormone (ADH). However, some children don’t make enough of it, which can cause incontinence. 
• Breathing During Sleep: Disrupted breathing patterns during sleep, often related to enlarged tonsils or adenoids, may contribute to nighttime wetness.
• Blood Sugar Regulation: In some cases, unexpected bed-wetting could signal changes in how the body processes sugar, especially when accompanied by increased thirst and fatigue.

Causes of Encopresis

Pinpointing the causes of bowel-control issues can help families find the right solutions. Main reasons include ^[4].

• Constipation: When children repeatedly hold in their bowel movements it can start a challenging cycle. The held-in stool becomes difficult to pass, leading to further withholding and eventually involuntary soiling. 
• Emotional Concerns: Emotional stressors, such as a rushed or difficult toilet-training experience, new routines like starting school, or big family changes such as a new sibling or parents separating, can affect a child’s bathroom habits. They can also contribute to holding patterns that may lead to physical complications.

Impact of Elimination Disorders on Mental Health

Elimination disorders can significantly affect a child’s emotional and psychological well-being, creating challenges that extend far beyond the physical symptoms to overall mental health ^[1].

Research published in Child and Adolescent Psychiatry and Mental Health has shown that children with elimination disorders frequently experience feelings of shame, embarrassment, and low self-esteem. These emotional challenges can be particularly intense during important developmental stages when children are building their sense of independence and self-confidence ^[6].

Keep in mind, however, that these emotional challenges are a normal response to living with an elimination disorder. Left untreated, however, these symptoms can become precursors to other childhood mental health disorders. Professional support can help children develop healthy coping strategies while working through both the physical and emotional aspects of their condition. 

Social Impact of Elimination Disorders

Elimination disorders can create significant social challenges for children, affecting their daily interactions and relationships with peers. These conditions often impact multiple aspects of a child’s social life, from school attendance to recreational activities ^[6].

Children with elimination disorders may also develop anxiety about social situations, particularly those involving overnight stays or extended periods away from home. Some children might become withdrawn or show signs of depression, especially if they face teasing or negative reactions from peers ^[1].

School life can be particularly challenging for these children. They might miss classes due to accidents or avoid using school bathrooms, which can affect their academic performance and social relationships. The fear of having an accident during school hours can make it difficult to concentrate on learning and participate fully in classroom activities ^[6].

Family dynamics can also be affected. Parents and siblings may need to adjust their routines and social plans to accommodate the child’s needs. Despite these challenges, families who maintain a supportive and understanding environment can help children develop resilience and cope more effectively with their condition ^[1].

Treatment for Elimination Disorders

Seeking an appropriate diagnosis and proper treatment for elimination disorders are crucial for the child’s physical health and emotional well-being. When these conditions go unrecognized and untreated, they can lead to increased social isolation, emotional distress, and potentially long-term psychological challenges.

Effective treatment begins by first identifying the cause of elimination disorders. For an initial diagnosis, healthcare providers provide a thorough evaluation, which generally includes physical examinations, detailed discussions about symptoms and family history, and analysis of the child’s daily routines. Additional testing may be recommended.

Throughout the treatment process, it is important to recognize that each child’s situation is unique and requires an individualized approach. Some children may respond well to behavioral modifications alone, while others might need a combination of treatments. The goal is not just to address the immediate physical symptoms but to help children regain their confidence and participate fully in daily activities.

Parents play a vital role in the treatment process. Understanding and a supportive approach can significantly influence treatment success. By maintaining a positive attitude and avoiding punishment or shame, parents can help create an environment where children feel supported while working through challenges. With proper medical support and positive family involvement, most children overcome these conditions and return to normal activities with renewed confidence.

Treatment for Bed-Wetting 

A comprehensive approach to treating bed-wetting typically involves multiple strategies working together. Common treatment strategies include ^[7]:

• Moisture Alarms: One of the most effective treatments is the use of bed-wetting alarms, which help children develop awareness of their bladder signals during sleep. These alarms work by alerting children at the first sign of moisture, gradually training their brains to respond to bladder signals while sleeping.
• Behavior Modifications: Making simple adjustments to the child’s daily routine can help manage bed-wetting effectively. While it’s important to ensure adequate hydration throughout the day, encouraging fluid intake during morning and early afternoon hours may help reduce nighttime wetness. Additionally, establishing regular bathroom visits every two to three hours during the day and implementing a “double voiding” routine at bedtime (going to the bathroom at the start of the bedtime routine and again right before sleep) can be beneficial. 
• Medications: When lifestyle changes aren’t enough to manage bed-wetting, healthcare providers may prescribe short-term medication treatments. The most commonly prescribed medication is desmopressin (DDAVP), which reduces nighttime urine production. It is approved for children age six and older. In some cases, especially when daytime wetting is also present, anticholinergic medications like oxybutynin may be prescribed to calm the bladder and increase its capacity.

Treatment for Encopresis

Treatment for encopresis (soiling) follows a structured approach that begins with addressing any immediate medical concerns and progresses to behavioral aspects. Common treatments for encopresis include ^[8]:

• Clearing Impaction: The first priority is clearing the bowel of impacted stool, which may require prescribed medications or enemas. This initial phase is crucial for breaking the cycle of constipation and soiling. 
• Maintenance: The maintenance phase often involves a combination of stool softeners or laxatives, dietary modifications, and behavioral strategies. Healthcare providers may recommend increasing fiber intake through diet or supplements, along with ensuring adequate fluid intake. 
• Behavioral Modifications: The behavioral component of treatment includes establishing regular toilet-sitting schedules, typically after meals when bowel movements are most likely to occur. Children are encouraged to sit on the toilet for 5-10 minutes at consistent times each day, helping to establish normal bowel patterns. 

Hope and Support for Families

Elimination disorders present unique challenges for children and their families, but understanding these conditions as medical issues rather than behavioral problems marks the first step toward successful treatment. With proper medical care and a supportive environment, children can develop healthy habits and regain their confidence. 

Most importantly, parents should remember they are not alone in facing these challenges. Millions of families have successfully navigated similar situations. By maintaining open communication with healthcare providers and creating a supportive environment at home, parents can help children overcome these temporary challenges while building resilience and self-esteem that serves them well throughout their lives.