Toilet training and elimination behaviour — formative SAQs

SAQ 1 (10 marks)

Parents of a 30-month-old want “strict potty training this weekend” because childcare demands dry pants. The child is not interested in the toilet, still has frequent wet nappies, and becomes distressed when sat for long periods. [1]

1. List readiness signs you will assess before supporting active toilet training. (3) [1]
2. Outline non-punitive counselling and a practical interim plan. (4) [1]
3. When would you reframe this as delayed continence needing medical assessment rather than training pressure alone? (3) [1] [2]

Model answer

Readiness: interest in toilet or potty; longer dry periods; can walk to toilet and sit; can pull pants up/down; can follow simple instructions or signal need; caregiver capacity for calm consistency. [1]

Counselling: explain that forcing before readiness raises conflict without accelerating genuine continence; stop smacking or shaming accidents; use short child-led sits with foot support; praise attempts; pause during major stressors; keep nappy/pull-up backup while practising; set a review rather than a weekend ultimatum. [1]

Reframe toward medical/developmental assessment if regression with red flags, continuous wetting, constipation with soiling, developmental delay suggesting developmental-age thresholds, day and night incontinence with LUTS, or safeguarding concerns from coercive toileting. After chronological thresholds (enuresis ≥5, encopresis ≥4 or developmental equivalent) use disorder pathways rather than training pressure alone. [1] [2]

SAQ 2 (10 marks)

A 7-year-old has primary night wetting several times a week, no daytime urgency, and stained underwear with large hard stools. Parents plan to punish wet nights and ask for a tablet before school camp next month. [2] [4] [11]

1. Classify the elimination phenotype and name the mechanism linking bowel and bladder. (3) [2] [3] [11]
2. Give a stepped non-punitive management plan including camp planning. (5) [4] [5] [6] [9] [12]
3. State two critical safety points for desmopressin if used. (2) [6] [14]

Model answer

Primary monosymptomatic nocturnal enuresis plus retentive encopresis/constipation with overflow. Rectal loading compresses the bladder (bowel–bladder axis) and can worsen urinary symptoms. [2] [3] [11]

Plan: stop punishment immediately; educate that overflow is leakage around retained stool; disimpact then maintain soft daily stools (often PEG 3350 titrated, commonly on the order of 0.5–1.5 g/kg/day depending on phase/product — verify PI) for months; scheduled toileting after meals with foot support; bladder/bowel diary; enuresis alarm for durable dryness once constipation is addressed and family is ready; for camp, desmopressin as short-term dryness if appropriate, then return to alarm pathway. [4] [5] [6] [9] [12]

Desmopressin safety: evening free-water restriction; stop during vomiting/diarrhoea; counsel hyponatraemia warning symptoms (headache, vomiting, seizures). [6] [14]