Equit / Sambach / Niemczyk Urinary and Fecal Incontinence

A Training Program for Children and Adolescents
1. Auflage 2014
ISBN: 978-1-61676-460-9
Verlag: Hogrefe Publishing
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 210 Seiten

A new and effective training program for children and adolescents with continence difficulties

Elimination disorders (such as bed-wetting or soiling) are common in childhood. This manual presents a new and effective training program for children and adolescents with nocturnal enuresis, daytime urinary incontinence, fecal incontinence, or a combination of these forms, who do not respond to standard measures.

After discussing the different types of incontinence and comorbid psychological disorders, the expert team of authors (a psychotherapist, a pediatric nurse, a psychologist, and a psychiatrist) describe a 7-9 session program of bladder and bowel training, primarily for use in groups but which can also be used with individuals. The training encompasses psychoeducation, operant reinforcement, emotion regulation, and relaxation techniques – all presented in a “child-friendly”, playful manner.

The manual itself is accompanied by a wealth of colorful, attractive, printable worksheets and other educational materials suitable for youngsters, which cover topics such as healthy drinking and eating habits, stress and emotion regulation, body perception, toilet training, and relaxation techniques.

This manual is a superb resource for pediatricians, specialists in child and adolescent psychiatry, psychologists, nurses, urotherapists, and all other professionals looking for well-founded, hands-on guidance on treating children and adolescents with incontinence.

Autoren/Hrsg.

Equit, Monika

Sambach, Heike

Niemczyk, Justine

Gontard, Alexander von

Fachgebiete

• Sozialwissenschaften Psychologie Psychotherapie / Klinische Psychologie Kinder- und Jugendlichenpsychotherapie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Urologie, Andrologie, Venerologie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizinische Fachgebiete Kinder- & Jugendpsychiatrie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Pädiatrie, Neonatologie

Inhaltsverzeichnis

1;Urinary and Fecal Incontinence;1
1.1;Table of Contents;6
2;Preface;8
3;Introduction;10
4;Chapter 1: Incontinence During Childhood and Adolescence;14
5;Chapter 2: Assessment;30
6;Chapter 3: Treatment of Incontinence;34
7;Chapter 4: Description and Structure of the Manual;42
8;Chapter 5: Conducting the Individual Versions;48
9;Chapter 6: Evaluation of the Treatment;88
10;References;92
11;Appendix;100

Leseproben

Chapter 3 Treatment of Incontinence (p. 25-26)

In the following chapter, methods for the treatment of incontinence are described. A detailed description of treatment steps and interventions can be found in von Gontard and Nevéus (2006) or in von Gontard (2012a, 2012b). For the treatment of complex elimination disorders, intensive urotherapy has proven to be effective (see Section 3.5).

3.1 General Treatment Principles

If comorbid elimination disorders (urinary and fecal incontinence) are present, fecal incontinence with or without constipation is always treated first. Generally, the therapy of fecal incontinence or constipation leads to a reduction of wetting. Subsequently, any kind of wetting during daytime will be treated because daytime urinary incontinence represents a peripheral disorder of the bladder function. In children with (NMNE), similar bladder dysfunctions are existent except that these children do not wet during daytime. If these bladder dysfunctions (as in daytime urinary incontinence) are treated adequately, nighttime wetting will stop for many children. If nocturnal enuresis persists, treatment of nighttime wetting itself is indicated. While the treatment order of combined elimination disorders is very clear, additional comorbid psychological disorders are treated according to clinical indication. A symptom-oriented treatment of soiling and wetting, however, should always be carried out. After successful treatment of incontinence, children feel better, their self-esteem increases, and sometimes even conduct problems are reduced.

Manifest comorbid psychological disorders (e. g., emotional disorders) can be treated simultaneously with incontinence. Other disorders, e. g., severe forms of ADHD, should be treated first (through psychotherapy or pharmacotherapy) to improve the compliance of children with further treatment.

3.2 Treatment of Fecal Incontinence

Psychoeducation of the parents and the child is the basis for all subsequent interventions. It provides information about the type of incontinence, possible causes, comorbidity, and pathogenesis. Along with the most important diagnostic steps, therapy planning and changes in the diet and in drinking habits are discussed.

The main treatment approach of fecal incontinence is regular toilet training. Children are asked to sit on the toilet 3 times a day for 5–10 minutes after the main mealtimes. The aim of toilet training is not necessarily to achieve micturition or defecation but the regulation of defecation behavior.

It is not completely clear which mechanisms lead to the success of this training. On the one hand, the emptying reflexes, which are mostly active after food intake (so-called gastrocolic reflexes), are regulated by developing the habit of emptying the stool into the toilet. Additionally, operant elements such as praise, attention, positive experience of the toilet times, and feelings of success are effective. Thus, toilet training is the basic therapy for all types of fecal incontinence (von Gontard & Nevéus, 2006) and is significantly more efficient compared to pharmacological treatment alone or biofeedback treatment (Borowitz, Cox, Sutphen, & Kovatchev, 2002). It is the main treatment component for fecal incontinence without constipation.

In the treatment of fecal incontinence with constipation, toilet training is combined with laxatives. Tabbers and colleagues (2011) named four steps for the treatment of constipation: education, disimpaction, prevention of re-accumulation of feces, and follow-up. Burgers and colleagues (2013) give an overview of treatment of constipation in children with lower urinary tract symptoms. Toilet training reduces the risk of constipation in chronic types of toilet refusal syndrome and slowly accustoms the children to going to the toilet. The parents should document the procedure of the toilet training on a chart; an additional documentation by the children is optional.

For most children, toilet training with simple reinforcements is sufficient. In case of lack of treatment success or relapses, further cognitive behavioral treatment elements can be added. Outpatient treatment programs with a multimodal approach have proven to be effective. The group training described in the second part of this book is such a multimodal approach.

Pharmacological treatment is only indicated in case of fecal incontinence with constipation. The initial emptying of colon and rectum fecal masses (disimpaction) is differentiated from the long-term maintenance treatment with the aim of preventing re-accumulation of feces.

There are three options available for disimpaction: oral, rectal and, on rare occasions, surgical disimpaction. For oral disimpaction, polyethylene glycol (PEG) is the first choice laxative. It is an osmotic laxative that binds water molecules, softens the stool, and activates defecation. The required doses are much higher than in maintenance treatment. In severe and chronic constipation, oral disimpaction is not sufficient. Usually, rectal enemas containing phosphate are necessary. Information on the required doses can be found in von Gontard & Nevéus (2006). Please note that Bekkali and colleagues (2009) demonstrated that oral disimpaction with PEG can be as effective as rectal disimpaction with enemas. If children prefer oral disimpaction, this should be tried first.

In rare cases of very severe constipation with megacolon, even rectal enemas may not be sufficient. In these cases, children should be referred to specialists in pediatric gastroenterology or surgery. Frequent and antegrade enemas or, on vary rare occasions, surgical evacuation may be necessary. After the disimpaction, maintenance treatment starts immediately. Toilet training and laxatives are the two relevant components of the treatment, which have to be carried out simultaneously. Again, PEG is the laxative of choice. The effectiveness of the drug depends on sufficient liquid intake. If the children do not drink enough, a drinking schedule may be established. In exceptional cases (e. g., intolerance of PEG), lactulose may be administered.

The effectiveness of the fecal incontinence treatment is dependent on the regular treatment over a long period of time. In summary, in fecal incontinence without constipation, toilet training is sufficient and no laxatives should be used. Fecal incontinence with constipation requires a treatment with both laxatives and toilet training.

3.3 Treatment of Daytime Urinary Incontinence

In this section, basic modules for treatment of daytime urinary incontinence are presented. An exact diagnosis of the subtype of urinary incontinence is necessary for a successful therapy. At the beginning of the treatment, detailed psychoeducation with the provision of information and counseling of children and parents is indicated.

3.3.1 Urge Incontinence

First-line treatment of urge incontinence consists of detailed psychoeducation and takes a cognitive approach. Children are instructed to perceive urgency and to go to the toilet immediately at the first signs of urge. They are asked to note in a voiding chart whether their underwear was dry or wet (e. g., using symbols such as a flag or a laughing smiley for dryness, a cloud or a sad smiley for wetting). Clinical experience has shown that this method can reduce wetting within a few weeks in one third of the children. Hagstroem and colleagues (2010) showed that 30% of all children with urge incontinence became dry through urotherapy in combination with programmed watches that reminded....