Elimination disorders are repeated passage of urine or stool into inappropriate places by a child who is old enough to have achieved control. DSM-5-TR includes enuresis and encopresis. They are diagnosed only when the behavior is not caused by a substance (e.g., diuretics, laxatives) or by another medical condition (e.g., diabetes, seizures, spina bifida, urinary tract infection), except through a constipation mechanism in encopresis.

Enuresis

• Repeated voiding of urine into bed or clothes, involuntary or intentional
• At least twice a week for at least 3 consecutive months, or causing significant distress or impairment
• Chronological or developmental age at least 5 years
• Subtypes: nocturnal only (most common; bedwetting), diurnal only, or both
• Primary (never achieved continence) vs. secondary (relapse after at least 6 months of dryness — look for stressors or medical causes)
• Mechanisms: high nocturnal urine production (low nighttime vasopressin), reduced functional bladder capacity or overactive bladder, and difficulty waking to bladder signals. Strong family history; constipation and obstructive sleep apnea can contribute. Most children outgrow it (about 15% resolve spontaneously each year).

Encopresis

• Repeated passage of feces into inappropriate places (clothes, floor)
• At least once a month for at least 3 months; age at least 4 years
• Subtypes: with constipation and overflow incontinence (most common, about 80–90%) and without constipation
• Pathophysiology of retentive encopresis: painful stool → withholding → rectal distension and loss of normal rectal sensation → liquid stool leaks around a hard fecal mass (overflow soiling). The child often does not feel the leakage.
• Encopresis without constipation is more often linked to oppositional behavior, stress, or trauma; soiling in only one setting (e.g., only at school) suggests toileting avoidance or situational stress.

Related elimination problems that mental health and general nurses manage in all age groups: functional constipation, laxative or enema overuse (sometimes linked to eating disorders or health anxiety), fecal incontinence in older adults (often overflow from impaction), and urinary retention caused by anticholinergic psychotropic drugs.

Child history

• Onset, duration and frequency of wetting or soiling — needed to meet diagnostic criteria
• Primary vs. secondary; daytime symptoms (urgency, frequency, holding maneuvers)
• Bowel pattern: stool frequency and consistency (Bristol Stool Form Scale), pain, large stools that block the toilet, withholding posture
• Fluid and fiber intake, toilet access and habits at school
• Sleep: snoring or apnea (linked with enuresis)
• Stressors: new sibling, school change, divorce, bullying, possible abuse (sudden secondary wetting or soiling warrants sensitive screening)
• Emotional impact: shame, low self-esteem, peer teasing, avoidance of sleepovers; family response (punishment increases shame and withholding)

Physical findings

• Palpable fecal mass on abdominal exam in retentive encopresis
• Perianal inspection; spine and lower-extremity neurologic exam (dimples or hair tufts suggesting spinal dysraphism)
• Signs of diabetes (polyuria, polydipsia, weight loss) or UTI (dysuria, fever)

Adults

• Dysuria or difficulty voiding: first assess the nature and location of pain, voiding pattern, and medications
• Urinary retention: suprapubic distension, discomfort, frequent small voids; bladder scan

Enuresis

• Reassurance and education: enuresis is common, involuntary, and not the child's fault
• Enuresis (bed-wetting) alarm — first-line behavioral treatment with the highest long-term cure rate. A moisture sensor sounds an alarm when urine touches it, waking the child to stop voiding and finish in the toilet; over weeks the child learns to wake to bladder fullness or hold urine. Needs parental involvement and 2–3 months of consistent use.
• Desmopressin (oral tablet or melt) — synthetic vasopressin that reduces nighttime urine production; works quickly, useful for sleepovers or when alarms fail; relapse is common after stopping.
  • Risk: hyponatremia and water intoxication (headache, nausea, vomiting, confusion, seizures)
  • Limit fluids from 1 hour before to 8 hours after the dose; hold during vomiting, diarrhea, or fever
  • The intranasal form is no longer indicated for enuresis because of hyponatremia-related seizures
• Anticholinergics (oxybutynin) when there is daytime overactive bladder — constipation, dry mouth, flushing, heat intolerance
• Imipramine — rarely used now; cardiotoxic and potentially lethal in overdose (baseline ECG); boxed warning for suicidality in children and adolescents; must be locked away
• Treat constipation and sleep apnea if present

Encopresis (with constipation)

• Disimpaction — oral polyethylene glycol (PEG 3350) at higher doses for several days, or enemas when oral therapy fails or is not tolerated (avoid sodium phosphate enemas in children under 2 years — risk of hyperphosphatemia and hypocalcemia)
• Maintenance — daily osmotic laxative (PEG 3350) for months, tapered slowly only after regular soft stools for an extended time; stopping too early causes relapse
• Scheduled toilet sitting 5–10 minutes after meals (uses the gastrocolic reflex), 2–3 times daily, with a footstool so knees are above hips
• Behavioral therapy: reward charts for sitting and cooperation, not for being clean
• Psychotherapy or family therapy for stress, trauma, or oppositional behavior

Adults with constipation or fecal incontinence

• Fiber, fluids, activity, regular toileting, and osmotic laxatives before stimulant laxatives
• Routine daily enemas are not recommended — they cause dependence, electrolyte imbalance, and rectal injury
• Review drugs that cause constipation or retention: anticholinergics, clozapine (can cause severe, sometimes fatal bowel hypomotility), tricyclic antidepressants, opioids

Listed in priority order.

1. Physiologic safety
   • Watch for hyponatremia in children on desmopressin; enforce the fluid limit
   • Acute urinary retention: after catheter placement, monitor for catheter-associated urinary tract infection and urosepsis; use aseptic technique and remove catheters as soon as possible
   • Clozapine or anticholinergic therapy: monitor bowel function daily; report abdominal distension, pain, or vomiting
2. Emotional support
   • Accept and support the child's feelings; state clearly that wetting and soiling are not deliberate misbehavior
   • Protect privacy and dignity; provide a discreet change of clothes at school
   • Screen sensitively for abuse or major stressors in secondary cases
3. Behavioral programs
   • Teach correct alarm use; help parents wake the child if the child sleeps through the alarm
   • Positive reinforcement: praise and small rewards immediately after success (dry nights, toilet sitting); no punishment, shaming, or scolding
   • Have the child help change sheets as a matter-of-fact routine, not a punishment
   • Encourage voiding at regular intervals during the day and just before bed
4. Bowel regimen
   • Scheduled toilet sitting after meals; track stools in a diary
   • Increase fluids, fiber (whole grains, legumes, fruits with skin, vegetables), and physical activity
   • Abdominal massage and warm fluids can relieve bloating and discomfort
5. Skin care — for incontinence: cleanse gently with lukewarm water and mild cleanser after each episode, pat completely dry, and apply a barrier cream
6. Coping — for adults requesting repeated enemas, address the underlying ineffective coping and teach a safe bowel routine

Toilet training (parents of toddlers)

• Start when the child shows readiness (stays dry for about 2 hours, shows interest, can follow simple instructions, can pull pants up and down), often between 18 months and 3 years
• Praise success immediately; avoid punishment for accidents; use a regular routine and a child-sized seat or footstool

Enuresis

• It is common and usually resolves; it is not laziness
• Limit fluids in the evening, avoid caffeine and sugary drinks, void before bed
• Use the alarm every night for at least 2–3 months; expect progress to be gradual
• Desmopressin: follow fluid limits exactly; stop and call if headache, vomiting, or confusion occurs

Encopresis

• The bowel needs months to regain normal size and sensation; continue laxatives as prescribed
• Relapse is common if medication is stopped early
• Ensure access to clean, private toilets at school

Constipation (all ages)

• Eat fiber-rich foods and drink enough fluids; respond promptly to the urge to defecate
• Avoid relying on daily enemas or stimulant laxatives

• Enuresis: age 5 or older; twice a week for 3 months or significant distress
• Encopresis: age 4 or older; once a month for 3 months; most cases are overflow from constipation
• Soiling only at school, normal at home → encopresis linked to toileting avoidance or stress
• Enuresis alarm = first-line; wakes the child when urine touches the sensor
• Desmopressin → risk of hyponatremia; restrict fluids 1 hour before to 8 hours after dose
• Encopresis treatment: disimpaction → maintenance laxative → scheduled toilet sitting after meals
• Praise success; never punish wetting or soiling
• Routine daily enemas are not recommended
• Incontinence skin care: gentle cleansing, dry completely, barrier cream
• After urinary catheterization: watch for UTI and sepsis