By Steve Hodges, M.D.
About 15% of my bedwetting patients are teenagers, and I frequently receive emails from teens who wet the bed. The common theme: Nothing works. Nobody will help me. How can I go college like this? From a 17-year-old girl: “I cannot feel any urine going out, but I wake up wet every day. My mom thinks I'm stubborn and I don't want to wake up at night. I’m a very bright student, I might add. This is the only thing that pulls down my self-esteem. I can’t go to camps, and it’s so embarrassing not even my best friend knows.” And this, from another 17-year-old: “I’ve done special diets, alarms, being woken up at all hours by my parents, limiting drinks after dinner, and desmopressin for a year now. My doctor isn't the kindest person and says I should just ‘get off’ my medication. If only he knew how hard it is. I try to live a life of a normal teen (sleepovers, trips, etc.) yet I'm always nervous to have an accident. Now college is approaching. I just can't give up on myself as quick as others have.” Teenage bedwetting is more common than you might think, affecting about 2% of teens — well over half a million U.S. kids and countless more worldwide. In a typical big-city high school, about 40 to 80 students will have enuresis.
I've worked with so many teenagers with enuresis that I wrote a book specifically for them: M.O.P. for Teens and Tweens: The Science-Based Way to STOP Bedwetting for Ages 10 to 18. I also run a private Facebook support group just for parents of teens and tweens.
Interestingly, about 3% of children wet the bed at age 9, according to a survey of more than 16,000 children. In other words, very few children spontaneously outgrow bedwetting in the tween and teen years. Without treatment, children still wetting in fourth grade are highly likely to wake up with wet sheets in high school.
As the study’s lead author noted, “Our findings challenge the myth that bedwetting will always get better and disappear as the child gets older."
What's more, children whose bedwetting persists also have high rates of daytime accidents. Among children ages 11 to 19 who wet the bed, 48% do so every night, and 29% have daytime accidents,
Yet pediatricians routinely dismiss bedwetting. A mom in our private Facebook support group for parents of teens posted: “A pediatrician told my 7-year-old not to be concerned until age 11 or 12 because there are such great pull-up-type products available nowadays.” (Never mind how 5th graders feel about wearing “pull-up-type products” on sleepovers!) Even more so than younger children, teens who wet the bed are blamed, shamed, and/or disregarded. Most of the teenagers referred to my clinic have never been told that bedwetting is caused by chronic constipation. That's right, a clogged rectum.
When children delay pooping, as so many children do, stool piles up in the rectum, and eventually a mass forms. Over time, this mass begins to press against and aggravate the bladder nerves, causing the bladder to spasm and empty without notice. These kids can't control bedwetting any more than they can stop a sneeze or a hiccup.
This is what's happening with virtually all of my patients who are otherwise healthy — in other words, who don't have neurological issues, such as spina bifida or tethered cord syndrome, or anatomical abnormalities that make them prone to constipation.
I know this because I x-ray all my enuresis patients. X-rays give you a clear picture of the stool mass, and you can measure just how enlarged the rectum has become. A normal rectum measures less than 3 cm in diameter. The rectum of a child with enuresis typically measures 6 cm — sometimes even 9 cm.
But instead of being properly screened and treated for constipation, most kids undergo all sorts of useless tests and treatments. One family I worked with had tried chiropractic for a year and then spent thousands on a bedwetting treatment center that advises parents to spray their children with cold water “to wake them out of their deep sleep.” The boy’s parents wouldn’t spray their son, the mom told me, and then wondered if they failed him by “not following the program to a tee.” Kids like that boy often land in my clinic because their doctors are out of ideas, and the family is longer buying assurances that the teen will outgrow the condition. As the “spray bottle” mom put it: “We patiently waited for our son to magically stop wetting the bed when he turned 12, but it didn’t happen.” Most teens who wet the bed have a long history of constipation that is apparent if you ask the right questions. But because the signs of constipation are often subtle and not well known, nobody ever connected the dots. I saw a 16-year-old boy who’d been so severely constipated at age 5 that his parents delayed kindergarten. His poop accidents stopped, but his bedwetting never did. “Through age 5, 8, 10, the pediatrician kept saying, ‘Don’t worry, he’ll grow out of it. When he was 14, he wanted to go to Rome with the Latin club. I was so stressed. Six months before the trip the urologist put him on DDVAP, but that didn’t work. I sent him to Rome with nine garbage bags for the bed.” The boy underwent numerous sleep tests. One doctor diagnosed him with narcolepsy. Another said no, anxiety. Another said no, it’s sleep apnea. Recalls his mom: “We thought, ‘OK, that’s it!’ He wore a headset for three months. It didn’t change a thing.” This mom recalls she was stunned to learn constipation causes bedwetting. “I was like, ‘WHAT???’ Our pediatrician never mentioned that, and we hadn’t seen the GI doctor since my son was 8. We thought the constipation was under control because he wasn’t having poop accidents anymore.” An X-ray showed otherwise. The boys was monumentally constipated. It took many months of daily enemas, the Peristeen pump (basically a high-powered enema system), and strong medications to get him reliably dry. The ordeal that began with him delaying kindergarten concluded with him taking a gap year at age 18 — all because his constipation went unrecognized and untreated. Says his mom: “You just get bounced around, from pediatrician to urologist to GI doctor to sleep specialist, and nobody looks at the big picture.” Google “Teenage Bedwetting,” And Find Dreadful Advice A family that gets no help from the doctor will naturally turn to the Internet, only to find the usual recycled nonsense. Let’s look at the purported causes of teenage bedwetting that surface in an online search. •The “cause”: an inherited small bladder. As one large New Jersey medical group puts it: “Most teens with enuresis have inherited a small bladder, which cannot hold all the urine produced during a night.” The reality: There is no evidence that teenage bedwetters have “inherited” small bladders. Yes, their bladder capacity is compromised, but that’s because a giant mass of poop is stretching the rectum and flattening the bladder. I see this daily on X-rays. Telling a teen the problem is inherited implies nothing can be done and encourages complacency. •The “cause”: deep sleep. This is a big favorite. The American Academy of Pediatrics (AAP) lists, among the “contributing factors” for teen bedwetting: “a deep sleep pattern that can be part of normal adolescent development, inconsistent sleep schedule and limited hours sleeping.” One medical group states: “Teens are deep sleepers who don't awaken to the signal of a full bladder. If they did, they wouldn't be wet.” The reality: Children with healthy bladders don’t need to pee overnight, so it makes no sense that deep sleep would trigger bedwetting. Most kids are deep sleepers; most kids don’t wet the bed. The culprit is the child’s squished and overactive bladder, not his sleep patterns. Why don’t these kids wake up? For one thing, an aggravated bladder often spasms too quickly for the child to react (and often before the bladder is even full). As countless studies show, many bedwetting children and teens also have daytime accidents; in other words, even when they’re awake, they often can’t make it to the toilet in time. So if they’re sleeping when their bladder hiccups, what are the odds they’ll jolt awake and sprint to the toilet in time? A team of Chinese researchers, writing in the New England Journal of Medicine, has proposed another explanation for why these kids don’t wake: because they’re too tired, having been denied restful sleep by their overactive bladders. Their study found children who wet the bed got significantly less REM sleep than children who were dry, because their bladders were basically hiccupping all night. This study did not look at whether these children were constipated or even speculate as to why their bladders were overactive during the night, so it’s of limited value. At any rate, whether or not this theory proves true, deep sleep absolutely does not cause the bladder to hiccup. And yet online you find doctors advising teens to do a “bedtime pep-talk about self-awakening.” This kind of advice only serves to frustrate teenagers. •The “cause”: a family history of bedwetting. The reality: Indeed, studies show children whose parents wet the bed are more likely to do so themselves, but it’s a leap to assume the bedwetting itself is inherited. It’s more likely, I believe, that what is passed down is the tendency toward constipation. But it doesn't really matter, because all bedwetting can and should be treated aggressively. The AAP states that “it is helpful to identify the age of nocturnal continence for both parents,” but in my experience it’s actually unhelpful. It just prompts families to wait around rather than take aggressive action. •The “cause”: too much caffeine. Nowhere in its "Nocturnal Enuresis in Teens" section does the AAP mention constipation as even a possible cause of bedwetting, but the organization does consider “poor dietary control with excessive caffeine intake” to be a “contributing factor” in teenage bedwetting. The reality: Women who drink high levels of caffeine are more prone to bladder leakage, but teens leak urine for different reasons than 45-year-old women do. (In middle-aged women, incontinence is related to age, hormonal changes, and childbirth.) Cutting out caffeine will not solve teenage bedwetting. It’s a clogged rectum, not a Starbucks habit, that’s causing the problem.
•The “cause”: urinary tract infections. This is yet another “contributing factor” cited by the AAP.
The reality: Yes, a UTI can prompt the bladder to go haywire, but if the UTI is really the culprit, the bedwetting will cease within two weeks of treating the infection. Far more commonly, the UTI is caused by the same rectal clog triggering the bedwetting, as I explain in “Why 1 Million Girls a Year Get UTIs.”
•The “cause”: social stress. According to the AAP, “secondary enuresis in older children or adolescence should prompt a review of social stress factors and the potential for sexual abuse.” Secondary bedwetting refers to bedwetting that arises after a long period of dryness.
The reality: Teens who wet the bed certainly can be stressed, but it’s bedwetting that causes stress, not the other way around. In “Is Bedwetting a Sign of Bullying?” I delve into the highly dubious “evidence” cited to support the notion that social stress causes bedwetting. The vast majority of secondary bedwetting has the same cause as primary bedwetting, though the medical community goes to great lengths to distinguish between the two.
As for sexual abuse, again, the evidence is thin. I’ve treated a handful of teen bedwetting patients who had been sexually abused. All of them were also shown via X-ray to be severely constipated. Studies linking bedwetting to sexual abuse never X-ray the children for constipation. When I hear about the sexual-abuse theory, I think of the aphorism “When you hear hoofbeats, think of horses not zebras."
The AAP states that diabetes and other chronic medical problem can trigger bedwetting, and this is true. I always check for diabetes, as well as anatomical and neurological conditions. However, I can’t emphasize how rare these causes are.
Given all the inaccurate information online about the causes of teenage bedwetting, it’s no surprise that the recommended treatments are off-base, too.
Teenage Bedwetting Treatments That Are a Waste of Time The AAP’s “practical approach” is to educate the family on “appropriate dietary intake,” such as eliminating caffeine, and to encourage the child to pee before bed and first thing in the morning. As every bedwetting teenager in the world already knows, peeing before bed (while a good idea, obviously) does not resolve bedwetting! The AAP also recommends bedwetting alarms and medication, treatments that do not get to the root of the cause.
Several websites advise parents to wake their bedwetting teens overnight. As the GoodNites website states, “As long as children do not fight getting up, this is an effective measure parents can use until a child becomes dry on her own or is ready to start a bedwetting program.” This is not an effective measure. Even if you’re able to time the wake-up exactly right, you haven’t solved anything except a laundry problem. You’ve simply adapted your teen’s sleeping patterns to her compromised bladder capacity.
More worrisome, a doctor on the GoodNites website also advises “encouraging the child to take some responsibility for his bedwetting . . . such as putting wet pajamas in the laundry basket.” He calls this a “basic intervention.” I call it blame. (I’m all for kids doing laundry, but not as some corrective measure.)
This doctor also advocates giving the child “positive reinforcement for dry nights.” I strongly disagree. It is simply wrong to reward children for something they have absolutely no control over.
The GoodNites website attempts to offer teens reassurance, but in a perverse way: “Chances are good that a teen with nocturnal enuresis won't suffer this condition forever.” I guarantee you every teenager who wets the bed already feels like this condition has gone on “forever.”
How to Actually Resolve Teenage Bedwetting
So if all the usual advice doesn’t help bedwetting teens, what does?
The same approach that helps younger children: aggressively treating constipation with a combination of enemas and laxatives. Despite all the talk of “adolescent sleep patterns” and caffeine intake, there is nothing unique about the cause of or treatment for teenage bedwetting.
By far the most effective way to tackle bedwetting is the Modified O’Regan Protocol, pioneered by pediatric kidney specialist Sean O’Regan, M.D., and explained in detail in The M.O.P. Book: Anthology Edition. (M.O.P. for Teens and Tweens is a Cliffs Notes version written for middle-school and high-school students.)
Enemas stimulate the rectum to fully evacuate; doing this daily for at least a month (before tapering) is necessary, allowing the rectum to remain unclogged long enough so it can shrink back to size and stop bothering the bladder nerves. In teenagers, the rectum has been stretched for so many years that these kids typically need a lot more than 30 days of daily enemas to start having dry nights.
Yes, daily enemas are really, truly safe for children! And yes, teenagers can be persuaded to give themselves enemas every day. In my experience, many teens feel so weary and embarrassed by their years of bedwetting that they are eager to try an approach that actually makes sense and works.
As one 14-year-old boy put it, "My first reaction to M.O.P. was, What the heck? But I had tried everything else and was feeling hopeless, so I was willing to try. I am glad I did. After two months I was having 2-3 dry nights a week. By the fourth month, it upped to 3-4 nights a week. Now I barely ever wet.”
Kids are really clever; some of my patients manage to maintain their enema regimen even while going on sleepovers.
If you are wondering about oral laxative clean-outs, even the high-powered, colonoscopy-type clean-outs, they won't do the job. I explain this in "Bedwetting Treatment: Why Even the “Nuclear” Option Can’t Replace Enemas." Most parents have no idea whether their teenager is constipated. You might show our infographic 12 Signs Your Child is Constipated to your teen and asking how many signs apply. Among them: extra-large poops, hard or formed poops (logs or pellets), an urgent or frequent need to pee. Don’t put too much stock in how often your child poops. Frequency is a poor indicator of constipation. Countless constipated children poop daily, but they never fully empty, which is what actually matters.
For definitive proof that a teen is constipated, get an X-ray. In the M.O.P. Anthology I describe how to make sure you get an accurate evaluation of the X-ray. Many physicians are not experienced at reading X-rays for constipation and will deem a child "normal" or "moderately constipated" when in fact the child's rectum is chock full of poop.
It’s impossible to know how quickly a teenager will respond to M.O.P. Some teens, especially those who have never been treated for constipation, get better within a few weeks. But that’s not the norm. When a child’s rectum has been stretched for literally a decade, resolving the problem can be a long and difficult haul, taking many months or longer.
My advice is to start with M.O.P. and closely monitor your teen’s progress or lack thereof. the M.O.P. Anthology includes helpful tracking charts; M.O.P. for Teens and Tweens provides a simplified tracking chart that will be less annoying for kids. Teens can give themselves the enemas, and in my experience, most are willing to do so. Going off to college with GoodNites is a scary prospect. This is critical: If your teen makes no progress after 30 days on M.O.P., you need to tweak the regimen. The Anthology provides lots of guidance on this front. It can take a much trial and error to find the right enema solution and the right type and dose of laxatives to help your child. Medication may help, but only in conjunction with aggressive treatment for the underlying constipation. Drugs alone won’t attack the root of the problem, and some bedwetting drugs actually cause constipation. It’s critical that teenagers (like all kids) pee during school whenever they feel the urge. If the child’s school restricts bathroom access, as many schools do, talk to the teachers or administrators. If your doctor won’t write a note, I will! Holding pee or poop during school hours will undermine your child’s recovery. Bedwetting is often dismissed by physicians because it’s not a life-threatening condition and because many doctors just don’t know how to treat it. But to teenagers and their families, it’s a nightmare. Resolving the problem is nothing short of life-changing. One mom in our Facebook support group posted that bedwetting made her son reluctant to participate in overnights, especially with the Boy Scouts. “How can you do winter camping or a backpacking trip with a bedwetting problem?" After a long haul on M.O.P. and then M.O.P.+ — “two steps forward and one step back” — he’s almost always dry and has been able to taper off enemas and suppositories, though he’s not out of the woods completely.
“Now the bedwetting is so much less likely to happen, he’s really enjoying being able to participate more with his friends,” she wrote. “Treatment has made him closer and more trusting of me overall, I guess because he sees me sticking with him and helping him find a solution.”
It's really important for teens to know that bedwetting at their age is a) common, b) not their fault, and c) totally fixable.