Occult Megarectum—A Commonly Unrecognized Cause of Enuresis

doi:10.1016/j.urology.2011.10.015

Urology

Volume 79, Issue 2, February 2012, Pages 421-424

https://doi.org/10.1016/j.urology.2011.10.015 Get rights and content

Objective

To determine whether occult megarectum remains a commonly unrecognized cause of enuresis and whether treating it will cure enuresis in most children. A landmark study proved constipation was a commonly unrecognized cause of enuresis in 1986 in which constipation was defined as abnormal rectal distension. However, modern recommendations have focused on signs of functional constipation, such as hard or rare stools.

Methods

A retrospective review of 30 consecutive patients seen in our clinic with a chief complaint of nocturnal enuresis was performed, with an analysis of the results of their plain abdominal radiographs. The results of the studies were determined using a novel method termed the rectal/pelvic outlet ratio and Leech criteria. These results were compared with the reported constipation history according to the International Children's Continence Society guidelines, which recommends asking parents and children whether the child's bowel movements occur less often than every other day and whether the stool consistency is hard. Patients diagnosed with megarectum were treated with laxatives, with the goal of restoring normal rectal tone.

Results

All patients demonstrated rectal distension according to the rectal/pelvic outlet ratio, and 80% were constipated according to the Leech criteria. Only 10% of the patient or families reported clinical symptoms of constipation. All the adolescent patients in our study and 80% of the younger patients were cured of enuresis with laxative therapy.

Conclusion

Occult megarectum remains a commonly undiagnosed cause of nocturnal enuresis. Abdominal radiographs represent a simple, noninvasive method to diagnose megarectum and might improve the treatment of nocturnal enuresis.

Section snippets

Material and Methods

Results

We reviewed the charts of 30 patients, 19 boys and 11 girls, referred to our clinic for nocturnal enuresis. Their age range was 5-15 years (average age 9). Four of the patients were adolescents.

All radiographs demonstrated fecal rectal distension, as defined by an RPOR >1. Of the abdominal radiographs, 80% demonstrated an abnormal fecal burden (as defined by the Leech criteria), consistent with constipation. Only 10% of the parents or children with abnormal radiographs described a bowel history

Comment

The current belief is that nocturnal enuresis arises from a combination of 3 main causes: nocturnal polyuria, detrusor overactivity, and an increased arousal threshold.1, 2 All studies agree, however, that comorbid conditions can influence these factors (eg, the effects of constipation on bladder capacity and overactivity) and must be treated before initiating direct therapy, because it might be difficult to succeed otherwise.²

Several dilemmas are inherent in the evaluation of children for

Conclusions

Occult megarectum, initially described by O'Regan et al³ in 1986, remains a commonly undiagnosed cause of nocturnal enuresis. We believe abdominal radiography is a safe and integral method to diagnose megarectum in children with nocturnal enuresis and have used it as a part of our standard care of these patients.

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Effect of rectal distention on lower urinary tract function in children
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Diagnosis and follow-up in constipated children: should we use ultrasound?
J Pediatr Surg
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T. Neveus et al.
Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society
J Urol
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W.L. Robson
Current management of nocturnal enuresis
Curr Opin Urol
(2008)

There are more references available in the full text version of this article.

Cited by (18)

Fecal disimpaction in children with enuresis and constipation does not make them dry at night
2022, Journal of Pediatric Urology
Citation Excerpt :
It can be assumed that the children examined represented a hard-core population that is not directly comparable to our sample. Our results differ even more from those of an American evaluation of 30 patients with enuresis in which it was, surprisingly, found that every single one of them had a distended rectum on plain radiographs and almost all were cured from their enuresis by laxative therapy [29]. This study was retrospective and we suspect that the population was highly biased.
Constipation, daytime incontinence and nocturnal enuresis often overlap. Treatment of constipation has been shown to be an important aspect of therapy for children with daytime incontinence. However, the value of fecal disimpaction, as a part of constipation therapy, in children with enuresis has not been evaluated.
Our aim was to evaluate the antienuretic effect of fecal disimpaction in children with enuresis and concomitant constipation.
The bladder and bowel function was assessed noninvasively in children aged six to ten years who sought help for enuresis for the first time. If they were constipated according to the Rome IV criteria or had a rectal diameter exceeding 30 mm, as assessed by ultrasound, they were given standard evacuation with mini-enemas and macrogol therapy for at least two weeks. Enuresis frequency was documented 14 nights preceding and following therapy.
In total, 66 children (20 girls, 46 boys) were evaluated, 23 (35%) of whom were constipated. There were no differences in age, sex or baseline bladder function between the two groups. The enuresis frequency per two weeks was 9.8 ± 4.1 nights before and 9.3 ± 5.1 nights after constipation therapy (p = 0.43).
This study found that fecal disimpaction in children with enuresis who are also constipated did not alleviate nocturnal enuresis. Bowel problems may still need to be addressed but the child should not be given the false hope that this approach alone will make them dry at night. It might be that evidenced based therapies, such as the enuresis alarm and desmopressin, could be less efficient in children with enuresis and constipation unless their bowel disturbance is first properly addressed.
Fecal disimpaction in children with enuresis and concomitant constipation will, by itself, not make the children dry at night.
Influence of constipation on enuresis
2021, Anales de Pediatria
Clásicamente se ha considerado el estreñimiento como un factor de riesgo de la enuresis, aunque cada vez hay más publicaciones que reportan una prevalencia de estreñimiento similar en enuréticos y no enuréticos.
Determinar la influencia del estreñimiento en la enuresis monosintomática y la no monosintomática y conocer la prevalencia de las 3 entidades así como de disfunciones del trato urinario inferior y disfunción vesicointestinal en la población.
Estudio observacional transversal de prevalencia sobre una muestra representativa de la población gallega de niños y niñas escolarizados de 5 a 9 años. Se realizó una encuesta en los colegios sobre hábitos miccionales e intestinales que incluía las preguntas del cuestionario Paediatric Lower Urinary Tract Scoring System (PLUTSS) de diagnóstico y graduación de las disfunciones del tracto urinario inferior. Se consideró la enuresis según los criterios de la Sociedad Internacional para la Continencia en Niños (ICSS), y si además asociaba sintomatología diurna, se clasificó como enuresis no monosintomática. El estreñimiento se valoró de acuerdo con los criterios Roma III y la escala de heces de Bristol adaptados.
Se incluyeron 772 encuestas en el estudio. La prevalencia de estreñimiento fue del 20%, la de enuresis del 9,1% (enuresis monosintomática 62,9% y no monosintomática 37,1%) y la de disfunción vesicointestinal del 5,2%. Observamos que el estreñimiento no influye en la presencia de enuresis monosintomática, pero sí en la enuresis no monosintomática y las disfunciones del trato urinario inferior, donde constituye un importante factor de riesgo.
Es fundamental el diagnóstico diferencial entre enuresis monosintomática y no monosintomática en la valoración inicial de un paciente enurético, ya que el manejo terapéutico y las características de ambas entidades son diferentes, constituyendo el estreñimiento un factor de riesgo solamente en el caso de las enuresis no monosintomáticas.
Constipation has classically been considered as a risk factor of enuresis, although there are increasingly more publications that report a similar prevalence of constipation in both enuretics and non-enuretics.
To determine the influence of constipation in monosymptomatic and non-monosymptomatic enuresis, and to find out the prevalence of the three disorders, as well the lower urinary tract dysfunction and bladder-bowel dysfunction in the population.
A cross-sectional observational prevalence study on a representative population sample of 5 to 9 year-old school boys and girls of Galicia, Spain. A questionnaire was completed in the schools on urinary and bowel habits, which included questions from the Paediatric Lower Urinary Tract Scoring System (PLUTSS) diagnostic questionnaire and grading of the lower urinary tract dysfunctions. The enuresis was diagnosed using the International Children's Continence Society (ICSS), and if it was also associated with diurnal symptoms, it was also classified as non-monosymptomatic enuresis. The constipation was evaluated using the Rome III criteria and the adapted Bristol stool scale.
A total of 772 questionnaires were included in the study. The prevalence of constipation was 20% and that of enuresis was 9.1% (62.9% monosymptomatic enuresis and 37.1% non-monosymptomatic), with the prevalence of bladder-bowel dysfunction being 5.2%. It was observed that constipation had no influence on the presence of monosymptomatic enuresis, but it did have an influence on non-monosymptomatic enuresis and lower urinary tract dysfunctions, where it was a significant risk factor.
The differential diagnosis between monosymptomatic and non-monosymptomatic enuresis is essential in the initial evaluation of the patient with enuresis, since the therapeutic management and the characteristics of both disorders are different, with constipation only being a risk factor in cases of non-monosymptomatic enuresis.
Constipation in nocturnal enuresis may interfere desmopressin management success
2019, Journal of Pediatric Urology
Citation Excerpt :
Constipation is a common pediatric problem that remains underdiagnosed and poorly treated and thus often leads to severe functional impairment [7]. Some studies are available on the relationship between constipation and enuresis, mainly focusing on the incidence of constipation in enuretic patients [8,9]. However, to authors knowledge, studies about the relationship of constipation in enuretic patients and the efficacy of desmopressin, which is considered as the first-line drug therapy in the management of NE, is lacking.
Previous studies indicated that the prevalence of constipation in enuretic patients is higher than that in the general population. Several studies have revealed that successful treatment of constipation may be helpful in resolving enuresis. However, constipation affecting the efficacy of desmopressin in treating enuresis remains to be clarified.
This study aimed to determine whether the presence of constipation is associated with the efficacy of desmopressin in treating enuresis.
Patients diagnosed with nocturnal enuresis (NE) were studied prospectively. Treatment responses in different stratified groups of patients with NE were compared by Chi-squared tests or Wilcoxon rank sum test. A logistic regression model was performed to investigate the relationship between the possible factors and the effectiveness of desmopressin.
In children with severe enuresis, patients with constipation had significantly lower complete response rate compared with patients without constipation. The presence of constipation was always related to the effectiveness of desmopressin whether in monosymptomatic NE or non-monosymptomatic patients with NE. With stratification for dose of desmopressin, non-constipated patients who received 0.2 mg of desmopressin had significantly higher complete response rate than patients with constipation. However, in subgroups of mild to moderate NE and 0.4 mg desmopressin, constipation was not associated with treatment response of enuresis. Logistic regression analysis revealed that constipation was significantly related to the effectiveness of desmopressin.
This study confirmed the negative effects of constipation in response to desmopressin in patients with NE. To the best of authors knowledge, this work is the first study to evaluate the relationship of constipation in enuretic patients and the efficacy of desmopressin.
The presence of constipation negatively affects the response to desmopressin in patients with NE, especially in patients with severe enuresis and in patients prescribed with low dose of desmopressin.
Children with enuresis
2012, CMAJ. Canadian Medical Association Journal
Urodynamic findings in children with primary refractory nocturnal enuresis: 10 years' experience of a tertiary center
2023, Health Science Reports
Impact of Chronic Functional Constipation on Lower Urinary Tract System: A Cases – Control Study
2022, Iranian Journal of Kidney Diseases

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Pediatric UrologyOccult Megarectum—A Commonly Unrecognized Cause of Enuresis

Objective

Methods

Results

Conclusion

Section snippets

Material and Methods

Results

Comment

Conclusions

J Urol

J Pediatr Surg

Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society

J Urol

Current management of nocturnal enuresis

Curr Opin Urol

Pediatric Urology
Occult Megarectum—A Commonly Unrecognized Cause of Enuresis