Nursing Management of Enuresis and Encopresis

Introduction to Childhood Behavioral Disorders
Common Behavioral Disorders in Children
Enuresis: Overview and Diagnosis
Encopresis: Overview and Diagnosis
Nursing Assessment
- Assessment of Enuresis
- Assessment of Encopresis
Nursing Management in Hospital Settings
- Hospital Management of Enuresis
- Hospital Management of Encopresis
Home-Based Nursing Management
- Home Management of Enuresis
- Home Management of Encopresis
Behavioral Management Techniques
Mnemonics for Nursing Practice
Case Studies
Conclusion
References

1. Introduction to Childhood Behavioral Disorders

Childhood behavioral disorders represent a significant challenge for healthcare providers, families, and the affected children themselves. These conditions can impact a child’s social, emotional, and educational development, making early identification and appropriate management crucial for optimal outcomes.

Definition: Behavioral disorders in children are characterized by a pattern of disruptive behaviors that last for at least 6 months and cause problems in school, at home, and in social situations. Unlike occasional behavioral issues that all children experience, these disorders involve persistent patterns that significantly impair functioning across multiple settings.

Among the various behavioral disorders that affect children, elimination disorders—specifically enuresis (involuntary urination) and encopresis (involuntary defecation)—represent common but often underaddressed conditions that can cause significant distress and social impairment for affected children and their families.

As nursing professionals, understanding the diagnostic criteria, assessment methods, and evidence-based management approaches for these conditions is essential for providing comprehensive care. Effective behavioral management requires a multidisciplinary approach that addresses the underlying physiological, psychological, and social factors contributing to these conditions.

Why These Notes Matter: These comprehensive notes aim to equip nursing students with the knowledge and clinical tools needed to provide evidence-based care for children with elimination disorders. By implementing effective behavioral management strategies, nurses can play a pivotal role in improving outcomes and quality of life for these children and their families.

2. Common Behavioral Disorders in Children

Before focusing specifically on elimination disorders, it’s important to understand the broader context of behavioral disorders in children. The most common disruptive behavioral disorders include:

Disorder	Key Characteristics	Prevalence	Age of Onset
Attention Deficit Hyperactivity Disorder (ADHD)	Persistent pattern of inattention, hyperactivity, and impulsivity that interferes with functioning or development	5-10% of school-aged children	Before age 12, often noticeable by age 6
Oppositional Defiant Disorder (ODD)	Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months	2-16% of children	Usually before age 8
Conduct Disorder (CD)	Persistent pattern of behavior that violates the rights of others or societal norms	1-10% of children, more common in boys	Childhood onset: before age 10 Adolescent onset: after age 10
Enuresis	Repeated involuntary or intentional urination in inappropriate places	5-10% of 5-year-olds, 3-5% of 10-year-olds	After age 5 (when toilet training should be established)
Encopresis	Repeated passage of feces in inappropriate places	1-3% of children aged 4-10 years	After age 4 (when toilet training should be established)

While ADHD, ODD, and CD are often what come to mind when discussing behavioral disorders, elimination disorders like enuresis and encopresis represent a significant subset that requires specific nursing attention and behavioral management approaches.

Important Note: Boys are more likely than girls to experience behavioral disorders overall, including elimination disorders. Cultural factors, parenting styles, and environmental stressors can also influence the manifestation and management of these conditions.

Understanding the relationships between different behavioral disorders is crucial for comprehensive assessment and management. For instance, children with ADHD may have higher rates of enuresis due to delayed maturation of central nervous system functions. Similarly, children with encopresis may develop secondary behavioral problems related to social stigma and reduced self-esteem.

Effective behavioral management of elimination disorders requires a thorough understanding of the underlying physiological mechanisms, psychological factors, and environmental influences that contribute to these conditions.

3. Enuresis: Overview and Diagnosis

3.1 Definition and Types

Definition: Enuresis refers to the involuntary passage of urine in inappropriate places (e.g., clothing, bed) in a child who is developmentally expected to have achieved bladder control (typically age 5 or older).

Enuresis is classified based on two main factors:

Time of Occurrence:

Nocturnal Enuresis: Occurs during sleep (bedwetting)
Diurnal Enuresis: Occurs during waking hours
Mixed Enuresis: Occurs during both sleep and waking hours

Etiology:

Primary Enuresis: Child has never achieved a period of sustained dryness (at least 6 months)
Secondary Enuresis: Child had achieved dryness for at least 6 months before the onset of wetting

3.2 Diagnostic Criteria

According to clinical guidelines, the diagnostic criteria for enuresis include:

Chronological or developmental age of at least 5 years
Repeated voiding of urine into bed or clothes (whether involuntary or intentional)
Frequency of at least twice a week for three consecutive months
The behavior is not due exclusively to the direct physiological effect of a substance or a general medical condition

Clinical Alert: Secondary enuresis warrants thorough investigation as it may indicate underlying medical conditions such as urinary tract infection, diabetes, sleep apnea, or neurological disorders. It can also be triggered by psychological stressors like family conflict, moving, or starting school.

3.3 Epidemiology and Risk Factors

Prevalence:

15% of children at age 5
7-10% of children at age 7
3-5% of children at age 10
1-2% of adolescents at age 15
Boys are affected 1.5-2 times more frequently than girls

Risk Factors:

Genetic predisposition (70-80% of children with enuresis have a first-degree relative with history of the condition)
Developmental delays
Sleep disorders (especially deep sleep)
Neurological conditions
Delayed bladder maturation
Reduced nocturnal antidiuretic hormone (ADH) production
Psychological stressors
Constipation (can place pressure on the bladder)

3.4 Pathophysiology

Understanding the pathophysiology of enuresis is crucial for effective behavioral management. Three main mechanisms contribute to enuresis:

1. Nocturnal Polyuria

Excessive urine production during sleep due to:

Decreased nocturnal ADH secretion
Failure of normal circadian rhythm of ADH
Increased evening fluid intake

2. Bladder Dysfunction

Problems with bladder function, including:

Reduced functional bladder capacity
Bladder overactivity
Delayed maturation of bladder control

3. Sleep Arousal Dysfunction

Inability to wake in response to bladder signals due to:

Abnormally deep sleep
Deficient arousal response to bladder fullness
Altered sleep architecture

Urinary System Anatomy

Source: Cincinnati Children’s Hospital

4. Encopresis: Overview and Diagnosis

4.1 Definition and Types

Definition: Encopresis refers to the repeated passage of feces in inappropriate places (e.g., clothing or floor) in a child who is developmentally expected to have achieved bowel control (typically age 4 or older).

Encopresis is classified based on etiology:

Retentive Encopresis (95% of cases): Associated with constipation and fecal impaction
Non-retentive Encopresis (5% of cases): Not associated with constipation, often related to psychological factors

Important Distinction: Understanding whether encopresis is retentive or non-retentive is crucial for appropriate behavioral management and treatment planning.

4.2 Diagnostic Criteria

According to clinical guidelines, the diagnostic criteria for encopresis include:

Chronological or developmental age of at least 4 years
Repeated passage of feces into inappropriate places (whether involuntary or intentional)
Occurrence at least once per month for at least 3 consecutive months
The behavior is not due exclusively to the direct physiological effect of a substance or a general medical condition except through a mechanism involving constipation

Clinical Presentation: Children with retentive encopresis often present with soiling, infrequent bowel movements, large-diameter stools, pain during defecation, and abdominal pain.

4.3 Epidemiology and Risk Factors

Prevalence:

1-3% of children aged 4-10 years
Boys are affected 3-6 times more frequently than girls
Peak incidence at 5-6 years of age
Spontaneous resolution rate of 15% per year

Risk Factors:

History of constipation
Painful bowel movements leading to stool withholding
Inadequate toilet training
Dietary factors (low fiber, high dairy)
Psychological stressors
Family history of bowel problems
Neurodevelopmental disorders
Anatomical abnormalities (rare)

4.4 Pathophysiology of Retentive Encopresis

The pathophysiology of retentive encopresis typically follows a cyclical pattern:

Stage 1: Initial Constipation

Child experiences painful bowel movement due to constipation (often from dietary factors, illness, or disruption in routine)

Stage 2: Stool Withholding

Child begins to withhold stool to avoid discomfort, leading to harder stools and reinforcing the withholding behavior

Stage 3: Rectal Distention

Rectum becomes distended with accumulated stool, leading to decreased rectal tone and sensation

Stage 4: Impaction

Fecal impaction occurs, with hard stool mass in rectum

Stage 5: Overflow Incontinence

Liquid stool leaks around the impaction, causing involuntary soiling

Key Insight: In retentive encopresis, the soiling is often involuntary and occurs when liquid stool leaks around the impacted fecal mass. The child may not feel the leakage due to decreased rectal sensation from chronic distention. This is why punitive approaches are counterproductive and appropriate behavioral management is crucial.

5. Nursing Assessment

Comprehensive nursing assessment is the foundation for effective behavioral management of elimination disorders. Assessment should be thorough, culturally sensitive, and age-appropriate.

5.1 Assessment of Enuresis

Subjective Data Collection:

1 History of present illness:

Frequency of episodes (≥ twice weekly for 3 months for diagnosis)
Timing of episodes (nocturnal, diurnal, or both)
Duration of the problem
Pattern (primary vs. secondary enuresis)
Associated symptoms (dysuria, urgency, frequency, etc.)

2 Developmental history:

Age of toilet training
Method of toilet training
Previous periods of dryness
Developmental milestones

3 Fluid intake patterns:

Amount and timing of fluid intake
Types of beverages (caffeine, carbonated drinks)

Additional Assessment Areas:

4 Psychosocial assessment:

Impact on child’s self-esteem and social interactions
Family response to episodes
Recent life stressors or changes
School performance and attendance

5 Family history:

Family history of enuresis
Family history of urological or renal conditions

6 Medical history:

Previous treatments and outcomes
Current medications
History of UTIs or renal conditions
Neurological conditions
Sleep patterns and disorders

Objective Assessment:

1 Physical examination:

Abdominal examination (palpable bladder, masses)
Genital examination (abnormalities, signs of irritation)
Lower back examination (signs of spina bifida occulta)
Neurological assessment of lower extremities

2 Urinalysis and urine culture:

To rule out infection, diabetes, or other abnormalities
Check for presence of blood, protein, glucose
Assess urine concentration and specific gravity

3 Voiding diary:

Frequency and timing of urination
Voided volumes
Fluid intake (timing, type, amount)
Episodes of urgency, frequency, or incontinence

4 Assessment for constipation:

Abdominal distention
Palpable fecal masses
Bowel movement frequency and characteristics

5.2 Assessment of Encopresis

Subjective Data Collection:

1 History of present illness:

Frequency of soiling episodes
Duration of the problem
Associated symptoms (abdominal pain, appetite changes)
Bowel movement patterns (frequency, consistency, size)
Pain or discomfort with defecation

2 Dietary history:

Fiber intake
Fluid intake
Dairy consumption
Fast food frequency

Additional Assessment Areas:

3 Toilet training history:

Age at toilet training
Method of toilet training
Child’s reaction to toilet training
Previous success with bowel control

4 Psychosocial assessment:

Impact on child’s self-esteem
School performance and attendance
Peer relationships
Family dynamics and response to soiling
Recent life stressors or changes

Objective Assessment:

1 Physical examination:

Abdominal examination (distention, palpable fecal masses)
Digital rectal examination (if indicated, to assess for impaction)
Perianal inspection (fissures, hemorrhoids, inflammation)
Assessment of anal tone and reflexes
Growth parameters (height, weight, BMI)

2 Stool diary:

Frequency of bowel movements
Stool consistency using Bristol Stool Chart
Episodes of soiling
Pain or straining with defecation

3 Diagnostic studies (if indicated):

Abdominal X-ray to assess for fecal loading
Basic laboratory studies to rule out organic causes

4 Behavioral observation:

Signs of stool withholding (posturing, crossing legs)
Toileting behaviors
Response to soiling episodes

Assessment Tools: Using standardized assessment tools can enhance the comprehensive evaluation of elimination disorders. Consider using:

Dysfunctional Voiding Symptom Score (DVSS) for enuresis
Bristol Stool Form Scale for encopresis
Pediatric Quality of Life Inventory (PedsQL) to assess psychosocial impact

6. Nursing Management in Hospital Settings

While most children with elimination disorders are managed on an outpatient basis, hospitalization may be necessary in certain circumstances such as severe constipation requiring manual disimpaction, concurrent medical conditions, or for intensive behavioral management programs. Nurses play a crucial role in the multidisciplinary hospital management of these conditions.

6.1 Hospital Management of Enuresis

Nursing Diagnosis:

Functional Urinary Incontinence related to bladder dysfunction or developmental delay
Disturbed Sleep Pattern related to enuresis episodes and treatment interventions
Situational Low Self-Esteem related to lack of control over elimination
Risk for Impaired Skin Integrity related to moisture from urine
Deficient Knowledge regarding management of enuresis

Assessment in Hospital Setting:

Continuous monitoring of voiding patterns
Measurement of intake and output
Urinalysis and urine culture
Assessment of skin integrity in perineal area
Evaluation of sleep patterns
Psychological assessment

Nursing Interventions:

1 Establish baseline and monitoring:

Maintain accurate intake and output records
Record frequency, timing, and circumstances of incontinence episodes
Monitor response to interventions

2 Bladder training protocols:

Implement scheduled voiding times (typically every 2-3 hours during daytime)
Teach double voiding technique
Provide positive reinforcement for successful toileting

3 Fluid management:

Maintain adequate hydration during daytime
Limit fluid intake 2-3 hours before bedtime
Avoid caffeine and carbonated beverages

4 Medication administration (if prescribed):

Desmopressin (DDAVP): Administer as ordered, typically before bedtime
Anticholinergics: Monitor for side effects (dry mouth, constipation)
Provide education about medication purpose, administration, and side effects

5 Skin care:

Implement skin care protocol to prevent breakdown
Change wet clothing and bedding promptly
Teach proper hygiene to prevent complications

6 Psychological support:

Maintain a non-punitive, supportive approach
Provide privacy during toileting and episodes
Include child in management plan as appropriate for age
Offer encouragement and positive reinforcement

7 Discharge planning and education:

Develop comprehensive home management plan
Educate about enuresis alarms if prescribed
Provide resources for ongoing support
Schedule follow-up appointments

6.2 Hospital Management of Encopresis

Nursing Diagnosis:

Constipation related to inadequate fluid/fiber intake and stool withholding behavior
Bowel Incontinence related to chronic constipation and rectal distention
Situational Low Self-Esteem related to social implications of soiling
Risk for Impaired Skin Integrity related to contact with fecal material
Compromised Family Coping related to chronic nature of condition

Assessment in Hospital Setting:

Abdominal assessment for distention and impaction
Rectal examination (if indicated)
Monitoring of bowel movements (frequency, consistency, amount)
Dietary intake assessment
Psychosocial assessment of child and family

Nursing Interventions:

1 Disimpaction (if indicated):

Administer oral laxatives as prescribed
Provide enemas or suppositories as ordered
Assist with manual disimpaction if required
Monitor patient’s response and discomfort

2 Ongoing bowel management:

Administer maintenance laxatives as prescribed
Implement bowel management protocol
Maintain stool diary
Monitor for effectiveness of interventions

3 Dietary management:

Collaborate with dietitian to increase fiber intake
Encourage adequate fluid intake
Limit constipating foods (excessive dairy, processed foods)
Document dietary tolerance and response

4 Toilet sitting schedule:

Implement regular toilet sitting times (usually after meals)
Ensure proper positioning on toilet (feet supported, comfortable position)
Provide privacy and adequate time
Use positive reinforcement for cooperation

5 Skin care and hygiene:

Implement skin care protocol for perineal area
Teach and assist with proper cleaning techniques
Manage odor with appropriate interventions
Ensure clean clothing is available

6 Psychosocial support and education:

Use non-punitive, matter-of-fact approach
Educate about physiological basis of encopresis
Involve child in age-appropriate management
Provide emotional support to child and family
Educate about behavioral management strategies

Hospital Discharge Planning: Preparation for discharge should begin early during hospitalization. Key components include:

Comprehensive education on home management plan
Ensuring family understands medication regimen
Providing written instructions for bowel/bladder programs
Connecting family with community resources
Scheduling appropriate follow-up appointments
Addressing school-related concerns

7. Home-Based Nursing Management

The majority of children with elimination disorders are managed in home settings. Nurses play a crucial role in developing, teaching, and monitoring home-based behavioral management programs. Successful management requires a collaborative approach involving the child, family, healthcare providers, and sometimes school personnel.

7.1 Home Management of Enuresis

Fluid Management:

Recommended Protocol:

Ensure adequate hydration during daytime (70% of fluids before 5 PM)
Limit fluids 2-3 hours before bedtime
Avoid caffeine, carbonated beverages, and citrus juices
Use a daily fluid intake record to monitor compliance

Voiding Schedule:

Structured Voiding Program:

Regular voiding every 2-3 hours during daytime
Double voiding before bedtime (void, wait 10 minutes, void again)
Wake for scheduled voiding during night (initially)
Gradually extend intervals between voidings

Bedwetting Alarms:

Implementation Guidelines:

Select appropriate alarm type (body-worn or pad-type)
Instruct on proper use and maintenance
Establish routine for response to alarm
Continue use for 2-3 months or until 14 consecutive dry nights
Consider overlearning (increased fluid intake before bed) to prevent relapse

Reward Systems:

Effective Reinforcement:

Implement star charts or token systems
Reward effort and compliance, not just dry nights
Set achievable goals with graduated rewards
Avoid punishment for wet episodes
Involve child in selecting rewards

Medication Management:

Medication	Dosage	Administration	Nursing Considerations
Desmopressin (DDAVP)	0.2-0.6 mg PO or 10-40 μg intranasal	One hour before bedtime	Restrict fluids after administration Monitor for hyponatremia Not recommended for children under 5 years
Anticholinergics (Oxybutynin)	5-10 mg daily	Divided doses or extended-release	Monitor for constipation, dry mouth Typically used for daytime symptoms May be combined with desmopressin
Imipramine	25-50 mg for 7-10 years 50-75 mg for older children	One hour before bedtime	Monitor cardiac status High relapse rate when discontinued Used as third-line agent due to safety concerns

Practical Home Management Tips:

1 Bedding management:

Use waterproof mattress protectors
Layer bedding for easy nighttime changes
Have clean pajamas readily available
Teach child to assist with changing (age-appropriate)

2 Psychosocial support:

Normalize the condition (emphasize prevalence)
Maintain confidentiality outside family
Provide age-appropriate explanation
Focus on child’s strengths in other areas

3 School considerations:

Ensure regular bathroom access during school hours
Provide discrete plan for accidents at school
Consider limiting school activities only if necessary

4 Progress monitoring:

Maintain voiding diary
Track dry and wet nights
Document response to interventions
Regular follow-up with healthcare providers

7.2 Home Management of Encopresis

Successful home management of encopresis typically involves a multi-faceted approach addressing the physiological, behavioral, and psychosocial aspects of the condition. The core components include:

Phase 1

Disimpaction

Oral laxatives as prescribed
Enemas if needed (usually administered in clinical setting)
Monitor bowel movements
Adequate hydration
May take 3-7 days

Phase 2

Prevention of Reaccumulation

Maintenance laxatives
High-fiber diet
Regular toilet sitting schedule
Adequate hydration
May continue for 3-6 months

Phase 3

Behavioral Reconditioning

Toilet sitting routine
Positive reinforcement
Gradual withdrawal of laxatives
Ongoing monitoring
May continue for 6-24 months

Medication Management:

Medication Type	Examples	Purpose	Nursing Considerations
Osmotic Laxatives	Polyethylene glycol (PEG), Lactulose, Milk of Magnesia	Initial cleanout and maintenance	Ensure adequate fluid intake Monitor for abdominal cramping Adjust dose based on response
Stimulant Laxatives	Senna, Bisacodyl	Promote bowel motility	May cause cramping Typically used short-term May be combined with osmotic agents
Stool Softeners	Docusate sodium	Soften stool consistency	Generally insufficient alone Often used as adjunct therapy Well-tolerated with few side effects

Dietary Management:

Recommended Foods:

High-fiber fruits (apples, pears, berries)
Vegetables (broccoli, peas, spinach)
Whole grains (oatmeal, brown rice, whole wheat bread)
Legumes (beans, lentils)
Prune or pear juice (natural laxatives)

Foods to Limit:

Excessive dairy products (cheese, ice cream)
Processed foods high in fat
White rice, white bread, pasta
Bananas (in large quantities)
Fast food and fried foods

Dietary Tips:

Aim for age + 5 grams of fiber daily (e.g., 10 grams for a 5-year-old)
Increase fiber gradually to prevent gas and bloating
Ensure adequate fluid intake (approximately 1.5-2 liters daily for school-age children)
Maintain a food diary to identify problematic foods

Toilet Sitting Program:

Recommended Toilet Sitting Schedule

Basic Protocol:

Schedule toilet sitting 15-30 minutes after meals (utilizing gastrocolic reflex)
Sit for 5-10 minutes (use timer)
Ensure proper positioning (feet supported, comfortable position)
Maintain consistency daily
Create relaxed, non-pressured environment

Proper Positioning:

Use foot stool if child’s feet don’t reach floor
Slight forward lean with elbows on knees
Relax abdominal muscles
Avoid excessive straining

Behavioral Management Strategies:

1 Positive reinforcement:

Create sticker charts or token systems
Reward sitting attempts (regardless of outcome)
Provide small rewards for successful bowel movements
Consider graduated reward system

2 Education and demystification:

Explain normal bowel function using age-appropriate terms
Use drawings or diagrams to explain constipation and soiling
Emphasize that soiling is not deliberate
Normalize the condition

3 Cleaning and hygiene routine:

Establish matter-of-fact clean-up protocol
Teach proper wiping technique
Involve child in age-appropriate clean-up
Manage odor with appropriate strategies

4 School considerations:

Develop discrete plan for school soiling episodes
Provide extra clothes at school
Identify safe bathroom location at school
Collaborate with school nurse and teacher

Record Keeping for Home Management: Maintaining accurate records is essential for monitoring progress and adjusting interventions. Recommend families keep:

Bowel movement diary (timing, consistency using Bristol Stool Scale, amount)
Soiling episodes log
Medication administration record
Dietary intake log
Toilet sitting compliance record

8. Behavioral Management Techniques

Effective behavioral management is central to the successful treatment of elimination disorders. These techniques complement medical interventions and address the behavioral and psychological factors that maintain these conditions.

8.1 ABC Framework for Behavioral Analysis

The ABC framework is a useful tool for analyzing behaviors related to elimination disorders:

A = Antecedent

(What happens before)

Triggers for withholding
Environmental factors
Timing of fluid intake
Psychosocial stressors
Access to toileting facilities

B = Behavior

(What occurs)

Enuresis episodes
Encopresis incidents
Holding/withholding patterns
Toileting avoidance
Hiding soiled underwear

C = Consequence

(What happens after)

Parental responses
Child’s emotional reactions
Social consequences
Reinforcement patterns
Avoidance of discomfort

Using the ABC Framework: By systematically analyzing these components, nurses can help families identify patterns, triggers, and reinforcers that maintain elimination disorders. This analysis forms the basis for targeted behavioral management interventions.

8.2 Behavioral Management Strategies for Enuresis

Enuresis Alarms:

The most effective long-term behavioral management approach for nocturnal enuresis.

How Enuresis Alarms Work:

Moisture sensor triggers alarm when wetting begins
Child awakens and stops urination
Over time, child learns to associate bladder fullness with waking
Success rate: 65-80% with proper use
Average time to success: 12-16 weeks

Implementation Tips:

Parents should assist child to wake fully at alarm
Complete bathroom visit even if bladder already emptied
Reset alarm and return to bed
Continue until 14 consecutive dry nights
Consider “overlearning” (additional fluid before bed)

Bladder Training:

Techniques to increase functional bladder capacity and control.

Stream Interruption Exercises:

Start and stop urine flow during voiding
Perform 3-5 times per voiding session
Practice 1-2 times daily (not every void)
Helps strengthen pelvic floor muscles

Bladder Stretching:

Gradually extend time between voidings
Delay urination when urge is felt (initially for 5 minutes)
Increase delay intervals gradually
Maintain adequate overall hydration

Motivational Techniques:

1 Star/Sticker Charts:

Use colorful chart with child’s input
Award stars/stickers for dry nights
Also reward compliance with protocol
Exchange earned stars for small rewards
Gradually increase criteria for rewards

2 Responsibility Training:

Child helps change wet bedding (age-appropriate)
Takes ownership of alarm use and reset
Maintains own voiding diary
Participates in scheduling toilet visits

3 Positive Self-Statements:

Develop affirming statements with child
“My body can stay dry all night”
“I can wake up when I need to use the bathroom”
Practice statements before bedtime

4 Celebration of Progress:

Acknowledge and celebrate improvements
Focus on effort rather than just outcomes
Create milestone celebrations
Maintain positivity during setbacks

8.3 Behavioral Management Strategies for Encopresis

Toilet Sitting Schedule:

Structured approach to establish regular bowel habits.

Implementation Protocol:

Schedule 5-10 minute sitting periods after meals
Use timer to define clear beginning and end
Ensure proper positioning with footstool
Maintain consistent schedule 7 days a week
Use visual schedule for younger children

Important Considerations:

Avoid pressure or criticism during sitting
Provide distraction if needed (books, small toys)
Never extend sitting time as punishment
Reward compliance with sitting, not just production

Reward Systems:

Structured incentives to promote compliance and success.

Token Economy:

Award tokens for compliance with toileting schedule
Additional tokens for successful bowel movements in toilet
Exchange tokens for small rewards or privileges
Increase value for consecutive days of compliance
Never remove tokens for accidents

Creating Effective Reward Systems:

Involve child in selecting rewards
Include immediate and delayed rewards
Make rewards attainable but motivating
Gradually increase criteria as child succeeds
Celebrate milestone achievements

Cognitive-Behavioral Techniques:

1 Education and Demystification:

Age-appropriate explanation of gastrointestinal function
Use simple diagrams to explain constipation and soiling
Frame as a “medical problem” not a “behavior problem”
Externalize the problem (“tricky bowels” vs. “your problem”)

2 Self-Monitoring:

Child maintains own bowel diary (age-appropriate)
Tracks compliance with medication and sitting schedule
Records successful bowel movements
Identifies patterns and triggers

3 Body Awareness Training:

Teach recognition of body signals for need to defecate
Practice identifying early warning signals
Encourage immediate response to signals
Use “listening to your body” imagery

4 Relaxation Techniques:

Teach diaphragmatic breathing during toilet sitting
Use guided imagery for relaxation
Practice progressive muscle relaxation
Apply techniques during toilet sitting

8.4 Visual Aids and Educational Tools

Visual supports enhance understanding and compliance with behavioral management programs for elimination disorders. Effective visual tools include:

Toilet Training Visual Schedules

Step-by-step visual guides for toileting routines

Sequential pictures of toileting steps
Customizable for child’s specific routine
Promotes independence
Especially helpful for younger children and those with developmental delays

Bowel and Bladder Diaries

Record-keeping tools for tracking progress

Visual calendars with symbols
Sticker charts for successes
Pictorial scales for stool consistency
Engaging designs to increase child’s interest

Educational Materials

Resources to explain elimination disorders

Simplified diagrams of urinary/digestive systems
Children’s books about elimination
Animation videos explaining the conditions
Interactive educational games

Recommended Resources: Nurses should develop a resource library of visual aids and tools that can be shared with families. Age-appropriate materials enhance understanding and engagement with behavioral management programs.

9. Mnemonics for Nursing Practice

Mnemonics provide valuable memory aids for nursing assessment and intervention. The following mnemonics are specific to the behavioral management of elimination disorders:

D-R-Y-N-E-S-S

Mnemonic for Enuresis Management

D – Daily voiding schedule and diary keeping

R – Regulate fluid intake (timing and type)

Y – Yearly (at minimum) reassessment of progress

N – Nighttime waking for scheduled toileting

E – Enuresis alarm as primary behavioral intervention

S – Support and positive reinforcement (never punishment)

S – Sleeping position and bedtime routine optimization

S-O-I-L-I-N-G

Mnemonic for Encopresis Management

S – Schedule regular toilet sitting times

O – Optimize diet with fiber and fluids

I – Implement medication regimen as prescribed

L – Log bowel movements and soiling episodes

I – Initiate positive reinforcement system

N – Non-punitive approach to accidents

G – Gradually withdraw laxatives as bowel function improves

T-O-I-L-E-T

Mnemonic for Toilet Training Protocol

T – Timing (scheduled sitting after meals)

O – Observe for cues of readiness

I – Instruct on proper positioning

L – Limit sitting time (5-10 minutes max)

E – Encourage with positive reinforcement

T – Track progress consistently

P-A-R-E-N-T-S

Mnemonic for Family Education on Behavioral Management

P – Patience and persistence with treatment plan

A – Avoid punishment or shame for accidents

R – Reinforce positive behaviors consistently

E – Explain the condition age-appropriately

N – Normalize the experience (prevalence statistics)

T – Track progress objectively

S – Support the child emotionally throughout process

A-B-C-D-E

Mnemonic for Comprehensive Behavioral Management Approach

A – Assess thoroughly (physical, psychological, environmental factors)

B – Basic medical interventions (appropriate medications, treatment of underlying conditions)

C – Consistent routine implementation (toilet sitting schedule, fluid management)

D – Develop motivation system (rewards, positive reinforcement)

E – Educate child and family (age-appropriate explanations, demystification)

10. Case Studies

The following case studies illustrate comprehensive nursing assessment and behavioral management approaches for elimination disorders:

Case Study 1: Nocturnal Enuresis

Patient Profile:

7-year-old male
Primary nocturnal enuresis
Wets bed 5-6 nights per week
No daytime symptoms
Family history of bedwetting (father until age 9)
Normal physical examination
Normal urinalysis

Nursing Assessment Findings:

Drinks large quantities of fluids in evening
Very deep sleeper; difficult to wake
Recent school stressors with transition to new grade
Parents expressing frustration with changing sheets
Child showing embarrassment and reluctance to discuss
Refusing sleepovers due to bedwetting
Previous unsuccessful attempts with restricting fluids alone

Nursing Interventions:

Education about enuresis physiology for family
Implementation of structured fluid management (70% before 5 PM)
Double-voiding before bedtime
Bedwetting alarm with parent assistance for waking
Star chart with rewards for compliance and dry nights
Waterproof mattress protector and layered bedding system
Age-appropriate involvement in changing sheets

Outcomes:

After 14 weeks of consistent behavioral management, the child achieved 14 consecutive dry nights. Occasional relapses occurred during periods of stress, but were managed with return to fluid restrictions and intermittent alarm use. Complete resolution occurred by age 8.5 years.

Case Study 2: Retentive Encopresis

Patient Profile:

6-year-old female
Soiling 3-4 times weekly for past 8 months
Bowel movements every 4-5 days, large and painful
History of constipation since age 3
Previously toilet trained successfully
Picky eater with low fiber intake
No known medical conditions

Nursing Assessment Findings:

Abdominal distention with palpable fecal mass in left lower quadrant
Abdominal X-ray confirms significant fecal loading
Withholding behaviors observed (crossing legs, squatting)
Child denies soiling despite evidence
Parents using punitive approaches for soiling episodes
Child refusing to use school bathrooms
Social withdrawal developing due to odor and teasing

Nursing Interventions:

Education for parents and child about physiology of encopresis
Initial bowel cleanout with PEG-based laxative
Maintenance therapy with daily osmotic laxative
Dietary modifications (increased fiber, adequate fluids)
Scheduled toilet sitting after breakfast and dinner (10 minutes each)
Footstool for proper positioning during defecation
Reward system for toilet sitting compliance
School management plan developed with school nurse
Non-punitive approach to accidents emphasized

Outcomes:

Initial improvement in soiling after cleanout, with ongoing behavioral management protocol. Complete resolution of soiling achieved after 4 months of consistent implementation. Maintenance laxative therapy continued for 7 months, then gradually weaned. Relapse occurred during family vacation but quickly resolved with reinstitution of protocol.

Case Study 3: Combined Enuresis and Encopresis

Patient Profile:

8-year-old male
Autism spectrum disorder
Nocturnal and diurnal enuresis
Encopresis with daily soiling
Chronic constipation
Limited dietary preferences
Communication difficulties

Nursing Assessment Findings:

Significant fecal impaction on examination
Enlarged bladder on palpation
UTI confirmed on urinalysis
Sensory aversions to toilet sitting
Communication limitations complicate understanding of bowel/bladder signals
Parents exhausted and frustrated with ongoing issues
Child shows distress with cleaning procedures

Nursing Interventions:

Treatment of UTI with appropriate antibiotics
Initial disimpaction with enemas in clinic setting
Daily PEG laxative with medication schedule chart
Visual schedule for toileting routine
Sensory accommodations (padded toilet seat, weighted vest during sitting)
Timed toilet sitting with visual timer (5 minutes, 4 times daily)
Visual reward system with special interest rewards
Social stories for toileting success
Coordination with school for consistent implementation
Parent support and respite resources provided

Outcomes:

Complex case requiring extended behavioral management approach. Encopresis improved first, with resolution after 6 months of consistent intervention. Enuresis required longer-term management with a combination of timed voiding, visual schedules, and eventually alarm therapy. Nighttime dryness achieved by age 10, with occasional relapses during illness or routine disruptions.

Key Insights from Case Studies:

Individualized assessment is essential for effective behavioral management
Combined approaches (medical and behavioral) yield best outcomes
Consistency and persistence with interventions are crucial for success
Family education and non-punitive approaches improve compliance and outcomes
Adaptations for special populations (e.g., developmental disabilities) may be necessary
School-based coordination enhances management effectiveness

11. Conclusion

Elimination disorders, particularly enuresis and encopresis, represent common challenges in pediatric healthcare that can significantly impact a child’s quality of life and family functioning. As these notes have demonstrated, effective management requires a comprehensive approach that addresses both physiological and behavioral aspects of these conditions.

Nurses play a crucial role in the assessment, management, and ongoing monitoring of elimination disorders. By implementing evidence-based behavioral management strategies, providing education and support to families, and coordinating care across settings, nurses can significantly improve outcomes for affected children.

Key Principles to Remember:

Comprehensive assessment is the foundation of effective management
Non-punitive, supportive approaches yield better outcomes
Consistent implementation of intervention protocols is essential
Combined medical and behavioral management strategies are most effective
Family education and involvement improve treatment adherence
Regular follow-up and monitoring support long-term success

Final Nursing Considerations:

Customize interventions to the child’s developmental level and specific needs
Support families through the often lengthy management process
Coordinate care with other healthcare providers and school personnel
Advocate for the child’s dignity and psychosocial well-being
Stay updated on evidence-based behavioral management approaches
Document interventions and outcomes thoroughly to guide ongoing care

By applying the knowledge and strategies outlined in these notes, nursing students can develop the competencies needed to provide effective, evidence-based care for children with elimination disorders, supporting them in achieving continence, preserving self-esteem, and promoting overall well-being.

12. References

Better Health Channel. (n.d.). Behavioural disorders in children. [Better Health Victoria](https://www.betterhealth.vic.gov.au/health/healthyliving/behavioural-disorders-in-children)
Mayo Clinic. (n.d.). Encopresis – Diagnosis and treatment. [Mayo Clinic](https://www.mayoclinic.org/diseases-conditions/encopresis/diagnosis-treatment/drc-20354500)
Nursing.com. (n.d.). Nursing Care Plan for Enuresis/Bedwetting. [Nursing.com](https://nursing.com/lesson/nursing-care-plan-for-enuresis-bedwetting)
Canadian Psychological Association. (2019). Psychology Works Fact Sheet: Enuresis and Encopresis in Children. [Canadian Psychological Association](https://cpa.ca/docs/File/Publications/FactSheets/PsychologyWorksFactSheet_EnuresisEncopresisInChildren_Feb2019.pdf)
Cincinnati Children’s Hospital. (n.d.). Encopresis in Children. [Cincinnati Children’s](https://www.cincinnatichildrens.org/health/e/encopresis)
Royal Children’s Hospital Melbourne. (n.d.). Acute behavioural disturbance: Acute management. [RCH Clinical Guide](https://www.rch.org.au/clinicalguide/guideline_index/Acute_behavioural_disturbance__Acute_management/)
National Center for Biotechnology Information. (n.d.). Encopresis. [NCBI Bookshelf](https://www.ncbi.nlm.nih.gov/books/NBK560560/)
NurseTogether. (n.d.). Impaired Urinary Elimination Nursing Diagnosis & Care Plans. [NurseTogether](https://www.nursetogether.com/impaired-urinary-elimination-nursing-diagnosis-care-plan/)
Autism Little Learners. (n.d.). FREE Toileting Sequence For Autism. [Autism Little Learners](https://autismlittlelearners.com/free-toileting-sequence/)
Beck Institute. (n.d.). Using the Mnemonic “Three Cs” with Children and Adolescents. [Beck Institute](https://beckinstitute.org/blog/using-the-mnemonic-three-cs-with-children-and-adolescents/)
NCBI. (n.d.). Chapter 12 Childhood and Adolescence Disorders – Nursing. [National Center for Biotechnology Information](https://www.ncbi.nlm.nih.gov/books/NBK590039/)
Nationwide Children’s Hospital. (n.d.). Enuresis (Bedwetting). [Nationwide Children’s](https://www.nationwidechildrens.org/conditions/enuresis-bedwetting)

Common Behavioral Disorders in Children