Elimination disorders — enuresis and encopresis stepped care (MEQ)

(i) Classification. Age thresholds: enuresis ≥5 years; encopresis ≥4 years (or equivalent developmental level). Night wetting never dry = primary nocturnal enuresis; no daytime LUTS suggests monosymptomatic nocturnal enuresis (MNE) in ICCS terms. Underwear staining with large hard stools and withholding = encopresis with constipation and overflow incontinence (retentive), not wilful dirtiness.[1][2][7]

(ii) Assessment. Bladder–bowel diary; constipation screen; growth, abdominal faecal mass, spine/neurology; ADHD screen given inattention/fidgeting; bullying/shame; parental punishment practices; urinalysis if indicated; escalate investigations for red flags (polyuria/polydipsia, continuous wetting, neuro signs, secondary onset with medical features).[1][2][3]

(iii) Management. Stop punishment. Bowel first: education, disimpaction, PEG maintenance to soft daily stools, scheduled toileting after meals, reward sitting/success — ESPGHAN/NASPGHAN-aligned.[6][7] Enuresis: alarm for durable cure if family ready; desmopressin for camp dryness with strict evening fluid restriction and hyponatraemia counselling; imipramine last-line only (cardiotoxicity/overdose).[3][4][5][8] Treat ADHD if confirmed.

(iv) Stigma. Name overflow mechanism to parents/school; no sheet-washing punishments; anti-bullying plan; discrete camp arrangements.[1][3]

(v) Prognosis/disposition. Spontaneous improvement common with age but impairment warrants active care; alarm more durable than desmopressin after stopping; bowel maintenance for months to prevent relapse. Paediatric/continence pathway for medical care; CAMHS for ADHD, family conflict, psychological sequelae.[3][4][5][6]