Dışa Atım Bozuklukları
Özet
Dışa atım bozuklukları, gelişim düzeyine göre beklenen mesane ve bağırsak kontrolünün sağlanamaması olup çocuk ve aile için ciddi psikososyal zorluklar yaratmaktadır. Enürezis, 5 yaşından büyük çocukların yatağa veya elbiselerine istemsiz idrar kaçırmasıdır ve monosemptomatik veya monosemptomatik olmayan şekillerde görülebilir. Tedavisinde ilk seçenek V2 reseptörlerine etki eden antidiüretik dezmopresinken, dirençli vakalarda antikolinerjik ilaçlar ve imipramin gibi trisiklik antidepresanlar tercih edilmektedir. Enkoprezis ise 4 yaşından büyük çocuklarda istemsiz veya istemli dışkı kaçırma durumu olup, vakaların %80’ini kronik kabızlığın tetiklediği taşma tipi inkontinans oluşturmaktadır. Enkoprezis medikal tedavisinde barsakları boşaltıcı lavman veya solüsyonların ardından lifli beslenme ve polietilenglikol gibi ajanlarla sürdürülen 6 aylık bir idame protokolü uygulanmaktadır. Her iki bozukluk da erkek çocuklarda daha sık görülmekte ve başta Dikkat Eksikliği ve Hiperaktivite Bozukluğu (DEHB) olmak üzere birçok psikiyatrik komorbidite ile yüksek oranda ilişki sergilemektedir; bu nedenle eş zamanlı psikiyatrik tedavi büyük önem taşımaktadır.
Elimination disorders represent the inability to maintain expected bladder and bowel control based on developmental age, creating significant psychosocial challenges for children and families. Enuresis is involuntary urinary incontinence in children over 5 years old, occurring in monosymptomatic or non-monosymptomatic forms, where desmopressin acts as the primary treatment option while anticholinergics and imipramine are preferred for refractory cases. Encopresis involves repeated passage of feces into inappropriate places in children over 4, with 80% of cases presenting as retentive incontinence triggered by chronic constipation. Medical management of encopresis requires initial disimpaction followed by a 6-month maintenance therapy utilizing laxatives and dietary fiber. Both disorders are more prevalent in boys and show high comorbidity with psychiatric conditions, particularly ADHD, necessitating simultaneous psychiatric interventions.
Referanslar
American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders fifth edition (DSM 5). Washington, D.C; 2013.
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. Neurourol Urodyn. 2016 Apr 1;35(4):471–81.
Summary of the Practice Parameter for the Assessment and Treatment of Children and Adolescents With Enuresis. 43:123–5. Available from: www.aacap.org
Nevéus T. Nocturnal enuresis-theoretic background and practical guidelines. Vol. 26, Pediatric Nephrology. 2011. p. 1207–14.
Kuwertz-Bröking E, von Gontard A. Clinical management of nocturnal enuresis. Pediatric Nephrology. 2018 Jul 1;33(7):1145–54.
Palm C, Gross P. V2-vasopressin receptor antagonists-mechanism of effect and clinical implications in hyponatraemia. Vol. 14, Nephrol Dial Transplant. 1999.
Nevéus T, Fonseca E, Franco I et al. Management and treatment of nocturnal enuresis—an updated standardization document from the International Children’s Continence Society. Vol. 16, Journal of Pediatric Urology. Elsevier Ltd; 2020. p. 10–9.
Glazener CMA, Evans JHC. Desmopressin for nocturnal enuresis in children. Vol. 2010, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2002.
Chua ME, Silangcruz JM, Chang SJ, et al. Desmopressin Withdrawal Strategy for Pediatric Enuresis: A Meta-analysis. Vol. 138, REVIEW ARTICLE PEDIATRICS. 2016.
Nevéus T. The Dilemmas of Refractory Nocturnal Enuresis. Vol. 179, Journal of Urology. 2008. p. 817–8.
Van Arendonk KJ, Austin JC, Boyt MA, et al. Frequency of wetting is predictive of response to anticholinergic treatment in children with overactive bladder. Urology. 2006 May;67(5):1049–53.
Von Gontard A. Diagnose und Behandlung der Enuresis und der funktionellen Harninkontinenz tagsüber. Vol. 116, Deutsches Arzteblatt International. Deutscher Arzte-Verlag GmbH; 2019. p. 279–85.
Blais AS, Bergeron M, Nadeau G, et al. Anticholinergic use in children: Persistence and patterns of therapy. Journal of the Canadian Urological Association. 2016 Apr 1;10(3-4April):137–40.
Acar O, Uluocak N. Current Medical Treatment Options for Enuresis Nocturna. Türk Üroloji Seminerleri/Turkish Urology Seminars. 2011 Feb 1;2(2):45–9.
Gepertz S, Nevéus T. Imipramine for therapy resistant enuresis: A retrospective evaluation. In: Journal of Urology. Elsevier Inc.; 2004. p. 2607–10.
Caldwell PHY, Sureshkumar P, Wong WCF. Tricyclic and related drugs for nocturnal enuresis in children. Vol. 2016, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2016.
Hjalmas K, Arnold T, Bower W, et al. Nocturnal enuresis: An international evidence based management strategy. In: Journal of Urology. Lippincott Williams and Wilkins; 2004. p. 2545–61.
Walker RA. Nocturnal Enuresis. Vol. 46, Primary Care - Clinics in Office Practice. W.B. Saunders; 2019. p. 243–8.
Neveus T, Eggert P, Evans J, et al. Evaluation of and Treatment for Monosymptomatic Enuresis: A Standardization Document From the International Children’s Continence Society. Vol. 183, Journal of Urology. 2010. p. 441–7.
Lundmark E, Stenberg A, Hägglöf B, et al. Reboxetine in therapy-resistant enuresis: A randomized placebo-controlled study. J Pediatr Urol. 2016 Dec 1;12(6):397.e1-397.e5.
Blais AS, Nadeau G, Moore K, et al. Prospective Pilot Study of Mirabegron in Pediatric Patients with Overactive Bladder. Eur Urol. 2016 Jul 1;70(1):9–13.
Shatkin JP. Case Report Atomoxetine for the Treatment of Pediatric Nocturnal Enuresis. Vol. 14, Journal of chıld and adolescent psychopharmacology. mary ann liebert, ınc. pp; 2004.
Sumner CR, Schuh KJ, Sutton VK, et al. Placebo-Controlled Study of the Effects of Atomoxetine on Bladder Control in Children With Nocturnal Enuresis.
Houts AC, Berman JS, Abramson H. Effectiveness of psychological and pharmacological treatments for nocturnal enuresis. J Consult Clin Psychol. 1994;62(4):737.
Bahali K, Ipek H, Uneri OS. Methylphenidate and atomoxetine for treatment of nocturnal enuresis in a child with attention-deficit hyperactivity disorder. Eur Child Adolesc Psychiatry. 2013;22(10):649.
Robaey P. Commentary: enuresis and ADHD in older children and an adolescent treated with stimulant medication: a case series. Journal of the Canadian Academy of Child and Adolescent Psychiatry. 2011;20(1):56.
Türkoglu S, Bilgiç A, Uzun N. Effectiveness of atomoxetine in the treatment of children with encopresis. J Clin Psychopharmacol. 2015;35(5):622–3.
Van der Wal MF, Benninga MA, Hirasing RA. The prevalence of encopresis in a multicultural population. J Pediatr Gastroenterol Nutr. 2005;40(3):345–8.
Loening-Baucke V. Biofeedback treatment for chronic constipation and encopresis in childhood: long-term outcome. Pediatrics. 1995;96(1):105–10.
Rajindrajith S, Devanarayana NM, Benninga MA. Review article: Faecal incontinence in children: Epidemiology, pathophysiology, clinical evaluation and management. Vol. 37, Alimentary Pharmacology and Therapeutics. 2013. p. 37–48.
Baroud E, Zar-Kessler C, Bender S. A Child Psychiatry Perspective on Encopresis. Journal of the American Academy of Child and Adolescent Psychiatry. Elsevier Inc.; 2022.
Di Lorenzo C, Benninga MA. Pathophysiology of pediatric fecal incontinence. Gastroenterology. 2004;126:S33–40.
Har AF, Croffie JM. Encopresis .Pediatrics in Review Vol.31 No.9 September 2010
Loening-Baucke V. Encopresis. Curr Opin Pediatr 2002;14:570-575.
Özen H. Çocuklarda kabızlık ve dışkı kaçırma. Hacettepe Tıp Dergisi 2004; 35:135-142.
Joinson C, Heron J, Butler U, et al. Psychological differences between children with and without soiling problems. Pediatrics. 2006 May;117(5):1575–84.
Çoban ÖG, Önder A, Adanır AS. Psychiatric comorbidities of children with elimination disorders. Archives de Pédiatrie. 2021;28(1):59–63.
Yektaş Ç, Cansiz MA, Tufan AE. Increased frequency of encopresis in a child diagnosed with attention deficit/hyperactivity disorder and encopresis after atomoxetine use: A case report. Clin Neuropharmacol. 2016 Jul 1;39(4):212–3.
Yılmaz S, Akça ÖF. Effectiveness of methylphenidate in the treatment of encopresis whether or not attention-deficit/hyperactivity disorder symptoms are present. J Child Adolesc Psychopharmacol. 2013;23(9):632–3.
