Nan E Tobias, MSN, APRN

It is paramount to emphasize to the family that bedwetting is not the child’s fault, particularly when the parent conveys a feeling of blame or anger toward the child. It should be emphasized that punishments and shaming do not help. When the child is developmentally ready to work on the bedwetting, it is time to pursue intervention. Most often, this occurs when the child‘s social interactions are reduced because of the bedwetting, usually in the form of sleepovers.

Families differ in their goals for treatment, so this needs to be clarified at the outset. Some families want to reduce their workload, whereas others want the assurance that nothing is physically wrong with their child, or a family vacation or school trip may occur in the near future for which they want to prepare. The pediatric PCP may then explain that a carefully constructed program can be developed that may involve several methods of treatment, used in sequence or combination.

 It cannot be overemphasized that a long-term treatment plan needs to have the child’s involvement. In other words, the child needs to have the maturity and motivation to participate. It is also imperative that the family handle the bedwetting and its treatment in a positive fashion. Should negativity be demonstrated by family members, they should be counseled about the poor influence this attitude will have toward treatment and be encouraged to change their thinking.

If constipation is diagnosed, a bowel cleanout is undertaken. Many PCPs initiate a bowel program with the family by starting with maintenance doses of laxatives. Quite frequently, the bowel program does not achieve its goals when begun in this manner. Parents report that with initiation of the laxative, the child was either stooling constantly, having bowel accidents, or that no change existed at all in bowel habits. Instead, the preferred method is to begin with a bowel cleanout. Only after the bowel is cleaned out appropriately will the maintenance laxative doses be effective (Table 6

If a large stool load or balls of stool in the recto-sigmoid are identified on AXR, it is often a good idea to initiate the cleanout with enemas. When hard stool is present in the rectum, painful abdominal cramping with oral laxatives given by mouth can occur. Enemas can be in the form of a small volume Fleet enema, a glycerin or bisacodyl suppository, or a soap suds enema. It is important to explain to parents when purchasing a Fleet enema that different types are available. The PCP should specify the specific type he/she recommends (Table 6). When making recommendations, it is imperative to recognize any presence of renal disease.

Once the bowel cleanout phase has been accomplished, maintenance doses of laxatives are continued. The length of bowel therapy has not been agreed upon by pediatric gastroenterologists as a group. Certainly rectal distention and an abnormally large stool burden can develop over several months-to-years’ time prior to constipation being identified. Even after successful initiation of therapy, it is common for children to have relapses of constipation and require further cleanouts over time. One study showed that children diagnosed with functional constipation continued to have chronic constipation 3 to 12 years after initial diagnosis and treatment.

 In this author’s setting, clinicians recommend that maintenance laxative therapy continue for at least a year prior to weaning the doses.31 Whereas stimulant laxatives are not recommended for chronic use, osmotic and lubricant laxatives and bulking agents may be used long term.

Other recommended treatments for constipation are adequate fluid and fiber intake. Fluid recommendations can be given based upon the Holliday-Segar maintenance fluid requirements (Table 7).

 Fiber intake recommendations are based upon the formula: age in years plus 5 grams equals the number of grams of fiber recommended per day up until the adult recommended amount of 25 grams to 35 grams/day.

 Current evidence does not support the use of fiber supplements.

 However, in children and adolescents who do not eat the recommended daily amount, fiber supplements such as fiber gummies, Benefiber, or fiber bars seem appropriate. Evidence does not support the use of probiotics in the treatment of childhood functional constipation. Anecdotal reports often do corroborate the successful use of probiotics and yogurt with active cultures (

An important word of advice when discussing toileting habits with families is that children’s feet should be flat on the floor when using the toilet. Toilets in general are made for adults. If the child’s feet cannot be positioned flat on the floor comfortably when sitting on the toilet, a step stool or other device should be used. A child sitting on the toilet with dangling legs will be unable to push to have a bowel movement and may not be able to sufficiently evacuate.

It has been shown that at least 50% of children with bladder and bowel dysfunction will improve with successful constipation treatment and behavioral management.

 For those with nocturnal enuresis, the pattern of fluid intake is important so that the majority of fluids are consumed early in the day rather than late afternoon and evening. Many children are not in the habit of drinking the majority of fluids early in the day as school activities do not encourage this behavior. Teachers may be hesitant to allow children to use the bathroom when needed, so that children learn not to drink during school hours. This encourages the majority of fluids to be consumed late in the day, thus producing a good deal of urine during sleeping hours.

In contrast, the general recommendation is for fluid intake to be completed 2 to 3 hours prior to bedtime. The child should void at bedtime, so the night starts with an empty bladder. Using the maintenance fluid formula and giving the family written recommendations for a schedule of timing of fluid intake is helpful. It is also beneficial to write notes for water bottle and bathroom privileges to give to teachers.

When treatment of bowel issues and behavior modification techniques do not result in resolution of bladder issues, other therapies are suggested. One therapy is the wetness alarm. Wetness alarms have been shown to give high cure rates for nocturnal enuresis. The alarm consists of a sensor is worn on the underwear that causes an alarm to sound or vibrate when wetness is sensed. The wearer is then instructed to immediately get out of bed and go to the bathroom. At the initiation of alarm use, the child will often awaken to a totally wet bed. As more time passes with the use of the alarm, the child may awaken in the middle of urination and then eventually prior to its initiation. The conditioning occurs when the child awakens to the sensation of a full bladder and associates that sensation with the alarm.

It has been shown to take approximately 12 to 16 weeks of nightly use for the wetness alarm to be effective. Often the parent needs to get up with the child, particularly during the initial use of the alarm. The child may not respond to the alarm without parental assistance. The child needs to be awakened so that he/she realizes what is occurring for the conditioning to occur. As can be seen from this description, the use of a wetness alarm requires a motivated child and family member(s). It is generally not recommended for children aged younger than 8 years. Enuresis alarms can be obtained from online sites such as 

. Insurance typically does not cover their cost.

One medication that has been used for children and adolescents for a “quick fix” for bedwetting is desmopressin (DDAVP). It is given for short periods, such as vacations, sleepovers, camping trips, or school trips. It works by increasing water permeability in the renal collecting tubules, which results in increased water reabsorption that causes decreased urine production.

 Its duration of action is estimated at 6 to 14 hours. Recommended dosing is to start at 0.2 mg and work up to a maximum of 0.6 mg nightly. It is recommended for use in nocturnal enuresis from age 6 years through adolescence. It is also recommended to keep fluid intake to a minimum in the hour prior to administration until at least 8 hours later. Desmopressin also may be used for long-term treatment of nocturnal enuresis, but is not considered a first-line therapy.

Other medications that are used for nocturnal enuresis are anticholinergics and the tricyclic antidepressant imipramine. Neither are used as first-line treatment. Some anticholinergics that are used are oxybutynin, tolterodine, and hyoscyamine. These medications suppress detrusor overactivity that can be present in monosymptomatic nocturnal enuresis. Imipramine has anticholinergic effects as well as a stimulant effect that is thought to lighten the level of sleep, making arousal from sleep easier. It is used in much smaller doses when treating nocturnal enuresis, as compared with depression. It may be prescribed nightly for 2 to 4 months, then weaned gradually by administering every 2, then every 3 days over the next 3 to 4 months to reduce risk of relapse.

 If imipramine is prescribed, special care must be taken for its storage at home as it is highly lethal when taken in overdose. There is no known specific antidote for its toxicity and death is usually the result of cardiac arrhythmia and cardiovascular collapse.

It is necessary for a UTI to be culture proven to determine appropriate treatment and subsequent diagnostic evaluation (Figure 3

The diagnosis of urinary tract infection cannot be made on symptomatology alone. A properly collected urine specimen for a macroscopic and microscopic urinalysis is the first step. It has become common practice for some primary care offices to obtain a midstream urine specimen from toilet-trained children and perform only a reagent test strip (dipstick) in the office in an attempt to diagnose a UTI. As discussed previously, this practice reveals many false-positive and false-negative results when checking for nitrites and leukocyte esterase. The urine must be sent to a lab for urine culture. Growth of any single organism from a midstream urine that is at least 50,000 colony forming units per high-power field (CFU/HPF) is indicative of a UTI. Bacterial counts of at least 10,000 CFU/HPF obtained by a catheter or any growth obtained by suprapubic tap are indicative of a UTI.

A urine culture obtained by bagged specimen is not reliable unless it reveals negative results. Any growth of any bacteria in a bagged specimen renders the results unusable.

 Therefore, a bagged urine specimen should not be performed in a febrile, symptomatic child. The only reliable result of a bagged specimen is a negative one.

Children who exhibit daytime symptoms and incontinence and/or UTIs will benefit from a recommendation for adequate fluid intake, a recommended fluid intake schedule, and a recommended voiding schedule in which voiding occurs at a minimum of 5 times daily. Vibrating watches at a reasonable cost that are attractive to children can be obtained through 

. Their alarms can be set to coincide with appropriate times during the school day for the child to take bathroom breaks. Reducing or eliminating acidic fruits and their juices (orange, grapefruit, tomato, lemon, lime) and caffeine and chocolate also may help, although much of this evidence is anecdotal.

If the clinician discovers findings of significant irritative voiding symptoms, interrupted urinary flow, urinary hesitancy or straining to void, daytime wetting, or UTI, urologic imaging can be undertaken. The PCP may initiate a workup with a renal and bladder US, which may diagnose structural abnormalities and determine bladder emptying. A voiding cystourethrogram (VCUG) also may be in order. Although the 2011 American Academy of Pediatrics (AAP) guidelines for diagnostic evaluation of the urinary tract after a first febrile UTI do not recommend a VCUG if the renal US is normal, many pediatric urologists are in disagreement with this recommendation. Many physicians believe that serious flaws existed in the interpretation of the data that was used to make this recommendation. Thus, many pediatric specialists recommend obtaining a VCUG after a first febrile UTI, particularly in a child aged younger than 4 years when the developing kidney is most prone to scarring. The data on this important topic continue to accumulate.

A referral to a pediatric urologist or nephrologist can be made depending upon local referral practices. When this referral is made, the diagnostic images must be available, not just the written report. Children who present with monosymptomatic nocturnal enuresis or non-monosymptomatic nocturnal enuresis who do not improve with standard therapies also should be referred. So should children with UTIs despite treated constipation. Physical findings of occult spinal dysraphism (lower lumbar spine abnormalities) may be referred to a pediatric neurosurgeon. For children who have evidence of nocturnal enuresis and enlarged tonsils and signs of sleep apnea, a referral to a pediatric ears/nose/throat (ENT) or sleep specialist can be made. Sleep apnea can be associated with an increased production of urine overnight. When constipation is refractory with continued attempts at cleanout and treatment, referral to a pediatric gastroenterologist is recommended.

Extraordinary daytime urinary frequency 

Another urinary disorder that deserves explanation is extraordinary urinary frequency, or pollakiuria. This disorder can begin with an abrupt or more gradual onset of urinary frequency of extreme proportion. Some children, generally in the age range of 3 to 7 years, will urinate small amounts as often as every 5 to 10 minutes. Many will exhibit such a strong urge that they cannot leave the toilet. When parents finally get them off the toilet, many return almost immediately or begin to cry due to discomfort. Children may spend nearly their entire day on the toilet. Some may even drink less fluids in an attempt to help their problem. It is important to take a good history and perform a physical exam. The children do not generally have daytime incontinence in association with the frequency. To rule out organic disease, potential conditions that deserve consideration are listed in Table 8.

Should any of the factors be present that are listed in Table 9, appropriate diagnostic testing should be undertaken. To many PCPs, this may seem like such a benign problem that parents are advised to ignore it, or clinicians may advise that the children are merely vying for their parents’ attention. Parents also may be told that the children just like to visit bathrooms in various places. To the family, this problem is not benign. The child may be unable to leave the house for even a few minutes, which severely limits the family’s ability to accomplish day-to-day activities and can interfere with schooling. The symptoms can last for days to weeks prior to being referred to a specialist. Parents bring their children to the pediatric urology specialist’s office in total frustration, often at their wits’ end. In the past, specialists advised that extreme urinary frequency began as the result of psychosocial problems or emotional stress. Whereas such issues can be involved, it is a good idea to sort out other potential accompanying issues, in particular UTI and constipation.

Should a UTI and/or constipation be present, they should be treated appropriately. Families may be counseled about other potential causes of urinary frequency including those listed in Table 8. Potential stressors and worries should be identified, being cognizant of questioning the children as well as the parents. Children may reveal stressors of which the parents may not be aware. If so identified, they can be discussed and referrals made if appropriate. Other recommendations to treat urinary frequency are a liberal intake of fluids, in particular, water. Very concentrated urine may irritate the bladder further. Should the above treatments fail, referral to a pediatric specialist is in order.

The pediatric PCP can become comfortable with the evaluation and early treatment of enuresis, constipation, and UTIs. The treatment of constipation may ameliorate or resolve many wetting problems and should be attempted prior to referral. Daytime incontinence also may benefit from the use of timed voiding and adequate fluid intake. Nocturnal enuresis may show improvement as well using these techniques in addition to fluid restrictions late in the day and voiding at bedtime.

It is helpful to understand the psychologic effects of nocturnal enuresis on children and the limitations of their voluntary control of the problem. Using quantified criteria, particularly in the diagnosis of UTIs, will assist the PCP to correctly manage UTIs and recommend subsequent testing. In the long run, children and families will benefit from the pediatric PCP providing care of the child with urologic issues and making referrals for lack of response to treatment earlier rather than later.

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2. Tu ND, Baskin LS, Arnhym AM. Nocturnal enuresis in children: etiology and evaluation. UpToDate. Available at: 

https://www.uptodate.com/contents/nocturnal-enuresis-in-children-etiology-and-evaluation

. Updated November 15, 2017. Accessed March 14, 2018.

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https://www.uptodate.com/contents/nocturnal-enuresis-in-children-management

. Updated October 19, 2017. Accessed March 14, 2018

4. Allen HA, Austin JC, Boyt MA, Hawtrey CE, Cooper CS. Initial trial of timed voiding is warranted for all children with daytime incontinence. 

5. Hagstroem S, Rittig N, Kamperis K, Mikkelsen MM, Rittig S, Djurhuus JC. Treatment outcome of day-time urinary incontinence in children. 

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https://www.uptodate.com/contents/urinary-tract-infections-in-infants-and-children-older-than-one-month-clinical-features-and-diagnosis?search=urinary-tract-infections-in-infants-and-children-older-than-one-month:clinical-features-and-diagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

. Updated October 5, 2017. Accessed March 14, 2018.

7. Cederblad M, NevÃ©us,T, Ahman A, Osterlund Efraimsson E, Sarkadi A. “Nobody asked us if we needed help”: Swedish parents’ experiences of enuresis. 

8. Moffatt ME, Kato C, Pless IB. Improvements in self-concept after treatment of nocturnal enuresis: randomized controlled trial. 

9. Longstaffe S, Moffatt ME, Whalen JC. Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. 

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13. Al-Zaben FN, Sehlo MG. Punishment for bedwetting is associated with child depression and reduced quality of life. 

14. Yang S, Chua ME, Bauer S, et al. Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children’s Continence Society. 

15. Bloom DA, Seeley WW, Ritchey ML, McGuire EJ. Toilet habits and continence in children: an opportunity sampling in search of normal parameters. 

16. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: update report from the standardization committee of the International Children’s Continence Society. 

17. Hodges SJ, Anthony EY. Occult megarectum-a commonly unrecognized cause of enuresis. 

18. O’Regan S, Yazbeck S, Hamberger B, Schick E. Constipation a commonly unrecognized cause of enuresis. 

19. Lewis, SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. 

20. Benninga MA, Tabbers MM, van Rijn RR. How to use a plain abdominal radiograph in children with functional defecation disorders. 

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https://emedicine.medscape.com/article/1464228-overview

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23. Leech SC, McHugh K, Sullivan PB. Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children. 

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Articles

The continuation of this informative article addresses treatments for nocturnal enuresis, constipation, UTIs, and extraordinary daytime urinary frequency in children.

Managing enuresis in primary care: Part 2

Primary care offices in the pediatric world are busy with numerous topics to cover during well-child visits. Development, prevention, and safety issues rank as high priority. By the time the primary care provider (PCP) asks if there are any other outstanding issues besides the required topics, the visit may already be winding to a close.

What does the busy PCP recommend when the parent brings up the topic of incontinence, urinary frequency, or nocturnal enuresis? If the child is of an age deemed likely to outgrow these issues, the PCP may say just that. Advice to not worry about the urinary issues because they will spontaneously resolve often will be offered. Yet is this advice ideal or just the best that can be offered in the time allotted?

The purpose of this article is to provide the pediatric PCP with the best knowledge available so that the child and family can be counseled adequately. What are appropriate strategies for evaluation and for recommendations to a parent who broaches these topics? What are the red flags that the pediatric PCP needs to recognize? What are the most important caveats during the evaluation and management of enuresis and incontinence?

Many pediatric PCPs have educated themselves on urologic issues or sought education from pediatric urology specialists. They may begin the evaluation of urinary issues, recommend treatment, and order diagnostic testing where appropriate. Perhaps one particular care provider in the office could develop an expertise in such issues and begin an educational program with the family. A nurse practitioner (NP) with such an interest would be a good choice for this role. This article provides evidence-based algorithms for diagnosing urologic complaints and is a starting point for the evaluation and management of common pediatric bladder and bowel issues (Figure 1,

It is important to remember that while reviewing the medical history and conducting the physical exam, potential physical causes of enuresis should be ruled out. These varied etiologies are included in Table 1. Physical issues, however, are not the single concern here. The psychologic and emotional harm that can result from urinary tract dysfunction is imperative to consider. Bladder issues including bedwetting and incontinence are legitimate problems. Families may be told, “Don’t worry about it . . . your child will outgrow it in due time,” or “Return to see me if it persists until the age of 10 years” (or the age a particular care provider deems appropriate). Whereas these statements may be made with the best intentions, families report much frustration over the presence of urinary issues.

One study that involved direct interviews with parents showed that having a child with enuresis can be stressful as parents feel the need to protect their children from teasing. Parents feel that enuresis is socially stigmatizing and say that support from healthcare providers would help.

 Other studies have shown that children with enuresis suffer lowered self-esteem and, when treated, actually exhibit increases in the same.

 The wetting creates a physical, financial, and emotional burden on the parents as they must do extra laundry, buy incontinence briefs, and deal with a malodorous house. It has been shown that between 30% and 80% of parents punish their children and adolescents for wet nights.

 Punishments described include reprimanding, deprivation of sleep, and beating.

 In addition, punishments for bedwetting have been associated with childhood depression.

 Punishments have been inversely correlated with successful treatment of bedwetting.

The International Children’s Continence Society (ICCS) is an organization that includes multiple disciplines and specialties that care for children with bladder and bowel dysfunction. This group recommends that pediatric PCPs, including pediatricians, nurse practitioners, and family physicians, develop early recognition and appropriate management skills of bladder and bowel dysfunction (BBD). These care providers can serve an important role in the initial evaluation and management of BBD and reduce the associated morbidity.

 Nocturnal enuresis, daytime incontinence, and functional constipation all impact the physical and emotional well-being of the child and family.

For this article, the ICCS terminology and definitions will be used. Monosymptomatic nocturnal enuresis is defined as night wetting without any lower urinary tract symptoms. By the age of 4 years, most children void 5 to 6 times a day.

 The definition of daytime urinary frequency is said to occur in children who void 8 or more times a day and the definition of daytime infrequency is those who void 3 or fewer times a day.

 Daytime urgency is defined as the sudden development of an overwhelming need to void.

Dysuria is defined as discomfort during urination.

 Holding maneuvers are visible postures or positioning of the body when a child is postponing urination, such as placing pressure on the perineum, the potty dance, or crossing the legs. Intermittent wetting during daytime (awake) hours is termed daytime incontinence (not enuresis). Any wetting during sleeping hours is called enuresis. This would include wetting during sleep at night or during daytime naps.

Dysfunctional elimination syndrome and dysfunctional voiding are terms no longer recommended. Instead, BBD is used as it is a term that describes lower urinary tract symptoms combined with fecal problems consisting of primarily constipation and encopresis.

Nocturnal enuresis and/or daytime incontinence

Many theories exist as to the etiology of nocturnal enuresis including genetics, small bladder capacity, detrusor overactivity, nocturnal polyuria, and sleep arousal thresholds. Figure 1 shows an algorithm for the evaluation of the child who presents with nocturnal enuresis.

 The history should include determining the presence of daytime wetting or other lower urinary tract symptoms.

The frequency of nocturnal enuresis and its effects on the family should be determined. Is the child developmentally appropriate? Were milestones such as gross motor skills and toilet training reached on target? Are there behavioral issues or family stressors that could affect the child’s and family’s ability to participate in working on the bedwetting? Of utmost importance is whether the child is bothered by the enuresis. If the child is motivated to work on the enuresis, it is time to assist the family. When the child is developmentally ready, and especially when the child’s life is negatively impacted by enuresis, the family needs help.

In the case of daytime and nighttime symptoms, the algorithm in Figure 2 should be followed.

 The history needs to elicit voiding habits in particular with children who exhibit daytime incontinence and/or urinary tract infections (UTI). Many of these children are found to have poor fluid intake and also may void infrequently. Both habits predispose to the development of incontinence and UTIs. Daytime incontinence may occur when the child has never been toilet trained or may have been trained for several months and then regressed.

Typically, the physical examination of the child with monosymptomatic nocturnal enuresis is normal. Certain findings could elicit an underlying medical cause. One finding is palpable stool in the abdomen, which suggests constipation. It is important to note, however, that many times copious amounts of stool are present in the bowel but not palpable.

 It is not safe to assume that a soft abdomen indicates the absence of bowel issues. Furthermore, the definition of constipation is not uniform in the medical literature, nor is it uniformly understood by physicians and lay people.

 Most pediatric PCPs would identify infrequent or large, hard, and painful stools as evidence that constipation is an issue. The presence of these symptoms would likely cause the care provider to initiate a bowel management program.

Most parents and many care providers think that a daily stool indicates that constipation does not exist. This could not be further from the truth. Oftentimes, multiple daily stools are an indication that the rectum has become stretched and does not empty completely. The rectum being in such close proximity to the bladder then places pressure on the bladder, never allowing it to fully expand or empty to completion. Furthermore, stool backed up in the transverse and descending colon continues to empty into the rectum, placing more pressure on the bladder.

The relationship between enuresis and constipation was initially described in 1986.

 O’Regan and colleagues measured rectal distention in 25 enuretic children to determine the presence of constipation. Twenty-two of the 25 patients with enuresis showed decreased perception of rectal distention, and the majority tolerated very large balloon insufflation in the rectum. Seventeen of these 22 patients were treated with an enema program and a regimen of increased fiber content in the diet. All 17 showed total or partial improvement of nocturnal enuresis within 6 weeks by managing the bowels alone. The remaining 5 patients did not undergo bowel management. Whereas rectal distention is probably not at the top of the list when identifying constipation, it is clear from this data that it has an important impact on treatment.

To add further clarification to the concept of rectal distention affecting bladder function, Hodges and Anthony undertook a retrospective study to review 30 consecutive patients who presented with nocturnal enuresis.

 The researchers used specific radiologic criteria to measure rectal distention and abnormal stool burden. Results showed that all 30 patients showed rectal distention and 80% had an abnormally high stool burden. Only 10% of those patients with an abnormally heavy stool burden by radiography had a history of being constipated. Aggressive bowel management alone cured about 80% of those with nocturnal enuresis within 3 months. The use of polyethylene glycol caused the nocturnal enuresis to resolve in 80% of children. For those children that continued with rectal distention at a month’s follow-up, stimulant laxatives and/or enemas were added.

Because the history and physical exam of children who present with enuresis often does not identify the presence of constipation or fecal impaction, alternative sources of identification are recommended. Children and their parents often do not know that constipation exists. Initially when questioned, children may say they have soft, easy-to-pass stools. Children may not pay attention to their own bowel habits and may not possess the ability to discern whether their stools are hard or soft, large or small. They may have no comparison in their limited experience. Parents often deny that any difficulties with their child’s bowel movements have ever existed. Once toilet training has been accomplished, parents may rarely or never see another of their child’s bowel movements.

The Bristol stool scale is a visual chart of 7 types of stool that can be used to determine if constipation is present (Table 2).

 Types 1, 2, and 3 are constipated stools, whereas types 4 and 5 are stools with more desirable consistency. Children may say their stools are soft until they are shown the Bristol chart. When they point out types 1 or 2 as their usual stools, it is apparent this is not the case.

Another source for determining the diagnosis of functional constipation is the Rome classification, which is accepted by both pediatric and adult gastroenterologists. This system consists of 6 criteria, 5 of which are based on clinical history (Table 3).

 When clinical history does not identify a child who is constipated, a plain abdominal radiograph can be obtained. Many children who are determined to be constipated by abdominal radiograph and the Bristol stool chart will not meet Rome criteria. This could be considered a shortcoming of the Rome criteria as the majority of findings are obtained through history, which can be difficult for families to recall or identify. The 1 physical finding of a rectal fecal mass is not easily determined by current criteria. Perhaps a seventh measure, that of the presence of an abdominal fecal mass or masses on physical exam, could be a vital addition. The early diagnosis and treatment of a large stool load and/or mega-rectum will cause the enuresis cure to be easier, shorter, and less costly. Some red flags that may be found in the history or physical exam that might lead to a diagnosis of an organic cause of constipation are listed in Table 4.

Primary care physicians may be hesitant to order a plain abdominal x-ray (AXR), particularly when obvious symptoms of functional constipation are not present. The sixth Rome criterion, that of fecal impaction, is made by rectal examination, radiography, or ultrasound (US). Rectal examination is not the norm in pediatric primary care. For children and adolescents, rectal examination can be frightening and potentially painful and may sour a good relationship between care provider and patient. Often, the main concern about ordering an abdominal film is the radiation exposure. To ease concern about this, it is helpful to realize that the radiation exposure from 1 AXR is equivalent to about 2 months’ worth of natural background radiation.

 Taking this into consideration makes the occasional abdominal film a highly justifiable tool.

Speaking from years of experience, this author has found that many parents will not even consider treating constipation in their child who shows no outward evidence. However, showing parents the computer image and pointing out the large colonic stool load, and in particular the recto-sigmoid, will likely convince the parents. Leech and colleagues also found that showing the abdominal film image to parents and children encourages compliance with treatment.

 The transabdominal US to measure rectal diameter is a useful method to diagnose fecal impaction, but it is not widely used. Its use has been described in Europe and Japan, and it has shown to be reliable when performed by an experienced clinician.

It is extremely important to note that when an abdominal radiograph is obtained, the ordering provider must assess the image, not just read the radiologist’s report. Over time, the PCP will become familiar with images that constitute a small, moderate, or large stool load and to pay specific attention to the recto-sigmoid. Of note is the recognition that not all PCPs will have access to the actual radiographic images via their electronic medical records system. Perhaps, families may be more inclined to begin a bowel regimen without an AXR when suggested by their trusted PCP with whom a professional relationship has already been developed. When the pediatric specialist has been consulted, the recommendation for bowel management often occurs during the first visit.

Significance of urinalysis and importance of urine culture

When BBD exists, or a UTI is suspected, it is necessary to review the results of a macroscopic and microscopic urinalysis. It is not sufficient to check the urine with a reagent test strip. Two significant substances to look for on the test strip when evaluating for UTIs are nitrites and leukocyte esterase. Nitrites are the reduced form of nitrates in the urine. Some bacteria that cause UTIs produce enzymes that reduce urinary nitrate to nitrite. For this reaction to occur, the urine must have been present in the bladder for a minimum of 4 hours. Children may not hold urine in their bladders for this long. In addition, not all bacteria that cause UTIs produce this reaction.

Furthermore, numerous other reasons for a false-negative test result exist (Table 5).

 A false-positive result may occur from urine that has been left sitting at room temperature or from highly pigmented urine. If the urine is red due to blood or orange due to nitrofurantoin or phenazopyridine, for example, a positive result is not valid. The leukocyte esterase reaction is based on the fact that neutrophils contain enzymes known as esterases. The esterases are detected by reagent strips that contain an appropriate substrate.

 False negatives can occur with a high urine specific gravity and in urines that contain glucose and protein. In this environment, white blood cells (WBCs) will crenate (become notched) and are not able to release esterase.

Also, the presence of certain chemicals and drugs in the urine can cause false negatives to occur.

 Because of these limitations with testing for nitrites and leukocyte esterase in the urine, it is necessary to always obtain a microscopic analysis of the urine. If the resources are not available in the PCP’s office, it is necessary to send the urine to a lab. Importantly, the nitrite and leukocyte esterase tests are screening measures and are not meant to take the place of a urine culture.

The microscopic urinalysis result will report the presence of red blood cells (RBCs), WBCs, and bacteria, in addition to other cells and microorganisms. On average, normal urine contains up to 5 RBCs and 5 WBCs per high-power field. A properly collected normal midstream urine specimen will not contain bacteria. When the urine specimen contains large numbers of bacteria, particularly when accompanied by many WBCs, it is indicative of a urinary tract infection. The type of bacteria will not be identified on urinalysis, which necessitates the sending of a urine specimen for culture. Should the urine grow bacteria, the colony count will be reported. A clean catch midstream urine culture growing 50,000 or more colony forming units per milliliter of a single organism is indicative of a urinary tract infection. This along with a microscopic urinalysis that shows pyuria or bacteriuria confirms a UTI.

The primary care physician needs to have in place appropriate strategies for evaluation of urologic issues and recommendations to parents who broach these topics.

Nan E Tobias, MSN, APRN

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Managing enuresis in primary care: Part 2

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