Elimination Disorders

This article provides a comprehensive overview of elimination disorders, including the specific types, causes, symptoms, and treatment options.

Key Takeaways:

• There are two main elimination disorders: enuresis (inappropriate urination) and encopresis (inappropriate defecation).
• These disorders primarily affect children. Rates tend to decrease each year in childhood and become much lower in adolescence and adulthood.
• Enuresis and encopresis both typically respond well to professional treatment, which may include behavioral interventions, medications, and parent training, among others.

Understanding Elimination Disorders

Elimination disorders involve the inappropriate elimination of urine or feces. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) groups elimination disorders into two general types: ^{[1] [2]}

• Enuresis: Elimination of urine in appropriate places
• Encopresis: Elimination of feces in inappropriate places

Enuresis and encopresis can occur separately or together. Elimination disorders often begin in childhood after an individual is past a certain developmental age. The requirement is at least 5 years old for enuresis and at least 4 years old for encopresis, or equivalent developmental levels.

How Common are Elimination Disorders?

Elimination disorders occur worldwide. Enuresis affects anywhere from 0.7 to 29.6% of children, with around 20% of 5-year-olds and 5 to 10% of 7-year olds affected. Encopresis rates in children range from 0.8% and 7.8%. ^{[1] [2]}

These wide ranges are due to the fact that prevalence changes with age. Specifically, in childhood and adolescence, the prevalence of these disorders decrease at around a rate of 15% per year. ^[3]

Who do They Affect?

Elimination disorders primarily affect children. Most elimination disorders are diagnosed in children aged 7 to 12. However, these disorders can persist into adolescence and even adulthood in some cases, if they are not resolved properly.

In addition, these disorders more often affect boys. Enuresis rates are 2 to 3 times more common in boys than girls, while boys are 3 to 6 times more likely to experience encopresis. ^{[1] [2]}

Types of Elimination Disorders

Elimination disorders are generally grouped into enuresis and encopresis, which are both grouped into specific subtypes.

Enuresis is divided into two main forms:

• Nocturnal only: This involves urination only during the night, particularly during the first third of sleep. It is the most common form.
• Diurnal only: This involves urination issues only during the day and is sometimes referred to as urinary incontinence.

Some individuals may also have both nocturnal and diurnal forms too.

Also, enuresis can be either primary or secondary. Primary refers to a situation where the individual never developed urinary continence, whereas secondary refers to situations where an initial period of urinary continence was established before enuresis symptoms started.

Encopresis is also divided into two main forms:

• Constipation-associated encopresis: In this form, individuals have constipation, which can make stool painful to pass. Thus, they refrain from trying to pass the stool, which can lead to more easily passable stool leaking out around the retained stool. It is the most common form of the two.
• Non-retentive (without constipation) encopresis: This involves inappropriate passing of stool without the presence of constipation or retention.

Just like with enuresis, encopresis can be primary, in which symptoms start without developing fecal continence, or secondary, in which the issues develop after a period of established fecal continence.

Symptoms

Symptoms of elimination disorders generally revolve around inappropriate urination or defecation. The specific symptoms depend on the exact type.

Symptoms of enuresis include:

• Urination during sleep
• Leading to bed wetting
• Inappropriate urination during the day
• Leading to wetting of clothes
• A strong urge to urinate

Symptoms of encopresis include:

• Leakage of stool or liquid stool in underwear
• Involuntary stooling
• Avoidance of bowel movements
• Constipation with dry, hard stool
• Long periods of time between bowel movements

Causes

Elimination disorders may be caused by a variety of physical, psychological, genetic, and environmental factors. Sometimes, however, the exact causes aren’t known, particularly with enuresis.

Enuresis Causes

Enuresis has a strong genetic component. The risk of a child developing enuresis when one or both parents have a history of bed-wetting is 44 and 77%, respectively. ^[1]

Certain conditions can also cause or increase the likelihood of enuresis. For example, constipation can increase bladder pressure and increase the need to urinate. Other abnormalities that may cause enuresis include: ^[1]

• Reduced arousal from sleep
• Making you less likely to wake up to urinate
• Decreased bladder capacity
• Decreased nocturnal antidiuretic hormone (ADH)
• This hormone plays key roles in fluid balance and urine output

There are also specific risk factors for the development of enuresis, such as: ^{[1] [4]}

• High or abnormal stress
• Growing up in a low socioeconomic area
• Parental divorce
• Birth of a sibling
• Being in a larger family

Encopresis Causes

One of the most common causes of encopresis is constipation, which leads to retention of stool. This factor occurs in more than 80% of children with encopresis. ^[2]

There are various reasons one may withhold stool, such as: ^[2]

• Avoiding unpleasant sensations
• Hard, painful bowel movements
• Reluctance of using a toilet at school due to:
• Lack of time
• Privacy concerns
• Worries about restroom cleanliness

Less often, physical or medical conditions can directly affect the bowel’s ability to function properly, which can also cause encopresis. Examples of these organic causes include: ^[2]

• Spinal cord trauma
• Cerebral palsy
• Dysfunctional muscles of the pelvic floor and/or external anal sphincter
• Repaired anorectal malformation

Lastly, known risk factors may increase the likelihood of encopresis, including: ^{[2] [4]}

• Unhygienic toilets
• Living in an urban area or war-affected zone
• Bullying
• Psychological or behavioral problems, such as:
• Anxiety
• Depression
• Aggression
• Disruptive and oppositional behaviors
• Hyperactivity

Can Elimination Disorders Develop in Adulthood?

Elimination disorders can develop in adulthood, although this is rare. More often, when looking at cases of elimination disorders in adulthood, these started in childhood and then persisted into adulthood.

Risks and Complications

Elimination disorders pose a number of possible risks and complications, especially related to psychological well-being and overall mental health.

Enuresis Complications

Children with enuresis may experience feelings of shame, guilt, or embarrassment, as well as bullying from others, particularly if the episodes occur at school. These effects can lead to decreased self-esteem and mental well-being. Individuals with enuresis also have higher levels of attention problems, aggression, and social problems. ^{[1] [3]}

Enuresis may also lead to physical complications too, such as genitourinary skin infections or rashes. It can also contribute to financial stress due to the need for frequent clothing replacements. ^[1]

Encopresis Complications

Just like with enuresis, children with encopresis also often experience shame, guilt, embarrassment, and/or bullying from others. They often also have higher levels of anxiety, depression, social withdrawal, aggression, impulsivity, and defiance. ^[2]

Encopresis may also negatively impact family relationships, school performance, and social functioning. And similar to situations of enuresis, financial strains may also result. ^{[2] [3]}

Diagnosing Elimination Disorders

Diagnosing elimination disorders requires a comprehensive medical history, physical exam, and implementation of specific diagnostic tools.

Diagnosing Enuresis

For enuresis, the physical exam may include specific tests to rule out other conditions, such as: ^[1]

• Urinalysis: to rule out urinary tract infection
• Bladder scan: if anatomical causes are suspected
• Sleep study
• Abdominal X-ray: if constipation is suspected

Your doctor will also gather information about your child’s toilet training, nutrition, sleep histories, and family history of enuresis. A voiding diary may also be used to track the episodes of urination, ideally for at least three days. ^[1]

Diagnosis of enuresis is based on the criteria established in the DSM-5, which are: ^[1]

• Repeated urination into bed or clothes, whether involuntary or intentional
• Behaviors are clinically significant due to either:
• Frequency of at least twice a week for 3 consecutive months or
• Clinically significant distress
• Impairment in social, academic, or other important functional areas
• Age of 5 years old (or equivalent developmental level)
• Behaviors are not due to substance use or a medical condition

Diagnosing Encopresis

For encopresis, a detailed history is required, including for medical history, diet, characteristics of the problems, trauma, stress, and other relevant factors.

A physical exam is also used to further understand the issues and to rule out other causes. The exam may include: ^[2]

• Abdominal examination
• Perianal area inspection
• Digital rectal assessment
• Anal sphincter functionality and anatomy assessment

Diagnosis of encopresis is based on the following DSM-5 criteria: ^[2]

• Repeated defecation into inappropriate places (e.g. clothes, floor), whether involuntary or intentional
• At least one episode occurs per month for at least 3 months
• Age is at least 4 years old (or equivalent developmental level)
• Behaviors are not caused by a substance or medical condition, except in cases of constipation

Treatment Options

A variety of treatments can help with elimination disorders. Listed below are the treatments for enuresis and encopresis.

Enuresis Treatment

Enuresis can be treated through non-pharmacological or pharmacological means. Also, it’s important to note that treatment is rarely used if a child is less than 7 years old.

Examples of non-pharmacological treatments include: ^[1]

• Bell and pad method: In this method, a pad is placed beneath the bed sheets (or in the child’s underwear) and is connected to an alarm system, which sounds whenever the pad becomes wet.
• Planned nighttime awakenings: These are deliberate wake-ups of the child to help encourage nighttime urination, if they don’t respond to the alarms
• Restricting fluids before bedtime
• Bladder control training

Pharmacological treatments for enuresis include: ^[1]

• Desmopressin, which is an ADH
• Imipramine, which is a tricyclic antidepressant

Non-pharmacological measures are typically more effective and recommended as first-line treatments.

Encopresis Treatment

Treatment for encopresis differs between retentive and non-retentive forms.

In retentive encopresis, constipation is very often the root cause. Thus, treatments are targeted at resolving constipation. This includes: ^[2]

• Oral use of laxatives, such as:
• Polyethylene glycol
• Lactulose
• Magnesium hydroxide

Along with this, preventive strategies are used, such as: ^[2]

• Eating a healthy, balanced diet
• Positive feedback and reinforcement from parents
• Addressing comorbid mental or behavioral issues
• Biofeedback training: This teaches children how to control their bowel movements to make them more comfortable and efficient

Final Thoughts

Elimination disorders can cause significant distress for children, as well parents/caregivers. Fortunately, enuresis and encopresis can be treated, especially with early intervention. This reduces the chance of elimination disorders persisting into later stages, while promoting better psychological well-being and life functioning. If you suspect your child may have an elimination disorder, make sure to seek out professional treatment.

Author

Jack Cincotta

Jack Cincotta holds a M.S. degree in Psychology. He is also a board-certified holistic health practitioner through AADP and an AFPA-certified holistic health coach and nutritionist.

Activity History - Last updated: March 19, 2026, Published date: March 19, 2026

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Reviewer

Kaye SmithPhD

Dr. Smith is a behavioral health coach, clinician, writer, and educator with over 15 years of experience in psychotherapy, coaching, teaching, and writing.

Activity History - Medically reviewed on March 22, 2026 and last checked on March 19, 2026