text:
Primary Care Pediatrics
1st Edition
© 2001 Lippincott Williams & Wilkins
Enuresis and Encopresis
William J. Discipio PhD
The current state of scientific knowledge about childhood dysfunctions or delays in bladder and bowel training suggests that good standards of pediatric practice should be proactive. The primary care provider needs to be knowledgeable about advances in early interventions, selecting treatments on an empirical footing. There is no longer a sufficient basis for ignoring the problem, treating with "tincture of time," or waiting for the child to "grow out of" a presenting problem of self-limiting or monosymptomatic urinary or bowel incontinence.
Most children are physiologically and psychologically ready for successful toilet training before age 4 years, some as early as 18 months. Cultural and familial determinants of the initiation of toilet training vary greatly, with few to no effects on later continence. Persistent failures to achieve diurnal and nocturnal urinary control may signal a need for medical or psychological intervention. The primary care provider should actively investigate the problem, especially if it is raised as a problem by the family. Similarly, the provider needs to intervene if the child experiences the negative psychological impact of not keeping up developmentally with siblings or peers. Chronic and persistent voiding dysfunction associated with high intravesicle pressure and postvoid residual urine can also contribute to infection, bladder decompensation (trabeculated interior), ureteral reflux, hydronephrosis, and ultimately renal failure.
Although the statistical prevalence of serious systemic or psychiatric disorders is low, the difficult-to-train child may be presenting important but subtle diagnostic cues implicating the interaction of the central and autonomic nervous systems. To find a treatment strategy for what is either a psychophysiologic or functional disturbance, the provider must rule out many different causes for the training lag. Cross-disciplinary consultation or referral may be appropriate from specialists in either pediatric urology or behavioral psychology.
Problems of storage and elimination of waste in children pose medical and secondary psychological adjustment and coping problems. The etiology is multidetermined. Therefore, wetting and soiling must be seen as symptoms to be investigated before an efficacious choice of treatment can be made. Incontinence symptoms in children are generally referred to as enuresis (poor bladder control) and encopresis (poor fecal control). These symptoms are rarely indicative of complete loss of function. Obvious lesions or limitations of the central nervous system (CNS) may be present, such as cerebral palsy, severe mental retardation, autism, psychosis, attention deficit disorder, or seizure disorder. In cases in which no primary physical or severe psychiatric diagnosis is present, a functional, or more accurately stated, psychophysiologic, diagnosis is reached by careful elimination of other differential causes for the incontinence. This chapter provides a framework for differentiating organic from functional causes of incontinence, while guiding the provider in appropriate treatment and referral.
Normal Bladder Function
Storage and elimination of urine in the infant bladder is entirely an autonomic function, without inhibitory or volitional control connections to the CNS. The bladder itself is composed of smooth muscle, while the length of the urethra contains an increasing presence of striated muscle as it projects distally from the bladder. As the bladder wall accommodates expansion in the storage process, a trigger threshold of fluid capacity is reached. An afferent neural message is sent through the pudendal nerve to sites at S2, S3, and S4, where a synapse is activated with nerves that innervate efferent muscles. Additional neural pathways connect this reflex with regions in the pons and detrusor motor nucleus. The bladder normally contracts in synchrony with the relaxation of sphincter muscle, expelling urine in one continuous stream. When bladder control persists in this automatic fashion in the absence of physical causes, such as a primary disease affecting the nervous system, the child is said to have a pediatric unstable bladder or bladder displaying uninhibited contractions. This can result in a chronic day or night wetting problem.
Primary Diurnal Enuresis
A child who does not show complete daytime urinary continence often experiences repeated and unexpected contractions of the bladder (primary diurnal enuresis [PDE]). These contractions result in intermittent wetting episodes, with accidents occurring at small capacities. Such a youngster has never been dry for a continuous 3-month period. In the presence of an intact nervous system, the child does not respond to a sensation of a gradient of bladder filling but rather will perceive a sensation of the bladder muscle in contraction. In the young child, the most readily available compensatory response to an uninhibited bladder reflex is a volitional contraction of the external sphincter muscles. The child eventually learns to apply pressure on the perineal area by crossing the legs and squeezing the thighs together or performing a "squatting" maneuver by sitting on the heel of one foot. At best, the child is able to inhibit some but not all of the urine flow, because the compensatory maneuver is initiated only after the bladder has begun an uninhibited contraction.
Clinical Warning
Wet underpants or remaining in diapers for protracted periods may contribute to the risk of bacterial
migration through the urethra to the bladder. Recurring urinary tract and bladder infections, especially in girls, will in turn exacerbate dyscontrol of the bladder and sphincter muscles.
Primary Nocturnal Enuresis
Bedwetting is a relatively common problem that frustrates children and parents long after daytime continence has been achieved. Although the condition most often appears as a monosymptomatic, nonorganically based problem, the psychological impact and persistence of the problem over many years must and should be addressed with active treatment interventions.
• Clinical Pearl
Genetics is now known to play a major role in the etiology of bedwetting. If the provider identifies family members who were symptomatic as children, a reasonable prediction can be made as to the age at which the patient will achieve spontaneous remission.
Many myths have been constructed about the causes and cures of primary nocturnal enuresis (PNE) that are based on coincidence and faulty logic. These myths have evolved because of the pervasive epidemiology of the problem combined with unpredictable spontaneous remission rates. Speculation has therefore included small functional bladder capacity, dietary influences, allergies, and excessive water intake as examples of mechanisms underlying the incontinence. To date, there is no support that any of these factors is explanatory of a single underlying cause. Although early studies have been confirmatory of small functional bladder capacity, the occurrence of bladder retention in some patients can also occur, especially in the presence of a mild daytime unstable bladder component (
Shima et al., 1998
Medel, Ruarte, Castera, & Podesta, 1998
). These children may have learned an overcorrective maneuver by chronic tightening of perineal muscles to overcome any symptoms of diurnal urine loss.
• Clinical Pearl
A retentive pattern of bladder capacity may also be manifested in bowel retention or "sluggish" and inconsistent bowel habits.
Loening-Baucke's (1997)
study adds evidence to this retentive pattern. He found that remission of nocturnal enuresis occurred by simply treating the subclinical constipation.
Explanatory mechanisms involving bladder storage have explored the notion of small functional bladder capacity interacting with high urine production at night (
Rasmussen, Kirk, Borup, Norgaard, & Djurhuus, 1996
Djurhuus & Rittig, 1998
). Conclusive evidence on this point has proven to be equivocal. Exceptions to the small functional capacity model are frequent, especially as children get older and often decrease their frequency of voluntary daytime voids because of previously acquired annoyance associated with trips to the bathroom.
Norgaard, Djurhuus, Watanabe, Stenberg, and Lettgen (1997)
implicated hormonal influences by studying bladder capacity with attention to rate of urine production and urine osmolality. Their findings built on work of a decade earlier, when they documented the presence of an insufficient nocturnal antidiuretic control in some patients with PNE, who were also usually treatment resistant (
Norgaard, Pedersen, & Djurhuus, 1985
Wide-scale distribution of DDAVP, a synthetic form of vasopressin, has shown the drug's dramatic immediate effects on abating PNE. Recurrence of symptoms after the drug is withdrawn is high, however, suggesting that a pharmacogenic solution is not likely to "jump-start" the youngster who may have a vasopressin deficiency.
Clinical Warning
Because DDAVP will lower kidney production of urine in all children, validation of a hormonal imbalance is not conclusively proven by the action of this particular medication.
Depth of sleep is another competing controversy in the pursuit of an etiologic model for PNE. Many parents and primary care providers have assumed that the bedwetter sleeps too deeply and therefore cannot respond to full bladder cues to awaken and toilet at night. A contradictory view is apparent when one considers that very few normal children awaken at night to void, and if they do, such awakening might be considered a pathologic symptom of nocturia. In addition, children sleep more deeply than adults. This fact might result in a false conclusion that the child is an abnormally deep sleeper when a parent tries to awaken the child to void and keep the bed dry. For many years, studies monitoring electroencephalograms (EEG) and enuresis showed no relationship between depth of sleep and enuretic events in the absence of a known paroxysmal or primary seizure disturbance (
Wolfish, Pivik, & Busby, 1997
Conversely, increasing numbers of recent scientific reports suggest that a possible deficit in CNS arousal underlies PNE (
Kawauchi et al., 1998a
Watanabe, Imada, Kawauchi, Koyama, & Shirakawa, 1997
). Clinical observations confirming that arousal factors may be implicated include the tendency for the child with PNE to sleep dry on occasion when going to bed very late or sleeping in a different bed when away from home (eg, at sleepovers or at relatives' houses).
Jenkins et al. (1996)
Neveus, Lackgren, Tuvemo, and Stenberg (1998)
found that children with PNE were indeed harder to bring to full awakening than a nonenuretic population. PNE has also been classified along the lines of arousability by sleep researchers who propose three distinct clinical groups (
Watanabe, 1998
Imada et al., 1998
Type I: Detectable change in EEG activity in response to bladder distension and stable cystometrograms
Type IIa: No detectable change in EEG; stable cystometrograms
Type IIb: No detectable change in EEG; unstable cystometrograms only during sleep
Kawauchi et al. (1998b)
propose that type I may involve an immaturity in the function of the thalamus, while type IIa may implicate the pons or the lower urinary tract. Type IIb most closely resembles a neurogenic bladder profile. Refer to
Chapter 62
for more information about the use of medications in managing PNE.
Functional Encopresis
Chronic encopresis is mostly an outcome of functional or behavioral causes for stool retention or inappropriate bowel elimination habits. Physical causes or syndromes are consequently an unlikely reason for a child's encopresis. An exception is Hirshsprung's disease, which is an anatomic basis of stool incontinence. Hirshsprung's disease is often apparent at birth or is identified long before the child is seen for encopresis. Other problems involving the integrity of the rectal sphincter and spinal cord innervation also must be considered before accepting a functional cause for incontinent stool loss. Children with functional encopresis (FEN) do not have identifiable anatomic malformations or neurogenic lesions. Abnormal pudendal nerve function, which often
contributes to fecal incontinence in adults, does not appear to be implicated in FEN (
Sentovich et al., 1998
The most common presentation of encopresis is a minor stool loss or staining of the underpants ("skid marks") accompanied by retentive toileting habits. Stool retention results in the compaction of large amounts of hard feces in the lower bowel. The passage of loose stool from farther up the intestine is then allowed to "leak" between the hardened stool and the wall of the lower bowel. Many parents mistake the cause of soiled underpants as being related to poor hygiene or wiping technique.
• Clinical Pearl
Dietary intake of fiber is likely to be very poor in these children, contributing to their fecal impaction.
Primary Diurnal Enuresis
About 1% to 5% of children are believed to experience daytime wetting in the absence of physical findings, including bacterial infection of the lower urinary tracts (
Bower, Moore, Shepherd, & Adams, 1996
). However,
Swithinbank, Brookes, Shepherd, and Abrams (1998)
reported that a recent survey of 1176 healthy English school children revealed prevalence estimates as high as 12% for day wetting in children aged 11 to 12 years. Nevertheless, the prevalence is much greater in girls than boys. This sex difference is probably related to higher incidence of chronic urinary tract infections (UTIs) seen in girls with PDE, secondary to the shorter urethral distance in girls, which may carry bacteria to the bladder.
Primary Nocturnal Enuresis
Primary nocturnal enuresis occurs in about 10% of all 5-year-old children who are otherwise normal in all other developmental functions. This estimate would include from 5 to 10 million children in North America. The National Kidney Foundation estimates that 5 to 7 million children age 6 years or older have PNE (1999). The prevalence rates vary among cultures, although the condition is documented among all cultures and racial groups (
Kalo & Bella, 1996
Trombetta, Savoca, Siracusano, & Liguori, 1997
Chiozza et al., 1998
Chao et al., 1997
Yeung, 1997
Serel et al., 1997
Popper & Steingard, 1996
Byrd, Weitzman, Lanphear, & Auinger, 1996
It is estimated that up to 70% of children with PNE have a primary relative who shares that history. There is also a 67% concordance rate for identical twins. Recent discoveries of genetic markers for PNE have clearly established a genetic basis of PNE (
Hublin, Kaprio, Partinen, & Koskenvuo, 1998
von Gontard, Eiberg, Hollmann, Rittig, & Lehmkuhl, 1997
von Gontard et al., 1997
Arnell et al., 1997
Eiberg, 1998
von Gontard, Eiberg, Hollmann, Rittig, & Lehmkuhl, 1998
The most conventional criterion for diagnosing PNE is wetting the bed on average at least two times per month. The number of children remitting without treatment is about 15% per year, which reduces the prevalence to 1% by puberty (
Petrican & Sawan, 1998
). When considering whether PNE will persist into adulthood,
Hjalmas (1997)
asserts that, if not treated, 10% of these youngsters will persist with PNE for life.
Special needs children have higher rates of PNE. This is especially true for youngsters diagnosed with attention deficit disorder with hyperactivity (ADHD). PNE in such children may in part be related to a "hyperactive" bladder or to behavioral problems encountered in toilet training. These problems may have emerged because of attentional impediments to efficient learning. Pervasive and chronic hyperactivity of the parasympathetic nervous system may also pay a role in uninhibited bladder contractions (
Yakinci, Mungen, Durmaz, Balbay, & Karabiber, 1997
). Refer to
Chapter 21
for more information on diagnosing and managing ADHD.
• Clinical Pearl
It is a good idea to assess for PNE when ADHD is identified (
Robson, Jackson, Blackhurst, & Leung, 1997
Functional Encopresis
Prevalence rates of FEN are frequently underestimates of actual occurrence. This may be a result of mild forms of stool loss going unnoticed or being tolerated by family members. Reasons for this tolerance may be multidetermined and can involve individual family and culture-bound attitudes toward hygiene or the belief that stool loss is not a treatable, medical symptom.
A well-informed parent or guardian is invaluable in establishing a confirmatory history of PDE, PNE, or FEN. A family history of wetting problems in parents or any primary relative is very helpful in identifying the genetic basis of many forms of functional bowel and bladder disturbances. A thorough but noninvasive routine evaluation for enuresis and encopresis starts with a structured interview, as demonstrated in
Display 63-1
Display 63-2
, and
Display 63-3
DISPLAY 63–1 • Intake Questionnaire for Nocturnal Enuresis
Has your child had nighttime wetting (bedwetting) or wetting after falling asleep at any time about twice a week or more for at least 3 consecutive months?
Has your child never been dry for 3 or more months?
Did the bedwetting start after you or your child experienced a major life event, such as a divorce, birth of sibling, hospitalization, or any other stressor?
Do you think the bedwetting is caused by a medical condition or the effect of drugs your child is taking?
Do you think the bedwetting is caused by your child's always being thirsty, resulting in excessive drinking?
Do you think bedwetting is caused by something your child eats or by fussy or selective dietary habits?
Do you think the bedwetting is caused by deep sleep?
Do you think the bedwetting is caused by nightmares, night fears or terrors?
Do you think that your child is just too lazy to get out of bed when he or she has to go at night?
Does your child usually wet more than once during the night?
Does your child help with changing the wet bed?
Does your child ever get up on his or her own to go to the bathroom during the night?
Does your child have a regular bedtime?
Does your child have trouble falling asleep?
Psychological Symptoms
Do you think your child is old enough to start treatment for bedwetting?
Does stress or other emotional problems seem to bring about or worsen the bedwetting?
Does your child try to hide or deny the bedwetting took place?
Is it very difficult to awaken your child?
Does your child miss going to overnight visits with friends or sleep-away camp because of the bedwetting?
Do you use a diaper, pull-ups, or special panty or pad for your child at night?
Does your child have his or her own room?
Do you think your child really wants to stop bedwetting?
Family Incidence
Did anyone in your family (including yourself) or your spouse and his or her family wet the bed?
Do you have other children who are or were bedwetters?
If someone in the family wet the bed, did the wetting stop before the age of 12 years?
Treatment History
Have you tried rewards for a dry bed?
Have you tried punishment for a wet bed?
Have you tried restricting fluids before bedtime?
Have you tried asking your child to retain or hold in urine after feeling a sensation to urinate during the day?
Have you tried awakening your child for toileting?
Have you tried medication?
Have you tried different foods or diets?
Have you tried a bell and pad or any kind of a urine sensor or wetting alarm?
Has your child been seen by a mental health therapist or received psychological help for bedwetting?
Has your child been evaluated or treated by a medical doctor, such as a pediatrician or pediatric urologist, for bedwetting?
DISPLAY 63–2 • Intake Questionnaire for Diurnal Enuresis
Has your child had damp underpants or daytime wetting twice a week or more in the past 3 months?
Does your child often seem to go to the bathroom after experiencing a strong urge?
Does your child seem to hold back urine and not go to the bathroom unless prompted?
Does your child often push and strain when trying to urinate?
Does your child show signs that he or she has to urinate, such as squirming, dancing, face turning red, squatting, or any movements or posturing?
Would your child rather play with friends than take time out for urinating, even when he or she experiences a strong urge to go?
Does your child experience pain, discomfort, or burning when urinating?
If you ask your child to urinate just after he or she finishes going, will he or she produce an unexpectedly large amount?
Do you have other children who are or were daytime wetters?
Urologic History
Has your child ever had a urinary tract or kidney infection?
Has your child been diagnosed or treated for any bladder, kidney, or urinary tract problem?
DISPLAY 63–3 • Intake Questionnaire for Encopresis
Has your child soiled or had a bowel movement in his or her underwear one or more times in the past 3 months?
Does your child ever skip 1 or more days between bowel movements?
Does your child tend to have constipation or hard stools?
Do you give your child laxatives, stool softeners, mineral oil, or enemas to help with bowel movements?
Has your child been diagnosed or treated for any bowel or gastrointestinal problem?
• Clinical Pearl
The provider may find that it is difficult to establish the history of the onset and pattern of wetting/soiling episodes reliably in one interview. Follow-up charting of base rates of daytime and nighttime symptom events is often required for a minimum of a 1-week period.
A thorough physical examination should be performed, with urine obtained for analysis and culture. The provider should also order a bladder ultrasound if poor bladder emptying or an unusual urinary stream (eg, intermittent flow) is known or suspected (
Lettgen, 1997
Kawauchi, Kitamori, Imada, Tanaka, & Watanabe, 1996
Pippi Salle et al., 1998
The clinician may find that child and parents have a limited accuracy for recalling soiling episodes. This is common, underscoring the need for the collection of prospective data (
van der Plas, Benninga, Redekop, Taminiau, & Buller, 1997
). Parents are often not aware of damp or soiled underwear during school hours and do not take note of their presumably trained youngster's daily bowel movement activities.
Primary Diurnal Enuresis
Children with PDE wet themselves during the day, in the absence of anatomic, neurologic, infectious, or pharmacologic iatrogenic causes. The differential diagnosis must also rule out causes secondary to family stressors, child abuse, or psychiatric crises (secondary diurnal enuresis). The problem of daytime wetting is usually characterized by small losses of urine throughout the day, although the cumulative loss may be greatest in the late afternoon and evening when the
bladder may be fatigued or liquid intake is at a maximum. The actual incontinent episode is associated with a reflexive partial bladder contraction and is not a result of incompetent sphincter function. "Squatting" maneuvers or obvious physical signs that the child is trying to inhibit a full bladder contraction are evident in 3- to 5-year-olds. Older children show more skill at unobservable urethral striated muscle contraction, keeping their perineal muscles at a chronically high resting potential.
• Clinical Pearl
UTIs are not uncommon in PDE, and they may be accompanied by symptoms of dysuria. These include marked urgency or frequency and burning or painful urination. In some cases, an odor may be noted by the parent and changes in mood, irritability, or unexplained fever. On the other hand, UTIs may also be asymptomatic. It would be wise to require periodic cultures, particularly after one episode of documented UTI.
Primary Nocturnal Enuresis
"My child wets the bed" is usually not reported as early as the daytime wetting of the child with PDE, because the latter condition is more socially distressing and may be accompanied by a symptomatic UTI. Many parents wait until at least school age (5 years) or later, when social demands, such as sleep-overs or sleep-away camp, necessitate attention to curing the bedwetting problem. Additional intrafamilial pressures, such as the competition imposed by dry siblings who may be younger than the bedwetter, also drive the need to seek treatment.
The following inclusive evidence confirms the diagnosis of PNE:
Positive family history for PNE, and
Persistent bedwetting at least two times per month for several months or 1 year and never dry for 3 months of consecutive nights
Exclusionary criteria for diagnosis include the following:
Medical or pharmacologic causes
Presence of psychological or traumatic causes or onset after a 3-month period of dryness (secondary nocturnal enuresis)
Diagnosis of mental retardation (
Spee-van der Wekke, Hirasing, Meulmeester, & Radder, 1998
), autism (
Taira, Takase, & Sasaki, 1998
or other arrested condition of mental development that has contributed to difficulty in acquiring learned toileting behavior
Functional Encopresis
Functional encopresis is a disturbance of bowel elimination involving the involuntary loss of formed or liquid stool after the age of culturally acceptable limits of toileting training. A pattern of sluggish bowel movement behavior is almost always associated with FEN. The American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders
, fourth edition (1994), describes this subtype as encopresis with constipation and overflow incontinence. A secondary subtype, described as encopresis without constipation and overflow incontinence, involves more volitional behavior that may accompany an additional psychiatric diagnosis of oppositional defiant disorder in young children and conduct disorder in older children. The possibility of a psychotic disorder may also be implicated, as might anxiety syndromes or symptoms associated with severe sexual abuse or sodomy.
The following inclusive evidence confirms the diagnosis of FEN:
Stool soiling occurring at least once a month and persisting for several months in the absence of diarrhea secondary to a medical condition or inappropriate use of laxatives, stool softeners, or lubricants, such as mineral oil
Exclusionary criteria in the diagnosis of FEN include the following:
Encopresis secondary to a medical cause, such as Hirschsprung's disease, anal or rectal malformation or trauma, spinal cord anomalies (mylomeningocele) or spinal cord injury, cerebral palsy, mental retardation, or physical abuse
Encopresis secondary to side effects of medication, such as antibiotics (
Loening-Baucke, 1996
Functional encopresis may also be considered as a diagnosis from either a primary or secondary perspective.
Foreman and Thambirajah's (1996)
examination of boys who failed to establish toilet training (primary FEN) provided evidence that these children had a greater likelihood to have developmental delays and PNE. Conversely, boys who displayed a breakdown in previously established toilet training (secondary FEN) were more likely to present with symptoms consistent with an excess of psychosocial stressors. They were also more likely to have the comorbid diagnosis of conduct disorder. The reader should refer to
Chapter 21
Chapter 23
Chapter 26
Chapter 27
, and
Chapter 28
for a more in-depth examination of these issues.
Bladder instability has long been thought to play a central role in the etiology of chronic diurnal enuresis (
Chandra, 1998
). A mechanistic approach to understanding diurnal enuresis as bladder instability carries considerable intuitive validity because the child seems to be caught off-guard when unexpected bladder contractions occur. These contractions lead to otherwise unexplained symptoms of urgency, frequency, and compensatory squatting maneuvers.
The first empirical evidence for this hypothesis was documented by
McGuire and Savastano (1984)
Firlit, Smey, and King (1977)
in urodynamic studies that showed uninhibited contractions when filling the bladder using urethral catheters or suprapubic vesicle tubes. The limitations of these urodynamic studies include iatrogenic effects of the intrusive nature of the tests, which may have produced artifactual pathogenic findings. There is also the likelihood that patients selected for comprehensive urodynamic study are the more serious cases who have not responded to conservative treatment, so they may represent an occult neurogenic group. In addition, bladder suppression by pharmacogenic agents, such as oxybutynin often results in improvement of wetting symptoms. The effect is usually only temporary, affording symptom relief but not a final solution to the problem. Because the diurnally enuretic child displays behaviors similar to children with identifiable
neurogenic lesions, this syndrome has been labeled the non-neurogenic neurogenic bladder and the pseudoneurogenic bladder (
Hanna et al., 1981
) or is referred to in the urologic literature as the Hinman syndrome (
Hinman, 1986
A contrasting and more recent hypothesis to explain diurnal wetting and comorbid chronic UTIs is the focus on the overtightening of the perineal floor as the primary mechanism. Children demonstrating bladder-sphincter dyssynergia while voiding are using the striated sphincter in an inefficient and maladaptive fashion, preventing the free flow of urine through an obstructed urethra. Collateral afferent pathways connect the external urinary sphincter with the bladder, which may result in further disruption of bladder functioning by inhibiting the full contractile reflex of the bladder. A partial bladder contraction will cause postvoid residual urine, a condition often seen in children with the Hinman syndrome. The sequela of postvoid residual urine often optimizes the conditions for bacterial growth, adding to the risk of bacterial infection introduced in chronically wet underpants. Biofeedback treatment raises cognitive awareness of the bladder-sphincter dyssynergia problem. Biofeedback has provided confirmatory evidence that the pelvic floor is a salient factor in cause and cure of the problem (
Herndon, McKenna, Connery, & Ferrer, 1998
Further helpful, relatively nonintrusive diagnostic measures for studying PDE or bladder-sphincter dyssynergia include measurement of the hydrodynamics of the urinary stream (flow study) and electromyographic recordings of the perennial floor during voiding with external skin electrodes. These measures are relative easy to perform when good rapport is established with the child. The parent may be present during these tests, which require the child to be alert and fully cooperative. The tests should follow any urine analyses or culture but may prove helpful even before deciding to perform an intravenous pyelogram (IVP), voiding cystourogram (VCU), or cystometrogram.
• Clinical Pearl
Most chronically wetting or soiling children will not require more intrusive methods for diagnosis, such as radiologic studies (IVP, VCU), magnetic resonance imaging, bladder cystoscopy, or rectal manometry (
Kawauchi et al., 1996
Pippi Salle et al., 1998
Clinical Warning
Either bladder cystoscopy or rectal manometry or both should be considered only if there is reason to suspect uropathology, such as urethral stenosis, neurogenic bladder, ectopic ureter, or duplicated urethra (
Hoebeke, Van Laecke, Raes, Vande Walle & Oosterlinck, 1997
Robson, 1997
Liu, Yeung, Lee, & Ku, 1996
). Children with these conditions should be referred to pediatric specialists in urology, nephrology, neurology, or gastroenterology.
Although a child's developing self-esteem and social functioning may be at risk as the child grows older, PNE usually does not have comorbid primary psychiatric components (
Friman & Jones, 1998
). Psychiatric concerns most often arise with secondary forms of enuresis. A child who has experienced a period of complete and successful toilet training of at least 3 months and resumes wetting may be exhibiting a psychological sequella of faulty stress-coping mechanisms. These faulty mechanisms may follow post-traumatic stress disorder or sexual or physical abuse (
Faust, Kenny, & Runyon, 1997
). Referral to a mental health professional is warranted. Such referral is especially important if the urologic symptoms are comorbid with signs of behavioral distress, depressive ideation, or poor parenting conditions (
Geroski & Rodgers, 1998
Efficacious treatment options of incontinence are varied. They may be classified as follows:
Psychological—any methodology aimed at retraining bladder or bowel functioning, assisting the family with behavioral management, or counseling patient and family regarding prognostic and preventive measures and collaborative treatment with the assistance of a behavioral psychologist or urologic nurse specialist
Medical—all prescriptive pharmacogenic approaches and special instructions concerning advisability of altering intake of fluids; restricting caffeine and carbonated sodas; use of laxatives, stool softeners, and lubricants, such as mineral oil
Conversely, symptoms or treatment response may point toward the need for referral, enlisting the assistance of a medical specialty when birth defects, neuropathology, or comorbid medical or psychiatric conditions are known or suspected.
• Clinical Pearl
Referral is an appropriate treatment option if symptoms do not abate after primary medical and prescriptive behavioral interventions have failed.
The child whose only symptom is nocturnal enuresis should be evaluated by both interview and prospective symptom observation. Parents should be asked to chart signs of diurnal urinary problems. These problems include diurnal frequency, retention, and wetting. Busy families often overlook minor occurrences of these symptoms. Children find ingenious ways of hiding or denying these annoying, socially intrusive manifestations. If any symptoms are present, the seven-void program is recommended. Stabilization of daytime voiding habits can contribute to better treatment response in a nocturnal program. Treatment gains and successful participation can lead to positive rewards, not the least of which is continence.
Corrective behavior modification interventions, such as establishing a controlled voiding program, should be suggested by the primary care provider if the initial clinical interview reveals the presence of minor encopretic events (soiling) or retentive bowel habits (skipping one or more days without a bowel movement). Return clinic visits should be scheduled over the full course of active behavioral contingency management. Visits may be spaced at increasingly longer intervals as progress is achieved in alleviating symptoms.
• Clinical Pearl
If the program becomes too time-consuming for the clinician to instruct and monitor, referral to a behavioral psychologist may be wise.
The child with diurnal enuresis is most likely to be seen first by the primary care provider. Referrals are often made because family distress is driven by social embarrassment and stigma, rather than because of presentation of "medical" symptoms or distress. The clinician should remember that many children with diurnal enuresis have UTIs. The clinician must also consider whether to treat for an acute event or, if the UTI is not the first one, whether to continue medication prophylactically. Long-term use of antibiotics must be weighed against the possibility of breakthrough infections. Such infections render one medication ineffective and potentially exhaust options for using other agents.
Figure 63-1
presents a diagnosis-to-treatment algorithm that the primary care provider may find helpful in managing or choosing to refer enuresis and encopresis in children.
Figure 63-1
Diagnostic, treatment, and referral flow chart.
• Clinical Pearl
If an active UTI is confirmed, the first priority is to treat the infection with antibiotic pharmacotherapy. Refer to
Chapter 40
Chapter 62
for other examples of appropriate pharmacotherapy, including age-appropriate choices.
Approaches to Bladder Retraining
Psychological approaches to retraining toileting behavior are not recommended during the course of an active infection. However, some form of training or efforts at normalizing voiding and defecating schedules should begin immediately after bacterial growth is arrested and symptoms have abated. A voiding schedule for children ages 5 to 12 years would require about seven voids per day. This frequency is slightly more than the normal rate of two to five voids per day. The increased programmed voiding program is aimed at optimizing bladder emptying by avoiding overdistention and reaching trigger capacity. This is because excessive urine storage may contribute to uninhibited contractions and wetting.
Biofeedback therapy is an appropriate option if there is clear documentation of either a bladder-sphincter dyssynergia or an inability to empty the bladder to completion. The method requires specialized equipment and trained biofeedback therapists who have experience working with children. Elimination of bladder-sphincter dyssynergia is accomplished, in part, by raising awarenenss of volitional control of the sphincter muscle while reducing overactivity of abdominal muscles. External electrodes are pasted on the perianal skin and abdominal areas, and the child is taught a computer assisted Kegel exercise. Emptying to completion may also be trained by combining electromyographic feedback with pre-and post-voiding bladder sonography and uroflowmetry (
Pfister, et al., 1999
Porena, Costantini, Rociola, & Mearini, 2000
Controlled (Timed) Voiding Regimen
Before prescribing the controlled voiding regimen, the child and family should be fully educated and counseled regarding its rationale. Parents should prompt, not force or coerce, their child into going to the toilet at the programmed times when there may be no internal sensation of fullness or perception of an uninhibited bladder contraction. It is a good idea to construct the schedule with a parent handout showing daily routine home and school activities to which a toileting reminder can be associated.
Figure 63-2
presents a sample weekly chart for a seven void per day program.
Figure 63-2
Weekly chart for seven-void program.
Integrating toileting reminders into a child's schedule avoids the problem of "timed voiding." Requiring voids by watching the clock may exceed the young child's ability to
tell time. Timed voiding is also problematic because it adds time-focused pressure and stress—difficult for anyone, regardless of age. At least three voids are required during school hours. Parents may need to enlist the confidential cooperation of a home-room teacher or school nurse to provide reminders. A system of positive reinforcement for each toileting attempt can be planned with the use of sticker charts for children between 4 and 8 years of age. Older children will require some form of an allowance system (usually monetary). Parents can be told that the rewards are contingent on positive behavior at maintaining the voiding program, not on having dry pants. Dryness itself is only an outcome of successful voiding behavior.
• Clinical Pearl
The use of a daily reward system removes the nagging and punitive approaches parents might otherwise use. The contingency reward system gives the child choices in determining the rate and amount of acquiring rewards. Monetary allowances are justified because the child is being asked to perform an additional chore. The parent should not assume that self-care and complex understanding of medical problems will motivate the young child to perform. The child is not to be restricted for going to the toilet at any other time, but extra trips will not earn extra contingent rewards.
Clinical Warning
The program should be followed for at least 3 months. Symptoms such as UTIs and wetting need to be monitored daily by the parent's charting. If the family is not able to participate in this self-care regimen or if multiple psychological or medical issues coexist, referral to a pediatric psychologist or psychiatrist may be necessary to help the child to achieve continence. Conversely, if the family is consistently involved and effective at participating in this regimen but there is no improvement in symptoms after 3 months, further urologic workup may be wise. The provider should refer the child to a pediatric urologist.
Other Methods for Achieving Continence
Urine Alarms
The use of a urine sensor and alarm apparatus for treating PNE has been around for a considerable time (
Mowrer & Mowrer, 1938
). Use of this method has proven effective in as many as 90% of families who choose to participate in a full course of treatment. The method is labor intensive, disruptive of parent and child sleep patterns, and takes considerable time and patience. Many parents initiate this program on their own but fail because of premature termination of training. The labor- and time-intensive factors may also contribute to the tendency for many providers to delay treatment while awaiting spontaneous remission or to prescribe medication as a primary intervention. The original apparatus (bell and pad) consists of two electrically conductive pads placed between and covered by bed sheets. When the child wets the bed, the auditory alarm connected to the now-completed circuit (urine between the pads) wakes the child and alerts the parent. The youngster is then led from bed to the toilet, where the void is completed.
Clinical Warning
Although effective, use of the older models of the bell and pad apparatus had serious flaws:
Too much effort and time to remake the bed at night
A large urine output required before the system alerts the child and parent
Of greatest concern, a safety problem related to the strength of the electrical current required to power the alarm. Without expensive optical isolation of the current, the child could receive a shock or develop skin excoriations secondary to low-level electrical leakage.
For these reasons, the provider should screen for and discourage use of older bell-and-pad apparatuses.
State-of-the-art forms of the apparatus now are battery-driven. The alarm unit attaches to the pajama or straps to the wrist. A wire extends from the alarm unit to metal clips which pin to the inside and outside of the underpants. With only a few milliliters of urine in the underpants, the alarm is triggered, sounding like a phone pager. This device poses no electrical danger to the child. The alarm must be unpinned to stop activation of the noise.
Parents must be prepared to use the microalarm system for 2 to 3 months before signs of improvement can be measured or complete dryness attained. Prepubescent children will almost certainly require assistance of one parent during the night; therefore, the parents must be prepared for disturbances in their own sleep patterns. The scientific explanation for the alarm system's effectiveness has not been firmly established. The provider can tell parents only that the alarm provides an arousal cue, which prevents the child from finishing the void in bed. A reasonable but overly simplified explanation is based on an avoidance paradigm of autonomic learning, in which the CNS is provoked into sending inhibitory messages to the bladder to avoid repeated sleep disturbances.
Improvement in self-esteem is often an accompanying outcome when a child and family are successful in achieving continence with the alarm (
Schulpen, 1997
Longstaffe, Moffatt, & Whalen, 2000
). This active treatment plan involves the child and family in comanagement of PNE. The plan most likely contributes to a good experience and acts as a positive contrast to spontaneous cures or pharmacologic interventions that only require taking a prescribed medication. An enuretic alarm costs the same as a 2-week supply of DDAVP (
Schmitt, 1997
Dry Bed Training
Dry bed training (
Azrin, Sneed, & Fox, 1974
) combines alarm training, reinforcement techniques, and urine retention control. Unfortunately, the method has proven to be only slightly better than an alarm-alone system (
Hirasing, Bolk-Bennink, & Reus, 1996
). A precaution is necessary in using a component described as behavioral urine retention training. Because daytime frequency has not been a consistent finding in all children with PNE, the practice of daytime urinary retention ("bladder stretching") may at best add unnecessary stress or at worst may exacerbate an already present problem of high-pressure bladder conditions, bladder trabeculation, or ureteral reflux. Reflux is difficult to diagnosis without imaging techniques. Reflux raises the risk of hydronephrosis or kidney infection if bacterial growth is present in the bladder.
Medication is used as a first-line treatment by as many as 52% of physicians (
Vogel, Young, & Primack, 1996
). This practice belies the evidence that sustained outcome after stopping medication is dismal and that side effects are troublesome. Ever since
Maclean (1960)
found that imipramine, a drug developed to treat depressive illness, had antidiuretic properties in the elderly, its use has been widely applied to treat children with PNE. Imipramine is an anticholinergic agent and a noradrenergic stimulant. It was thought to effect bladder contractility by increasing the threshold capacity. More recently, imipramine has been linked to changing arousal thresholds. Efficacy rates of 60% response while on the drug and 70% recurrence when off the drug are disappointing for a definitive first-line treatment.
Clinical Warning
The temporary efficacy of imipramine treatment of PNE must be weighed against the risk of accidental, serious, dose-related cardiac and CNS side effects in children (
Rohner, 1975
Oxybutynin provides an anticholinergic action on the detrusor muscle, which may temporarily result in a reduction of bladder spasms and a secondary gain in bladder capacity in the child with diurnal enuresis with urinary frequency problems. Oxybutynin has not proven efficacious in any form of PNE.
Clinical Warning
Therapeutic gains in reducing daytime wetting and frequency are often only temporary. The necessity of increasing dosage levels only adds the risk of side effects, including headache, akathesia, facial flushing, and hypotension. These problems must be weighed against interfering with progress in implementing behavior modification programs for bladder retraining.
More recently, work in Scandinavia has focused on the hormonal pathways controlling the kidney production of urine.
Norgaard and colleagues (1985)
were among the first researchers to propose that treatment-resistant children showed a hormonal deficiency. Their research focused on a deficiency in the production of plasma arginine vasopressin. This antidiuretic hormone is secreted by normal children and results in reducing urine output to the bladder as the sleep cycle progresses into the night. Introduction of an artificial form of the antidiuretic hormone (DDAVP) showed great promise in abating symptoms during active drug treatment. However, the problem with DDAVP is recurrence of symptoms when the drug is discontinued. Medication can provide an immediate form of relief of bedwetting, but it is not a permanent solution for PNE. Some parents may want to consider medication for temporary solutions like vacations, sleep-overs, or summer camp. As with all medications, the risk of side effects must be considered carefully by parents.
Clinical Warnings
Although DDAVP is safer than imipramine, there have been increasing numbers of reports of seizure activity, hyponatremia, and cerebral convulsion with DDAVP usage (
Schwab, Wenzel, & Ruder, 1996
Robson, Norgaard, & Leung, 1996
Bernstein & Willingford, 1997
Donoghue, Latimer, Pillsbury, & Hertzog, 1998
). DDAVP must therefore take its place as a secondary intervention, falling behind the alarm program in outcome and safety. In all likelihood, some children may have faulty antidiuretic hormone production, but they should be assessed for this failure before medication is prescribed. The possibility of using DDAVP in tandem with an alarm training system is also to be considered in
children who are resistant to treatment with alarm training alone.
Parents are particularly in need of fully informed consent regarding the risk-benefit ratio of medication use. The possible psychological harm resulting from yet another short-term solution or another failure at attaining self-controlled dryness cannot be overestimated.
Incontinence Comorbidity
The problem of FEN may coexist with enuresis (
O'Regan, Yzback, Hamberger, & Schick, 1986
) or may occur alone. In either case, primary treatment should involve methods of behavior modification. Behavior modification can help in establishing a differential diagnosis of a nonorganic functional disorder if the child responds well to the intervention. Behavior modification can also provide an active, effective treatment for maladaptive bowel habits in the same way that applications to bladder training are efficacious.
When a diagnosis of encopresis with overflow fecal incontinence is established with children approaching school age (chronologic age of at least 4 years), the problem of relieving fecal impaction is the first order of business. Some gastrointestinal specialists advise mild laxatives, such as senna (Senokot), or pediatric enemas, such as children's Fleet, to remove the large collection of fecal material in the lower bowel.
Clinical Warning
A child who has a severe impaction may require an emergency visit or office procedure performed by a gastroenterologist. Whatever method of removal of fecal impaction is chosen, the provider must bear in mind that this is often only a temporary acute care measure. Behavioral treatment plans should be considered for the follow-up need of establishing regular daily bowel movements in the toilet.
A slower but equally effective approach to treating mild impaction may be taken by immediately initiating dietary changes assisted by a behavior modification program of bowel movement attempts. This program requires at least two bowel movement attempts daily, which are monitored and reinforced by parents (
Reimeres, 1996
Stark et al. (1997)
found that 59 children with retentive encopresis showed soiling decreases of 85% with a combined dietary and behavioral management program. The dietary program aims to increase the quantity of fiber in the child's diet by adding foods including fruits, fresh vegetables, and salads. A small daily quantity (1 teaspoon) of unprocessed wheat or oat bran is also very effective with younger children. It can be made palatable by mixing with applesauce or a favorite cereal. It can also be used as a cooking additive with muffins, breads, and soups.
The provider should reinforce the importance of avoiding repeated use of laxatives. Laxatives pose a risk of dependency and preclude self-controlled learning of normal full bowel sensations and volitional defecating. If lubricants such as mineral oil are used on a routine basis, they are more likely to exacerbate the problem because of increased leakage around entrapped stool formations.
Rectal biofeedback therapy has been reported as unsuccessful in controlled studies in treating anismus as defined by dyssynergic external anal sphincter contraction during attempted defecation (
Nolan, Catto-Smith, Coffey, & Wells, 1998
Loening-Baucke, 1996
van der Plas, Benninga, Redekop, Taminiau, & Buller, 1996
). Poor results with this method may be attributed to neglect of dietary adjustment and generalization of rectal sphincter training to the home setting. On the other hand, successful biofeedback interventions have been reported in one case of a postsurgically corrected imperforate anus (
Griffiths & Livingstone, 1998
What to Tell Parents
Setting up a behavioral program is most effective when all adult members who share parenting functions attend at least one meeting, usually the first treatment planning visit. Parents who understand and accept the treatment rationale and who are willing to provide closely monitored toileting prompts, instructions, and rewards for appropriate behavior will have the most efficacious and immediate results. The primary care provider may need to refer inaccessible or discordant families to a mental health or family therapy specialist.
Clinical Warning
A small cottage industry has been active on a national basis, offering behavioral programs for treatment of PNE. These companies are to be viewed critically in relation to using nonprofessionally licensed sales personnel who carry out treatment programs without sufficient medical or psychological consultation. Some companies offer the obsolete bell and pad apparatus at extraordinary rental prices exceeding $1000, in contrast to the number of small battery-operated alarms available for under $100 from mail-order companies.
National Kidney Foundation (NKF)
30 East 33rd Street, Suite 1100
New York, NY 10016
Telephone: For PNE: (888) WAKEDRY
For other problems: (800) 622-9010 or (212) 889-2210
Fax: (212) 889-9261
Internet address:
A brochure is available, as well as referral to providers who have indicated a willingness to treat bedwetting. This foundation provides information for parents and professionals regarding kidney and urinary tract diseases and referral services to pediatric nephrologists who specialize in kidney and bladder dysfunction.
American Urological Association
1120 North Charles Street
Baltimore, MD 21201
Telephone: (410) 727-1100
Fax: (410) 223-4370
Internet address:
This is an important resource for parents and primary care providers in locating a qualified pediatric urologist.
American Psychiatric Association
1400 K Street, N.W.
Washington, DC 20005
Telephone: (202) 682-6000
Fax: (202) 682-6850
Internet address:
This group is helpful for parents or referring primary care providers in locating qualified child or adolescent psychiatrists if coexisting mental health problems, including ADHD, post-traumatic
stress disorder, child abuse, or neglect, are known or suspected. Psychotropic medication prescribed by a child psychiatrist may be very helpful in assisting behavioral enuresis and encopresis treatment programs.
American Psychological Association
750 First Street, N.E.
Washington, DC 20002
Telephone: (202) 336-5500
Internet address:
This association helps parents and referring primary care providers to locate qualified child or adolescent behavioral or family psychologists to provide behavioral bladder or bowel retraining or to provide treatment of coexisting mental health problems (such as problems with compliance, self-esteem, and intellectual and emotional disturbances), which often accompany secondary enuresis and encopresis.
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Wolfish, N. M., Pivik, R. T., & Busby, K. A. (1997) Elevated sleep arousal thresholds in enuretic boys: Clinical implications.
Acta Paediatrica, 86,
Yakinci, C., Mungen, B., Durmaz, Y., Balbay, D., & Karabiber, H. (1997). Autonomic nervous system functions in children with nocturnal enuresis.
Brain and Development, 19,
Yeung, C. K. (1997). Nocturnal enuresis in Hong Kong: Different Chienes phenotypes.
Scandinavian Journal of Urology and Nephrology, 183
(Suppl), 17–21.


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2010 Guigal - Condrieu La Doriane Viognier - France - Northern Rhone - Condrieu - White
France - Northern Rhone - Condrieu
Producer Notes
Marcel Guigal - the so-called "pivot" of the Cote-Rotie appellation - is both an owner and negociant, and vinifies over 40% of all Cote-Rotie. His father, Etienne, started out quite modestly in 1946, and over the next decades the company has grown to encompass all that is best in the Rhone Valley. Not only known for the massive hits in Hermitage and Cote-Rotie, the Guigal name is... More »
Drink DatesComm: 2013-2013 VF: 2013-2022
Community Tasting Notes average score of 96 points based upon 2 reviews
1 of 1 people found this useful
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0Posted on Sep 9th, 2010 | re: Stereogum's 40 Best New Bands Of 2010 (142 comments)
So how many of these 'Brooklyn' bands are actually from NY? Where are you all crawling from? There's a new great white hope on here every 15 minutes. Btw, How to Dress Well is one of the worst band names I've heard in a while. Makes me want to vomit in my mouth.
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December 22, 2014
LAS VEGAS (AP) - A judge in Las Vegas has revoked bail for a former Nevada state assemblyman now being held in California on felony charges stemming from a freeway chase and violent struggle with police last week.
The action on Wednesday against Steven Brooks came after prosecutors accused him of abiding by a court order to stay out of trouble while awaiting an evidence hearing on felony and misdemeanor charges in a Feb. 10 arrest in Las Vegas.
Justice of the Peace Melanie Andress-Tobiasson's ruling means that if Brooks gets out of jail in Rancho Cucamonga, Calif., he'll be jailed without bail in Las Vegas.
Brooks' attorney, Mitchell Posin, says he hopes the judge's decision won't jeopardize Brooks' chances of getting into a psychological treatment program while he's held in California.
Copyright 2014 Associated Press. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
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Leopoldo López, center, mayor of the central Caracas district of Chacao, at Mother's Day celebrations in Caracas in May. (By Fernando Llano -- Associated Press)
Defenders of Hugo Chávez like to argue that there is no alternative to the Venezuelan caudillo other than the feckless and unpopular politicians who preceded him in the 1990s. The simple refutation of that canard is Leopoldo López, the 37-year-old mayor of central


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Auditioning for Movies and Reality TV
Posted by Marylou Curnutte | Posted in Auditions | Posted on 29-03-2012
Tags: reality show auditions 2012
For those who are in the running for auditions 2012 this year for shows then you do just you have found the right post to ensure that you run through the whole gamut of the checklist below:
• Foremost, be sure you are essentially dealing with a reputable acting agency; an entity with such a shade will typically, at the very least, demand that the individuals in question essentially signs an application form and better still make sure that such one essentially presents an acting resume of sorts regardless how modest it could be.
• Secondly, an agency which has pretensions to any sort of professionalism elects to go the way of being identified by some statutory body being a modeling agency; a great sign, though not to be taken wholly, legitimacy is certainly evidence much like the entity having its details in the talent search directory-this is often a good pointer to some claim to legitimacy. Be wary of entities that essentially tag themselves as free agencies along with the potential of harm that runs through their brand of doing business.
• Thirdly, ensure that your so called auditioning agency essentially conducts structured talent searches with an annual basis; to this end a reality seek for the current year 2012 auditions, should be more of a normal feature as opposed to something that remains in the hands of happenstance.
• Fourthly, you must do well to link up with an agency that essentially will cater for a wide portfolio of possible castings that you can finds in the marketplace. Such possible casting could quite possibly include the following, voice over's, comedy's, extras in movie sets, reality shows, and who knows possibly even a normal role from the movies that could herald a possible breakthrough in the movie industry.
If all the stars are aligned in your favor with regards to the above listed points then one thing that you could possibly count in 2012 or specifically relating to the issue of reality show auditions 2012 is basically that you essentially have one foot in – in so far as matters legitimacy are concerned. The other half of the journey – specifically how one can leverage this talent to your advantage and even go one better by being sure that you not only get your role but have a foot hold in the industry is hinged upon factors that are at times beyond your control. Take your shot and best of luck.


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Humidity 87%
Winds 11.5mph
Humidity 87%
Winds 11.5mph
Aug 1, 2013 5:54 PM
KINGSVILLE, Texas - Texas A&M-Kingsville senior football players Robert Armstrong, Zane Brown and Angel have been named to the 25th Annual USA College Football Division II Preseason All-Allmerica team it was recently announced.
Armstrong and Millan each received second-team All-America honors, while Zane Brown was a third-team selection to the preseason team.
Armstrong was one of three Lone Star Conference players to share LSC Receiver of the Year honors and is in the midst of one of the best - if not the best - career by a Javelina receiver. Armstrong, who was named first-team All-LSC is coming off a season in which he had a school-record 67 receptions with 11 touchdowns for 849 yards. He finished the season with three straight games of 100-yards and now has six in his career. Entering his final season, he has 2,065 yards receiving with 25 touchdowns. Armstrong is just five TD catches off the school record and fourth in total receptions with 163.
Millan is coming off the best season of his career en route to second-team All-LSC honors. He average 41.1 yards a punt in 65 attempts. He just missed a Javelina record for the longest punt by a single yard when booted a kick 87 yards at Tarleton State. Of his 65 punts, 25 landed inside the 20, and 14 travelled over yards.
A second-team, All-LSC performer Brown is entering his third season with the Javelinas. Last season, the senior defensive tackle had 41 tackles including 5.5 tackles for a loss. Of those 5.5 tackles, he had four sacks including two against A&M-Commerce. Off the field, Brown received CapitalOne Academic All-America honors as a kinesiology and exercise science major.
Here is the link to the complete team: http://www.usafbn.com/d2fb.htm
1 day ago
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Tracy, Iowa 50256
Phone: 641-828-8545
Fax: 641-842-3722
View Map
M-F: 7:30 a.m. - 4:00 p.m.
S: 7:30 - Noon
Malcom, Iowa 50157
Phone: 641-528-2801
View Map
M-F: 7:30 a.m. - 3:30 p.m.
S: 8:00 a.m. - 11:30 a.m.
- 2011-2012 pamphlets: electronics recycling, managing household chemicals
- 2011 audit report
- Monthly board minutes
Your SCISWA Quick Tip
Welcome to the SCISWA Home Page
The South Central Iowa Solid Waste Agency (SCISWA) is a four-county inter-governmental unit serving Lucas, Marion, Monroe and Poweshiek Counties. The Agency area, which was formed in 1994, consists of 26 towns including Victor in Iowa County. The counties and cities in the Agency area joined forces so they could manage waste in the most effective and cost-efficient way possible and to better meet state and federal regulations.
Excavator Bid
The South Central Iowa Solid Waste Agency is accepting sealed bids for the purchase of a Hydraulic Excavator. Specifications are available in this download.
2014 Upcoming Events
- November 27, 2014 Closed for Thanksgiving Day
- December 10 - 9:00 a.m., SCISWA Board of Directors meeting
- December 24, 2014 Close at 2:00 p.m. for Christmas Eve
- December 25, 2014 Closed for Christmas Day
- December 31,2014 Close at 2:00 p.m. for New Year's Eve
SCISWA News
Asphalt Shingle Recycling Comes to Poweshiek County
The Poweshiek Transfer Station has opened a recycling drop-off for clean asphalt shingles. With the new program, roofing companies and residents can save money and help the environment by separating asphalt shingles from other roofing materials during projects. The recovered asphalt shingles are dropped in a separate storage bunker at the Transfer Station and hauled to a processing facility when a full semi-load has been accumulated.
SCISWA is providing a $20 per ton discount from standard disposal rates for the separated shingles. However, contaminants (including wood, plastic and vinyl, felt, and other garbage) are being handled as waste. If not separated, SCISWA staff will charge the full disposal rate for the mixed load.
Shingles from roofing projects on single family homes (including multi-family dwellings up to a 4-plex) are not required to be tested for asbestos.
For shingles from commercial buildings (businesses and multi-family dwellings with more than 4 units), the contractor must provide certification and test results documenting that the recovered shingles do not contain asbestos
How to Recycle Household Batteries
There is a difference in household batteries. Some should be recycled; some should still go out with the trash. And, frequently you will need to read the label to know which is which.
Read more to find out what you should recycle and what you shouldn't.
Site Last Updated: 11/14/2014


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Garlic, an Edible Biography
The History, Politics, and Mythology behind the World's Most Pungent Food—with over 100 Recipes
Garlic is the Lord Byron of produce, a lusty rogue that charms and seduces you but runs off before…Read More
Imagine you are in a bright, breezy kitchen. There are large bowls on the counter full of lush, colorful…Read More
From homemade root beer to hard cider, fresh-squeezed ginger lemonade to handcrafted Irish cream, do-it-yourself beverages are gaining interest and…Read More
- The Joy of Discovery : an interview with Lynn Brunelle
Roost Books: Your new book chronicles how you, a self-proclaimed geek mom, get through the challenges of parenting by turning to the logic of science. What do you hope parents take away from your stories? Lynn Brunelle: That we're all doing our best and things come up. Parenting is a great challenge. Laugh if you … Continue reading
- Entertaining on the Fly by Ashley English
Last night, without much planning, my husband and I hosted eight adults and four children for a potluck dinner. Three other couples gathered at our home, each with a child in tow, and we collectively created an Indian food-themed meal of epic proportions. We made a huge mess in the kitchen (which we later all … Continue reading
- Watch the Make & Give Book Trailer!
Our brand new book trailer is here and we're so excited! Make & Give: Simple and Modern Crafts to Brighten Every Day by Steph Hung and Erin Jang is a fun, bright, modern craft book with 35 projects that are unique and inspiring. Covering a wide range of techniques, from simple prints and sewing to … Continue reading
- At Home in the Whole Food Kitchen: The Book Trailer
We are very pleased to share with you the book trailer for At Home in the Whole Food Kitchen: Celebrating the Art of Eating Well by Amy Chaplin. If you are an omnivore, you will delight in this book for its playful use of produce and know-how in balancing food groups. If you are a … Continue reading
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Explore what's new and soon-to-come...
Crafting a Colorful Home
A Room-by-Room Guide to Personalizing Your Space with Color
Lomelino's Cakes
27 Pretty Cakes to Make Any Day Special


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It's funny, last night I was watching the USA Mens Team take on Italy in the World League (and congrats to the USA Men for earning a spot in the finals), and was listening to Kevin Barnett talk about Head Coach Alan Knipe not having his line-up set for the Olympics. New-comer Paul Lotman is battling it out with veteran and 2008 Olympic Gold Medalist, Riley Salmon, on the outside. Why I find this amusing is while Kevin Barnett was disappointed the USA Mens Team roster wasn't set and that "winning the World League was more important", the USA Women's Team played a "2nd string" line-up throughout half of the World Grand Prix.
You think Alan Knipe has an interesting dilemma on the Mens Team, how about Hugh McCutcheon on the Women's Team? Megan Hodge was named World Grand Prix MVP and Best Scorer, but she probably will not start on the Olympic Team. Jordan Larson and Logan Tom will likely start ahead of her (oh yeah, and that leaper, Destinee Hooker, will play opposite). The main reason, the game comes down to serving and passing. Jordan and Logan will start over Megan because of passing. In addition, both players are smarter, more effective hitters than Megan. Continue Reading


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Lane closures continue near Coffee Road, Brimhall Road
Overnight closures will be Jan. 27-29
BAKERSFIELD, Calif. -
The contractor for the Westside Parkway is continuing nighttime lane closures near the intersection of Coffee Road and Brimhall Road on Jan. 27-29.
The lane closures will affect lanes between the hours of 9 p.m. and 5 a.m., as the contractor continues work on a storm drain installation in the area.
The lane closures will occur through the intersection, and to the west on Brimhall Road.
At least one lane in each direction will remain open to traffic at all times. All lanes will be reopened in time for the morning commute.


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some time in the next couple of weeks… We'll see if I like it or not!!
Big B has written 2 entries about this goal
like to just rent a pair of skis and gear and take a lesson to see if I even like this… Haven't done it since high school… What if I hate it? Hmmm, this will require some additional investigation I believe…
Big B has gotten 1 cheer on this goal.
- Got Papi? (Papacito) cheered this 8 years ago


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Cisco Beats Earnings Estimates, Delivers Record Revenue (Update2)
(Story updated with information on Cisco's earnings tax benefit, cash position and share price.)
NEW YORK ( TheStreet) -- Cisco (CSCO) beat Wall Street's second-quarter earnings and revenue estimates, allaying concern about tepid enterprise spending.
The networking company reported revenue of $12.1 billion, up from $11.5 billion a year earlier and just above analysts' estimates of $12.06 billion. Excluding items, Cisco earned 51 cents a share, compared with 47 cents a year earlier. Analysts surveyed by Thomson Reuters were looking for 48 cents.
The company's non-GAAP earnings included a tax benefit of approximately 1 cent a share thanks to the reinstatement of the U.S. federal R&D tax credit last month."Cisco delivered record earnings per share this quarter and record revenue for the eighth quarter in a row in a challenging economic environment," CEO John Chambers said in a statement released after the market close. The CEO struck a positive tone during the conference call to discuss the results. "We continue to be pleased with the traction of our company," he said, and cited "a tone of cautious optimism" among Cisco's customers. Chambers noted particular strength in U.S. commercial orders, which he said could be an early indication of GDP growth. "U.S. enterprise and commercial, I really believe that that is the key to what the U.S. is going to do over time," he said. "At the moment, that looks good -- our pipeline is good." The CEO, however, acknowledged that other parts of the world are still challenging. "We continue to see a soft global recovery," he said, pointing to weakness in parts of Europe, particularly southern Europe. For the third quarter, Cisco predicted revenue between $12.06 billion and $12.3 billion and earnings, excluding items, between 48 cents a share and 50 cents a share. Analysts surveyed by Thomson Reuters were looking for sales of $12.22 billion and earnings of 49 cents a share. During the second quarter, Cisco's switching revenue grew 3% year over year to $3.72 billion while the company's services business rose 10% to $2.66 billion. Sales of Cisco's Next-Generation-Routing (NGN), however, slipped 6% to $1.95 billion although service-provider video climbed 20% to $1.22 billion. Collaboration revenue fell 11% to $945 million, while data-center revenue climbed 65% to $548 million. Revenue from the company's wireless business rose 27% to $520 million, although security was a more modest gainer, with sales rising 1% to $336 million. Cisco's second-quarter gross margin came in at 60.7%, down from 61% in the first quarter. In the prior year's quarter, Cisco's gross margin was 61.3%. Excluding items, the networker's gross margin was 62.3%, down sequentially from 62.7%. During the second quarter of fiscal 2012, Cisco's gross margin was 62.4%. Cisco exited the quarter with cash, cash equivalents and investments of $46.4 billion. The networking giant's shares, which closed up 0.8% during Wednesday's session, dipped 1.9% to $20.74 in extended trading. -- Written by James Rogers in New York. Follow @jamesjrogers >To submit a news tip, send an email to: firstname.lastname@example.com.
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Mary Macias
Mary Macias, 89, of Las Vegas, Nev., a beloved mother, grandmother, great-grandmother and friend, entered into eternal rest March 25, 2011, of natural causes. Mary was born in Abo, N.M., on Sept. 23, 1921, and moved to Roswell, where she spent most of her adult life. She then moved to Login to read more
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Named Burlington Free Press Academic All-Stars
Congratulations to Aiman Ginawi for being selected BFP Boys Soccer Player of the Year.
Alex Pasanen, Eli Rachlin, and Ismail Temirov were all selected for the Burlington Free Press All-Star Boys Soccer Team, while Posie Nash-Gibney received an Honorable Mention for the Girls Team.
|The World Language department is now accepting applications for TIE France and Japan 2015-2016. This is an awesome opportunity for students to experience language and culture first hand. Please contact Theresa Mazza-Anthony (TIE Coordinator) or click on the link below for more information and the application. Link to TIE information, email@example.com 802-652-7092
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Amazing people, hot topics, wild outdoors - get more from David Whiting
Regardless of where you stand on the Trayvon Martin verdict, we can all agree on some things, and one is how clever Kathy Bates' character, Bettina, was in HBO's "Six Feet Under."
Bettina tells her friend Ruth that they can shoplift to their heart's content because as older women, they're invisible – people no one pays attention to. What Bettina doesn't mention is that they're white.
I suspect we also can agree that Bates' insightful quip wouldn't have worked if the two actors were black.
Consider what Thomas Parham, vice chancellor for student affairs at UC Irvine and a black man with flecks of gray in his hair, told me last year after Martin was killed. Of his race, Parham said, "That's what makes a security guard follow me in a mall."
Saturday's not-guilty verdict for George Zimmerman has only made many African Americans feel less secure.
Eva Paterson of the Equal Justice Society sent this email about a protest: "One black woman had a sign that said, 'Are my sons next?' One white man had a sign that said, 'Nobody follows me anywhere.'"
But the issues surrounding the verdict aren't black and white. Like race in 21st-century America, the issues are far more complex.
• • •
Despite protests largely by people of color, this isn't a time to mourn for a racially polarized America. Rather, it's a time to mourn the senseless death of a teenager, the senseless acts of an adult and a troubled judicial system.
It's also an opportunity to come together, learn and try to fix what's broken.
In talking with both whites and blacks, it's clear there is much thought and little agreement – among people of the same race. Heck, my wife and I debate what happened in the courtroom.
But this column isn't about my marriage. It's about what some black leaders think. In a county that is less than 2 percent African American, it's especially important to understand minority viewpoints. After all, that's what democracy's about.
Ron Owens, acting assistant fire marshal for the Oceanside Fire Department, lives in South County and doesn't allow race to factor in his life. Speaking not as an official but as an individual, the Navy veteran tells me he doesn't believe the shooting was racially motivated. He also says the verdict was spot-on.
The Rev. Mark Whitlock, senior minister at Christ Our Redeemer AME Church in Irvine, has a very different take.
"Justice was not in the Florida court room on Saturday night," Whitlock tells me. "The truth is, justice for men and boys of color is rarely in the room.
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Go beyond pre-made shades. The McCormick formulas here show you how. By adding two colors together, you can make wonderful new shades.
Select the shade you want from the photos below. The chart is read like a multiplication table.
In the first photo, Yellow is added to each other color.
In the second photo, Red is added to the other colors.
In the third photo, Neon Blue is added to the other colors.
Each pair of colors was tested at the ratios 1 to 3, 2 to 2 and 3 to 1.
Colors used with abbreviations:
#1 = 1 part Yellow and 3 parts Red.
#2 = 3 parts Yellow and 1 part Neon Blue.
Base yarn used: recycled off-white wool from a thrift store sweater.
Each sample is 3 yards of yarn.
How the dyestock was made: the McCormick was measured by the drop. Each pair of colors was tested at the ratios 1 to 3, 2 to 2 and 3 to 1.
I didn't simplify the ratio 2:2 as 1:1 because I wanted the same amount of dye in each McCormick formula. 1:1 would have produced a lighter shade.
A = Yellow
E = Blue
Notes on colors:
Hints on using blue food color.
Yes, we have videos.
Can't find the page you want? Here's our site map.
Go from McCormick Formulas to Dye Your Yarn home page.
Search DyeYourYarn.com
Short bits that aren't full pages on Dye Your Yarn.


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RELEASED: Nov. 21, 2007
|Eau Claire resident, Steve Ambroe, working behind the camera. (contributed photos)
EAU CLAIRE — First Fridays will give senior citizens a glimpse of the world "Behind the Camera on an Eco-Tour" on Dec. 7, with Eau Claire resident Steve Ambroe. Doors will open at 8:30 a.m. for breakfast and the program will follow at 9 a.m. at Christ Church Cathedral, which is on the corner of Lake and Farwell streets in downtown Eau Claire.
Ambroe, an eco-tour videographer, will take the audience to exotic places as he shares stories of his recent travels. He will share video clips and discuss traveling in areas ranging from the Arctic to Antarctica. From penguins to fjords to desert islands, this is guaranteed to be an amazing journey.
Ever since grabbing the family video camera in the mid 1980s, Steve Ambroe has taken a keen interest in the field of video production. A native of Minnesota, he graduated from Carleton College where he gained an appreciation for ethnographic and documentary film as an anthropology major. For the past three and a half years he has worked extensively with Lindblad Expeditions, which, in partnership with the National Geographic Society, excels at finding unique encounters with wildlife for the guests aboard its fleet of small ships.
For the safety of the senior audience, the event will be cancelled if the Eau Claire Area School District has cancelled or delayed classes because of hazardous weather.
First Fridays programs are presented on the first Friday of each month October through May, except in January, at no cost to the senior community. People with season passes that are stamped each month will be eligible for a prize drawing at the May presentation.
The program is funded in part by the University of Wisconsin-Eau Claire Foundation Community Outreach Program for the Arts, the Great Harvest Bread Company and Elliot Roberts. First Fridays is coordinated by Beverly Soll and Jennifer Brockpahler of the Activities and Programs office and is hosted by Scott and Heather Kirby of Christ Church Cathedral.
The mission of First Fridays is to provide no-cost entertainment and educational experiences for area senior citizens through shared community and university sponsorship.
For details about First Fridays or to be placed on a mailing list, call 715-836-2787.
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