By Steve Hodges, M.D.
Two emails this week raised so many good questions — about limiting water before bedtime, waking a child overnight, staying hopeful in the face of no progress, handling encopresis relapses, and more — that I am posting them here, in hopes my answers will help guide your child's treatment.
My bottom-line advice with regard to enuresis and encopresis: 1.) act aggressively, 2.) act immediately, and 3.) don’t cut treatment short!
Avoiding enemas and delaying or limiting treatment won’t resolve accidents and will only serve to prolong your family’s distress.
Question: Our smart, 7-year-old son has never had control of his nighttime peeing and needs two nighttime diapers simultaneously to stay dry. We tried night training him a few years ago and were 100% unsuccessful. He shows no interest in being night trained. We tried M.O.P. for 35 days last year but saw no progress and lost hope. My husband thinks waking him up at night might help, and my doctor thinks he drinks too much water after dinner. Please help.
Answer: Lots to comment on here!
•Intelligence has no bearing on bedwetting or daytime accidents.
No one would think, "How could my son be so smart yet have diabetes?" or "How did my super bright daughter come down with the flu?" Yet parents often mention their child’s intelligence when they ask me about enuresis or encopresis.
The implication seems to be: My child is smart enough to know better. Or, it seems impossible that a kid so smart can’t realize he’s pooped in his pants.
Encopresis and enuresis are medical issues, straight up. These kids have accidents because a stool-stuffed rectum is aggravating the bladder and/or compromising rectal tone and sensation. They can't prevent accidents any more than they can prevent hiccups. Plenty of highly intelligent children have accidents, just as plenty of highly intelligent kids get the flu or develop diabetes.
•You can’t “train” a child to stay dry overnight.
You can’t train your child to achieve dryness overnight, just as you can't train a baby to crawl or walk. Overnight dryness happens naturally, as we explain in “Nighttime potty training is not a thing.” If it doesn’t happen by around age 4, it’s likely the child is constipated (an x-ray can confirm this), in which case I recommend treatment with M.O.P. (the Modified O’Regan Protocol).
Don’t fault a child for appearing to have “no interest” in staying dry overnight!
Many kids who appear unbothered by bedwetting or daytime accidents are, in fact, quite embarrassed and distressed about it. They will tell me as much in private, even though they act unconcerned around their parents, maybe because they don't want to draw more attention to the problem.
•Waking a child overnight won’t resolve bedwetting.
Pretty much every parent of a bedwetting child tries this approach at some point. But it’s difficult to time your wake-up to prevent accidents, and even if you’re able to keep your child’s sheets dry using this technique, you haven’t actually solved anything except a laundry problem. You’ve simply adapted your child’s sleeping patterns to her compromised bladder function. It’s a mug’s game (one of my favorite British expressions, meaning “a futile endeavor”).
Instead, you need to get to the root of the problem, chronic constipation, which is making your child’s bladder unstable.
•Drinking water at night does not cause or even contribute to bedwetting.
Likewise, restricting water before bedtime won’t stop bedwetting. A child with a normal, stable bladder — a bladder unbothered by a rectum full of stool — can drink plenty of water right before bed and have no need to pee overnight, whereas a chronically constipated child whose bladder is prone to hiccups will have accidents overnight even if he doesn't drink in the evening.
Restricting a child’s water intake may actually aggravate the bladder more. Let your child drink as much as he wants to, and focus on treating the constipation.
•While doing M.O.P. for 35 days without progress is discouraging, it’s not uncommon. Lack of progress means you need to step up the protocol, not abandon it.
When parents first hear about M.O.P., they assume a regimen as “extreme” as daily enemas will very quickly clear up their child’s constipation and resolve the accidents pronto. When that magic doesn’t happen, they may jump to the conclusion that “the problem isn’t constipation” or “M.O.P. doesn’t work.”
To the contrary!
If you have any doubts about whether constipation is the cause of your child’s wetting, an abdominal x-ray will easily resolve that question. (Just make sure your physician knows how to properly read the x-ray.)
Lack of progress on M.O.P. almost always signals the child is so stubbornly constipated that stronger enemas are needed. Most parents have no idea just how much crusty, hard, dry stool can be packed into a small kid's rectum. As one mom put it, “I feel like I am chipping away at a cement block with a garden hose!”
Any 30-day period without progress warrants a change in the regimen, as we emphasize in the M.O.P. Book: Anthology Edition. Don't stick with what is not working! (But do give each tweak 30 days before you move on.)
There are many variables you can change. For example, you can switch from store-bought enemas (which contain phosphate solution) to large-volume enemas with stimulants such as glycerin or Castile soap (the M.O.P.+ regimen). Or, you can switch from store-bought enemas to liquid glycerin suppositories (LGS). LGS have a smaller volume than store-bought phosphate enemas, but for some kids they produce more output and are certainly worth a try.
You might also add Ex-Lax to your regimen, as we discuss in the Anthology.
M.O.P. is not a quick fix; it’s a process of trial and error and can take a long time. Your child’s rectum did not become stretched overnight, and it’s not going to get cleaned out and bounce back to size overnight, either. If only!
Our private M.O.P. support group is filled with parents who are dealing with very challenging cases.
The following was recently posted by a departing member of the group who showed great perseverance and used the lessons she learned to help out her younger daughter. Perhaps her words will encourage you to stick with the program.
I wanted to share some hope for you all. My daughter has been constipated since birth and started poop accidents as soon as we potty trained. For years we worked with various doctors who only pushed Miralax. After much research, I landed here with M.O.P. We started enemas when my daughter was 7.5, and gradually worked our way thru the M.O.P. protocol. While we are by no means out of the woods (still doing daily enemas) my daughter has had 3 months with ZERO accidents (never gone more than a week before)!
Incidentally, my younger daughter started having accidents at age 5, and we immediately put her on enemas too. After about 6 months, we were able to slowly wean her off enemas, and she has gone about 5 months without them now, with no accidents, either.
Question: We completed the 30-day enema program more than a year ago with our now 9-year-old old son, and after the enema month, accidents were infrequent. But now he’s had a relapse. He says he’s having too much fun playing to stop and use the toilet or doesn’t want to use the restroom where he is. Also, he's not drinking enough water.
He is good about taking his Miralax and Ex-Lax every morning but does not want to do potty sits, even with bribery. He is having good sized poops about 5 times a week. Usually he will have an accident and then have a full poop on the toilet after. What direction should we turn? How common is this regression at his age?
He is bright, and we think he is capable of understanding how to get better, but at the same time he seems unfazed by pooping his pants and can’t seem to be responsible for drinking enough water to keep himself on track.
Answer: Lots to say about this one, too!
•M.O.P. isn’t a “30-day enema program.”
Thirty days is the absolute minimum length of time for Phase 1, the daily enema phase. As we explain in the M.O.P. Anthology, you taper to Phase 2 (enemas every other day) only after a child has had at least 30 consecutive days of enemas and has had zero accidents for at least 7 days.
So, if a child stopped having accidents on Day 23 and remained free of accidents for the ensuing 7 days, then, yes, daily enemas can stop after 30 days, and you can move on to Phase 2.
However, in this case, it seems daily enemas were halted prematurely — at a point when accidents were “infrequent” rather than nonexistent.
•Failing to drink enough water did not prompt the recurrence of accidents.
Yes, staying hydrated is important for keeping the intestinal conveyor belt running, but inadequate water intake isn’t the culprit here.
The withholding habit is deeply ingrained in chronically constipated kids; if constipation isn’t managed aggressively — not just with laxatives but also with enemas — these kids fill right back up, well before the rectum has had a chance to shrink back to size and regain tone and sensation.
Certainly encourage your son to drink plenty of water, but don’t put too much emphasis on that aspect of his treatment. The key is re-starting enemas. You might also stop the Miralax, as it can make stool leakage worse.
•Yes, recurrences are common — at any age.
Kids with encopresis tend to be superstar withholders and are at very high risk for a relapse, especially if M.O.P. was not carried through to completion, but kids can relapse even if M.O.P. is followed to the letter.
However, in this case, I wouldn’t use words like “regression,” “recurrence,” or “relapse” since accidents diminished but never completely stopped.
No matter what phase of M.O.P. a child is in, it is critical to re-start the protocol — in other words, to do another 30 consecutive days of enemas (minimum) before tapering — as soon as a child has a single accident or even a poop smear in his underwear. It’s also important to finish the entire program again. Yes, this is a lot of work, but it’s also very helpful in resolving accidents for good.
In fact, on the second go-around, many families choose to extend each phase of the program by several weeks to minimize the odds of another relapse. I think this is a great idea. One mom in our support group posted that instead of jumping from daily to every other day, she started with 3 days of enemas, 1 day off and eventually went to 2 on/1 off before tapering to every other day. Even after all that her child relapsed a month after they stopped enemas altogether. The good news: They jumped back on M.O.P. and the child has now been accident free for 5 straight months. Only now is this family thinking about tapering.
Also, know that children who have not achieved a daily spontaneous poop — in other words, kids who don’t poop every day in addition to after an enema — are at higher risk for a recurrence than kids who are initiating a poop every single day on their own. Adding Ex-Lax to M.O.P. can help kids achieve and maintain the spontaneous poop.
•Kids who seem “unfazed” by pooping in their pants typically cannot feel it happening.
Parents are universally astonished, and horrified, when children appear not to care that they’ve pooped in their pants. But children do care! Believe me, they are mortified when a parent — or worse, a kid at school — points out they’ve had an accident. Nothing I encounter in my practice is more traumatic for a child than having poop accidents.
When a child’s rectum is chronically stretched, the rectum loses sensation, and poop falls out without the child even noticing. Kids can become so desensitized that they don’t smell it, either.
I know this seems hard to believe! It’s a lot easier to believe your child is being stubborn or irresponsible or having some kind of psychological issue.
But that’s just not the case.
•Don’t place responsibility for recovery on your child.
The whole family is in this together!
Even when a child is “capable of understanding how to get better,” the embarrassment of having accidents in elementary school can be overwhelming, and many kids just shut down.
If bribery doesn’t motivate your child to do potty sits or drink more water or stop playing to use the bathroom, just back off. At this point, enemas are the most important aspects of treatment, so focus on that, and give your child loads of credit and love for working with you to resolve a really crummy problem.