ELIMINATION
DISORDERS
Functional
Encopresis
The essential feature of this disorder is
repeated involuntary (or, much more rarely,
intentional) passage of feces into places not
appropriate for that purpose (e.g., clothing
or floor). In order to make the diagnosis,
the event must occur at least once a month
(or at least six months, the chronologic and
mental age of the child must be at least four
years, and physical disorders that can cause
fecal incontinence, such as aganglionlc
megacolon, must be ruled out.
The stool may be of normal or near-normal
consistency, or liquid, as in the case of
overflow incontinence secondary to functional
fecal retention. When the passage of feces is
involuntary rather than intentional, it is
often related to constipation, impaction, or
retention with subsequent overflow. The
constipation may develop because the child,
for psychological reasons, avoids defecating,
because of either anxiety about defecating in
a particular place or a more general pattern
of oppositional behavior. In other children,
the constipation develops for physiologic
reasons, such as dehydration associated with
a febrile illness or medication. Once
conitipation has developed, it may be
complicated by an anal fissure, painful
defecation, and further fecal retention.
Functional Encopresis is generally referred
to as primary if it has not been preceded by
a period of fecal continence lasting at least
one year, and secondary if it has been
preceded by a period of fecal continence
lasting at least one year.
Associated features. Very
often the child feels ashamed or embarrassed,
and may wish to avoid situations that might
lead to embarrassment, such as camp or even
school. When the incontinence is clearly
deliberate, antisocial and other
psychopathological features are common.
Smearing feces may be deliberate, and should
be differentiated from smearing that takes
place accidentally in the child's attempt to
clear or hide feces passed involuntarily.
Twenty-five percent of children with
Functional Encopresis also have Functional
Enuresis.
Course. Functional
Encopresis rarely becomes chronic, but unless
treated, can persist for years.
Age at onset. By definition,
primary Functional Encopresis begins by age
four. Secondary Functional Encopresis usually
begins between the ages of four and eight.
Impairment. The amount of
impairment directly attributable to the
disorder is primarily a function of the
effect on the child's self-esteem; the degree
of social ostracism by peers; and anger,
punishment, and rejection on the part of
caretakers.
Complications. None.
Predisposing factors.
inadequate, inconsistent toilet training and
psychosocial stress, such as entering school
and the birth of a sibling, may be
predisposing factors.
Prevalence. it is estimated
that approximately 1 % of five-year-olds have
the disorder. Primary Functional Encopresis
apparently is more common in lower
socioeconomic classes.
Sex ratio. The disorder is
more common in males than in females.
Familial pattern. No
information.
Differential diagnosis.
Functional Encopresis must be differentiated
from structural organic causes of Encopresis,
such as aganglionic megacolon, which need to
be ruled out by physical examination and
laboratory procedures.
Diagnostic Criteria for Functional
Encopresis
A. Repeated passage of feces
into places not appropriate for that purpose
(e.g., clothing, floor), whether involuntary
or intentional. (The disorder may be overflow
incontinence secondary to functional fecal
retention.)
B. At least one such event a
month for at least six months.
C. Chronologic and mental
age, at least four years.
D. Not due to a physical
disorder, such as agalgIionic megacolon.
Specify primary or secondary type.
Primary type: the
disturbance was not preceded by a period of
fecal continence lasting at least one year.
Secondary type: the
disturbance was preceded by a period of fecal
continence lasting at least one year.
Functional
Enuresis
The essential feature of this disorder is
repeated involuntary or intentional voiding
of urine during the day or at night into bed
or clothes, after an age at which continence
is expected. In order to make the diagnosis,
etiologic physical disorders must be ruled
out. The disorder is somewhat arbitrarily
defined by at least two such events per month
for children between the ages of five and
six, and at least once a month for older
children.
Functional Enuresis is often referred to as
primary if it has not been preceded by a
period of urinary continence lasting at least
one year, and secondary if it has been
preceded by a period of urinary continence
lasting at least one year. Either of the
above types may be nocturnal (most common),
defined as the passage of urine during sleep
time only, diurnal, defined as the passage of
urine during waking hours, or both diurnal
and nocturnal.
In most cases of nocturnal Functional
Enuresis, the child awakens with no memory of
a dream and no memory of having urinated.
Typically the disturbance occurs during the
first third of the night. In a few cases the
voiding takes place during the rapid eye
movement (REM) stage of sleep, and in such
cases the child may recall a dream that
involved the act of urinating.
Associated features.
Although the great majority of children with
Functional Enuresis do not have a coexisting
mental disorders; the prevalence of
coexisting mental disorders is greater in
those with Functional Enuresis than in the
general population. Functional Encopresis,
Sleepwalking Disorder, and Sleep Terror
Disorder may also be present.
Course. Most children with
the disorder become continent by adolescence,
but in approximately I % of cases, the
disorder continues into adulthood.
Age at onset. Primary
Functional Enuresis by definition begins by
age five. In most cases of secondary
Functional Enuresis, onset is between the
ages of five and eight.
Impairment. The amount of
impairment directly attributable to the
disorder is primarily a function of the
effect on the child's self-esteem; the degree
of social ostracism by peers; and anger,
punishment, and rejection on the part of
caretakers.
Complications. None.
Predisposing factors. Among
predisposing factors are delay in the
development of the supporting musculature of
the bladder, and impaired ability of the
bladder to adapt to urinary filling without
changes in intravesical pressure, resulting
in a lower bladder volume threshold for
involuntary voiding; delayed or lax toilet
training; and psychosocial stress, in
particular, hospitalization between the ages
of two and four, entering school, and the
birth of a sibling.
Prevalence and sex ratio.
The prevalence of Functional Enuresis as
defined here is: at age 5, 7% for males, and
3% for females; at age 10, 3% for males, and
2% for females; and at age 18,1 % for males,
and almost nonexistent for females.
Familial pattern.
Approximately 75% of all children with
Functional Enuresis have a first-degree
biologic relative who has, or has had, the
disorder. The concordance for the disorder is
greater in monozygotic than in dizygotic
twins.
Differential diagnosis.
Organic causes of enuresis such as diabetes,
seizure disorder, and urinary tract infection
should be ruled out by appropriate physical
examinations.
Diagnostic Criteria for Functional
Enuresis
A. Repeated voiding of urine
during the day or night into bed or clothes,
whether involuntary or intentional.
B. At least two such events
per month for children between the ages of
five and six, and at least one event per
month for older children.
C. Chronologic age at least
five, and mental age at least four.
D. Not due to a physical
disorder, such as diabetes, urinary tract
infection, or a seizure disorder.
Specify primary or secondary type.
Primary type: the
disturbance was not preceded by a period of
urinary continence lasting at least one year.
Secondary type: the
disturbance was preceded by a period of
urinary continence lasting at least one year.
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