By Steve Hodges, M.D.
If one child outgrew bedwetting, can you expect the child's sibling to have the same luck? Will an enema clear out the entire colon or just the rectum? Should kids who have accidents wear pull-ups or underwear?
These are a few of the questions I address below, all pertaining to constipation in children.The questions were posted by parents in our private encopresis/enuresis support group. The answers may surprise you!
Q: My 6-year-old used to have 20+ accidents per week, mostly poop but some wetting, plus wet pull-ups every night. Per the GI, we started daily Ex-Lax and Miralax. I don’t think her daytime pee accidents are physiological. Behavioral incentives have helped minimize accidents at kindergarten — accidents are down to 1-3 a week, from 1-2 per day. A side note: My 9 y.o. had bedwetting until age 7.5. Given that history, nighttime wetness doesn’t stress me out. It’s the daytime poop accidents that consume our lives. What do you recommend?
A: For my patients with the “trifecta” — poop accidents, daytime pee accidents, plus bedwetting — I recommend Multi-M.O.P., a regimen involving two liquid glycerin or docusate sodium enemas per day and no laxatives. The protocol, far more effective than a laxative-only regimen, is spelled out in detail in the M.O.P. Anthology 5th Edition.
Your daughter’s poop accidents will stop quickly, and then her pee accidents will stop. Nighttime enuresis will take considerably longer to resolve, a phenomenon I refer to as the “Long Lag.”
It’s important to understand that daytime pee accidents are indeed physiological, not behavioral. All accidents — pee and poop, daytime and nighttime — are symptoms of the same condition: chronic constipation. Kids don’t wet or soil their parents because they’re anxious or seeking attention. Their signals to pee and poop are on the fritz.
An aggravated bladder can spasm any time. Sometimes the child may feel the urge to pee; other times she might not, and the bladder will randomly hiccup and empty. If your daughter didn't have chronic constipation, she wouldn't have wetting accidents at all.
I'd focus on constipation treatment rather than incentives. Incentives send the message to kids that they could stop having accidents if only they put forth effort. But kids with enuresis and/or encopresis aren’t in control of their bladder and bowels. So, when they have accidents despite incentives, they may feel as if they’ve failed or disappointed their parents.
In addition, I wouldn't compare one sibling's experience with another's. It's great your older child stopped wetting without treatment. However, I have plenty of teenage patients who did not stop wetting even though a sibling did. Siblings often follow different trajectories. To nip accidents in the bud, I always advise erring on the side of more aggressive treatment.
Q: Our GI doctor said we can do M.O.P. if we want, but she doesn’t recommend it because enemas only clear out part of the colon. Is this true?
A: It is true that enemas primarily clear out the rectum, the end portion of the colon, but that is precisely the part of the colon that causes accidents!
An accumulation of stool further up in the colon — specifically in the right (ascending) colon — is commonly seen in x-rays of children with enuresis and/or encopresis. However, a back-up in this part won’t trigger accidents. The real culprit is the stool-clogged rectum.
The rectum sits right next to the bladder, so when the rectum becomes clogged by an idle mass of stool, it stretches and weakens. In children with a sensitive bladder, the bulging rectum aggravates the bladder nerves, triggering accidents.
In the case of encopresis, the floppy rectum loses sensation and tone. So, children with this condition don’t feel the urge to poop and don’t have the tone to fully evacuate, anyway. As a result, even more stool piles up, and poop just drops out of the child’s bottom, without the child noticing.
An accumulation of stool further up in the colon may cause a stomachache, but it’s not going to trigger accidents. The key to resolving enuresis and encopresis is to completely empty the rectum and keep it clear on a daily basis for several months. Only then can it shrink back to size, regain full tone and sensation, and stop aggravating the bladder.
An enema-based regimen such as the Modified O'Regan Protocol is far more effective at clearing out the rectum than a Miralax “clean out” and/or daily “maintenance” Miralax.
The problem with a high-dose laxative “clean out” is that the softened stool just washes past the impacted mass. So, the child ends up with both diarrhea and constipation — a big mess that accomplishes nothing. Sometimes, the laxative just pushes poop that’s stuck higher in the colon further downstream, further clogging and stretching the rectum and allowing accidents to worsen. Even when the rectum actually does empty, the results tend to be temporary. These kids fill right back up because the rectum hasn’t had time to heal.
In my clinic, we use the term “O’Regan sign” to refer to the pattern we commonly see in the x-rays of patients with enuresis and/or encopresis: an accumulation of poop in ascending colon plus a back-up in the rectum, the part that matters. The term is named after Sean O’Regan, the doctor who first recognized that incomplete emptying of the rectum is the root cause of enuresis and encopresis. Dr. O’Regan, a pediatric kidney specialist, also pioneered the step-down enema regimen on which M.O.P. is based.
Q: When I mentioned M.O.P. in an online parents’ group, I was met with backlash stating that “daily enemas strip the mucosal lining.” Is this accurate?
A: No. Some children do experience a burning sensation or colitis, an inflammation of the colon lining, from chronic use of phosphate enemas (such as Fleet “saline” enemas). But that is easily rectified by switching to liquid glycerin or docusate sodium, enema solutions that are gentle in almost all kids.
The majority of my patients on M.O.P. use homemade liquid glycerin enemas, a much less expensive option that requires nothing more than a bottle of vegetable glycerin and a pack of syringes. You can find instructions for DIY glycerin enemas in the M.O.P. Anthology 5th Edition, and parents have posted video demonstrations in our private Facebook support group.
Certainly, the low risk of colitis with phosphate enemas is not a reason to avoid M.O.P. altogether.
Q: My 5 y.o. has daytime enuresis, “skid marks,” and bedwetting. He went through 8 pairs of undies/pants at school yesterday. When I asked if he feels uncomfortable in wet undies, he says he's gotten so used to it that he doesn't notice. Should I put him in pull-ups so he remembers what feeling 'dry' is like?
A: Definitely keep him in pull-ups for his comfort, confidence, and convenience — but not for any reasons pertaining to sensation. Pull-ups won't help him "remember" what it's like to feel dry. Children with enuresis and/or encopresis don’t receive the signal they’re about to pee or poop and often don’t notice when they’ve had an accident, whether they’re wearing pull-ups or underwear.
Q: My 7 y.o. has bedwetting, and has struggled with naptime wetting and skid marks. I think the 40-minute school bus and school atmosphere make him withhold. He is a healthy eater and plays sports except in winter. After 2 years of laxatives with no progress, we started M.O.P.x. He has had a dry diaper 3-4 nights in a row and once stayed dry for 7 nights but still mostly wakes up wet. I just started having him exercise more. Please advise what else we can do.
A: Exercise and nutritious eating are, of course, important for all children (and adults, too!). However, these healthy habits tend to make little difference in resolving enuresis and/or encopresis, so I wouldn't expect much improvement from increased exercise. I have many patients who are high-level athletes and nonetheless struggle with chronic constipation and accidents. There is a significant genetic component to constipation, and other factors contribute as well.
The fact that your son already has had some dry nights bodes well, and continuing with M.O.P.x may suffice. However, I recommend getting an abdominal x-ray to assess your child’s rectum. If he’s still significantly clogged, you might add overnight olive oil enemas to his regimen. (See the
Double M.O.P. and J-M.O.P. sections of the Anthology for details,) Then, when accidents cease, re-introduce Ex-Lax as a tool to help him overcome withholding. Alternately, if his x-ray looks good, I recommend staying the course.
READ: Olive Oil Enemas for Childhood Constipation: An Old-School Treatment Gets Scientific Validation
The variety of keywords in Quick Draw creates many different challenges. Sometimes, you have to create from simple lines to describe a complex concept, challenging your ability to express.