By Steve Hodges, M.D.
Here's a round-up of recent questions posted by parents in our private Facebook support group or asked live in our monthly Zoom sessions. We covered poop and pee withholding, bladder medication, Ex-Lax and Miralax, a recurrence of accidents in a teenager, and explosive pee accidents versus a "drip drip drip."
Q: We’re 6 weeks into M.O.P. with my 4 y.o. who has encopresis and enuresis. Her poop accidents and streaks have stopped, but she leaks small amount of pee more or less constantly — whenever I check her underwear, there’s a pee stain. Plus, she’ll periodically explode with a massive pee accident, day or night, and she withholds urine, rarely initiating peeing. Her baseline x-ray showed she was up to her ears in poop, but her latest x-ray is much better. Why is she leaking pee all the time, and what can we do?
A: It sounds like your daughter is contending with two separate issues. The explosive pee accidents are classic enuresis: Her rectum, enlarged by the poop pile-up, is is aggravating her bladder nerves, triggering sudden, forceful bladder contractions. Meanwhile, the constant small leakage is caused by an easily rectified phenomenon called vaginal voiding. Some girls have both issues.
To treat the explosive pee accidents, continue with M.O.P. Her x-ray indicates she’s on the right track, and eventually — once her rectum has fully emptied and healed — the accidents will stop. Six weeks isn’t nearly enough time to resolve both encopresis and enuresis, so try to be patient! It typically takes three months for a stretched rectum, once emptied, to shrink back to normal size, and aggravated bladder nerves can take even longer to settle down. When children begin with both encopresis and enuresis, you can expect a long haul.
Regarding your daughter's pee withholding: In my experience, it’s not worthwhile to nudge kids with enuresis to pee more often. Earlier in my career, I would recommend “timed voiding” — for example, instructing children to pee every hour or two. But that was before I really understood enuresis. Kids would sit on the toilet forever and nothing would come out, and then a few minutes later, they’d have an accident. Both parents and kids would get frustrated.
What I’ve learned is that you can’t successfully tell (or teach) a child to pee any more than you can force someone to fall asleep. This became obvious to me when I gave one of my enuresis patients a bladder Botox injection. The day after the injection, the boy was peeing normally — after a lifetime of accidents and pee withholding. Now, I didn’t “teach” that kid to pee. Rather, the combination of M.O.P. and Botox restored his urge to pee. Bottom line; if you just fix the underlying cause of a child's overactive bladder — chronic constipation — peeing and pooping will fall into place.
As for the drip, drip, drip in your daughter's underwear, that’s easily resolved. This phenomenon is known as vaginal voiding because these girls are literally peeing into their vagina, where the urine pools and later drips out.
Vaginal voiding happens when girls pee with their legs close together. Some of the urine is directed up into the vagina and sits there until it spills out with vigorous activity. Since the pee isn’t coming from the bladder, the child doesn’t feel herself wetting but ends up wet all the same. When I examine girls in my clinic, I often see urine pooled in the vagina.
To prevent vaginal voiding, advise your daughter to pee with her legs as wide apart as possible and to spread apart her labia. She’ll feel like she’s almost going to pee over the toilet. This position directs urine directly from the bladder into the toilet, without touching the skin.
To really emphasize the point, you could even have your daughter sit backward on the toilet, ensuring that her legs are far apart and that all her pee ends up in the toilet.
When she wipes, she should lean forward, so any urine that went up into the vagina can drip out. Also, she should wipe the inside of her privates when she is done peeing. Most little girls tend to wipe only the outside.
Q: My 12-year-old has had nighttime enuresis since forever. She’s never had more than 5 dry nights in a row, even on M.O.P. She is now on Multi-M.O.P. with two liquid glycerin suppositories [LGS] daily, in addition to oral laxatives, and it’s been three months since her last dry night. Her doctor prescribed her .2 mg desmopressin. She has tried it twice and was dry both times, but she hasn’t taken the medication routinely, because then we wouldn’t know if the enemas are working. Please evaluate our current x-ray and advise.
A: Her x-ray shows there is actually still some rectal poop, which confirms just how difficult it can be to clean out some kids. However, she’s made great progress, and the fact that she was able to stay dry on desmopressin twice is an excellent sign. Probably fewer than 5% of children can stay dry on such a low dose, and kids with significant amounts of rectal stool can’t stay dry on desmopressin at all. I predict she is close to dryness. Keep up the good work!
By the way, it is fine for her to take desmopressin daily while continuing Multi-M.O.P. She can take a day off periodically to test whether the dryness holds. Once she's able to remain accident-free without desmopressin, she can start tapering off enemas and then laxatives. The M.O.P. Anthology 5th Edition (see page 89) includes an interview with a mom and her 14-year-old son who was on Multi-M.O.P. and desmopressin. Once a week, the boy would skip desmopressin to see if he still needed it. Eventually, after staying dry for a month on Multi-M.O.P. without desmopressin, he felt confident enough to start tapering. Your daughter could do the same.
Q: My 5-year-old has encopresis. We’ve had so much success with Multi-M.O.P. — zero accidents last month, compared with 5 or 6 per day before M.O.P. — that we’re moving on to Phase 2. With one LGS per day, should we expect him to poop twice a day, or is once a day OK as long as he says accident-free? Also, with Phase 2, I know we’re supposed to add an osmotic laxative, but I have PTSD from Miralax before M.O.P. I was thinking of switching to magnesium citrate, but how do I know if I’m giving him enough?
A: As your son transitions to one enema per day, it’s fine for him to poop once a day, as long he stays accident-free. However, once he tapers further, it will be critical for him to poop on non-enema days, and if that doesn’t happen on an osmotic, I suggest giving him Ex-Lax (or another senna-based stimulant laxative) on those days. Then, assuming all goes well, you can taper the Ex-Lax and, eventually, the osmotic.
The purpose of osmostic laxatives, such as Miralax and magnesium citrate, is to keep poop soft, like hummus or a milkshake or a cow patty. You want to avoid diarrhea or poop that’s too firm. It can take some experimentation to find the right dose.
You certainly can try magnesium citrate, but I wouldn’t be fearful of trying Miralax again. Now that he’s accident-free and, presumably, pretty cleared out, an osmotic laxative, whether Miralax or another type, won’t cause the big mess you experienced before. I discuss the pros and cons of the four most popular osmotic laxatives — PEG 3350, lactulose, magnesium citrate, and magnesium hydroxide — on pages 101-103 of the Anthology, under “Osmotic Laxatives: Options, Timing, and Dosing.”
Q: My son is 18 and has been a hot mess of bladder problems since he was small. At 14, we started trying to solve this, and eventually he got dry on M.O.P. Then he stopped doing enemas and Miralax because he thought he was good. But recently he got sick and then had a few accidents. He was back to hard poop like rabbit pellets. Is a few days of constipation enough to set him this far back, or are the accidents from being sick?
A: Every kid is different in terms of how much rectal stretching is needed to cause a bladder spasm. With your son, it appears that he is highly prone to getting backed up and even a slightly enlarged rectum is enough to trigger these spasms.
It’s unlikely that the illness itself caused the accidents but rather dehydration (from the illness) or a dietary change or whatever it is that sets off constipation for him. If enemas plus laxatives resolved the accidents in the first place, the regimen will work again. I suggest he return to whatever M.O.P. variation enabled him to get dry. Then, once he’s reliably accident-free again, he might follow one of the Slow Taper regimens (see pages 68-69 of the Anthology) and remain on Miralax or another osmotic laxative for a good year before weaning off. At that point, he should stay vigilant for signs of constipation and return to a laxative at the first hint that he’s getting backed up.
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