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Dysfunctional Elimination Syndrome

Dysfunctional elimination syndrome at a glance

  • Dysfunctional elimination syndrome covers common conditions where a patient has difficulty urinating or defecating normally.
  • Dysfunctional elimination syndrome most often affects children, beginning at or shortly after toilet training.
  • Many cases of dysfunctional elimination syndrome respond to behavioral correction.
  • Some people have a physical or neurological condition, such as vesicoureteral reflux (VUR), which may need surgical correction.

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What is dysfunctional elimination syndrome?

Dysfunctional elimination syndrome describes a group of conditions affecting a person’s ability to urinate and defecate normally and without difficulty. These common voiding problems primarily affect children. These individuals may have trouble with bladder control (either with an overactive bladder or underactive bladder). Frequently, they also suffer from constipation and/or bowel incontinence, though most problems are related to urination.

Urination is a complex system involving two different muscle groups: the bladder and sphincter muscle systems. The bladder stores urine and the sphincter muscle, which people can control by flexing it, keeps urine from leaving the bladder. When full, the bladder signals the brain to empty it and the sphincter muscle relaxes, allowing urine to flow from the bladder as its muscles contract. Malfunctioning of this process results in urinary problems, or voiding dysfunction.

Infants’ bowels and bladders reflexively empty, with children usually gaining control of these functions by 3 years of age. At that age, the bladder normally voids 5-6 times a day and bowel movements generally occur once a day or every other day.
By age 3, most children gain control over daytime urinating, with nighttime control coming later. However, some children wet their bed much longer, but most stop by age 7. Children with abnormal voiding of urine or abnormal defecation have dysfunctional elimination syndrome.

Because many children with this condition urinate infrequently or incompletely, they may experience repeated urinary tract infections (UTIs). As a result, they may be at risk for bladder or kidney infections.

Causes of dysfunctional elimination syndrome

In many children, dysfunctional elimination syndrome appears after toilet training. In some children these problems are caused by anatomical issues present at or before birth. But in most cases of dysfunctional elimination syndrome the child has developed an abnormal pattern of urination, with the functions of the urinary tract no longer properly coordinated. In a few cases it occurs due to infection or nervous system problems.

  • Congenital problems: Some children are born with physical problems or blockages in the urinary tract.
  • Nervous system conditions: Abnormalities or diseases, such as epilepsy, spinal cord injury or cerebral palsy, may affect the nerves that control bladder function, bowel function or function of the urinary sphincter.
  • Disease: Some diseases that can affect the urinary tract may appear in childhood, such as endocrine diseases (diabetes), kidney diseases and genetic diseases (Ochoa syndrome, Williams syndrome).
  • Vesicoureteral reflux (VUR): Up to 10 percent of children may have VUR, in which a malfunctioning valve allows urine to flow backward into the kidneys, instead of out of the body.
  • Irritations or infections: UTIs, a foreign body in the urinary tract or urethritis can irritate the bladder and result in elimination problems.
  • Tumors or trauma: Can cause problems in the urinary tract’s physical anatomy.

Symptoms of dysfunctional elimination syndrome

Common voiding problems and symptoms include one or more of the following:

  • Daytime wetting (diurnal enuresis). Can range from small leaks of urine to complete bladder release that soaks garments.
  • Bedwetting (nocturnal enuresis). Nighttime wetting occurs when a child cannot control urination while sleeping. Common among young children, after age 5 nocturnal enuresis is considered abnormal.
  • Constipation. This is the inability to pass stool normally every day or two, without excessive straining or discomfort. With constipation a child is likely to tense his or her pelvic floor muscles to avoid having an accident. Because these muscles control urination, too, habitually tensing the muscles can affect bladder function as well as bowel function.
  • Bowel accidents (encopresis). A bowel accident, also called bowel incontinence, occurs when stool leaks during the day or night. Sometimes this is noticeable with streaks on undergarments.
  • Infrequent urination (“lazy bladder”). This is urinating three or fewer times per day.
  • Recurrent urinary tract infections (UTI). When a person doesn’t empty the bladder completely, or often enough, it might cause bacteria to remain in the body, resulting in frequent or recurring UTIs.
  • Urge syndrome (overactive bladder). This is when a child frequently feels the need to void (seven times daily or more), with mild urine leakage. The child may demonstrate “holding” maneuvers, like crossed legs or squatting.
  • Giggle incontinence. Children lose control of their bladder during vigorous laughter or giggling.

Diagnosis of dysfunctional elimination syndrome

A physician usually can diagnose dysfunctional elimination syndrome based on the symptoms above. It is important, however, to understand the cause of the dysfunctional elimination syndrome. To find the cause, the physician will consider several factors.

  • Social issues, such as how wetting or bowel problems affect the child’s emotions and school performance, presence of attention deficit disorder (ADD) or sensitivity to sensory stimulation. These are common in children with dysfunctional elimination syndrome.
  • Physical exam of the back, rectum and genitalia to look for physical abnormalities.
  • Medical history provides the doctor with important background information, and the doctor may ask the parents to keep a “voiding diary” for their child.
  • Neurologic exam looks for issues with the nervous system that might affect elimination. The doctor is likely to study the strength, tone, reflexes and sensation of the lower extremities.
  • Lab tests, such as blood tests, urinalysis and/or urine culture, can show infection and problems with how the kidneys work.
  • Imaging tests such as ultrasound or MRI tests study the structures of the body and help to identify or rule out spinal cord disorders.
  • Voiding cystourethrogram is an x-ray of the urethra and bladder most often recommended for children with a history of UTIs. This test can help identify whether the child has vesicoureteral reflux. An alternative to this test is a radionuclide cystogram.
  • Renal scan tells a doctor whether the kidneys are damaged and how well they are working.
  • Urodynamic assessment or bladder pressure study tests how well the bladder works in holding and releasing urine.

Treatment of dysfunctional elimination syndrome

Depending on the cause of dysfunctional elimination syndrome, treatment may vary from behavioral techniques and bladder/bowel training to surgical treatments. Surgery is most common in children with vesicoureteral reflux. The more common treatments follow.

Managing bowel/bladder irritants

For some children dysfunctional elimination syndrome results from constipation, infection and/or bladder irritation. Physicians may recommend one or all of the following to help manage the condition.

  • Antibiotic treatment of UTI.
  • Eliminating bladder irritants. Physicians sometimes recommend patients drink more water and avoid irritating substances, such as carbonated beverages, citrus juices, caffeine and chocolate.
  • Managing constipation. Physicians will work to improve bowel habits and try to eliminate constipation. Usually, this process involves increasing fiber and liquid, and forming regular bathroom habits. Laxatives, stool softeners or enemas can help regulate bowel habits.
  • Medication for urge syndrome. Anticholinergic medications may be prescribed. 

Behavioral treatment for dysfunctional elimination syndrome

For many patients behavioral treatment goes hand in hand with other treatments, such as medication. Consistent reinforcement of new habits can help patients achieve regular elimination. The key to successfully “retraining” the bladder is for children to learn to eliminate intentionally and completely.

For nighttime wetting (nocturnal enuresis) a urine alarm can alert the child when the bed gets wet. The child then can learn to respond to the sensation of a full bladder at night.

For daytime wetting doctors may recommend a variety of techniques including:

  • Scheduling urination every 2-4 hours, using a watch alarm.
  • Relaxation and biofeedback exercises to help patients learn to relax as they urinate.
  • Drinking more water to teach the bladder to hold and release urine.
  • Kegel exercises (contraction/relaxation) to strengthen the muscles of the pelvic floor.
  • High fiber intake to help manage constipation, which can affect bladder problems.

The bladder retraining process can take months to a year. Very often, however, the treatment is successful. Once the dysfunctional elimination has been re-trained, it often does not occur.

It is very important, however, to seek medical attention for dysfunctional elimination syndrome in order to rule out or deal with any anatomical issues or recurring infections.