By Steve Hodges, M.D.
Parents ask me excellent questions about treating enuresis and encopresis. If your child is struggling with accidents, whether daytime or nighttime, you may have the same questions. Here's a round-up of recent queries sent via email or posted in our private Facebook support groups.
Q: My son is 5 and has urinary incontinence. He’s on a low dose of Miralax daily, but I still think he’s constipated. I’m considering M.O.P. but wondering: Is it possible to avoid enemas? My son is terrified of them.
A: I would never say rectal therapy is “absolutely necessary” for enuresis, and certainly, the child must be on board with enemas. However, objectively speaking, M.O.P. is far more effective than Miralax for treating daytime and/or nighttime wetting.
In a study my clinic conducted on children with daytime wetting, daytime accidents resolved in three months in 85% of the children who used enemas, compared to 30% of the children who used Miralax. Many families waste years on the Miralax merry-go-round!
For most kids, enemas become routine pretty quickly. Our Enema Rescue Guide, included in the M.O.P. Anthology 5th Edition, offers practical and creative strategies to help children become more comfortable with the idea — all recommended by parents who have been there. Two of our children’s books, Emma and the E Club and Bedwetting and Accidents Aren’t Your Fault, also help kids warm up to the idea of enemas.
Here are a few blog posts that might help:
Q: It feels like my son had better output — good, big bowel movements — and more spontaneous pooping before starting M.O.P., even though he had 1-2 daily soiling accidents. After 3 weeks on enemas, his accidents have stopped, but how do I get him back up to having good output when he poops?
A: Your son is off to a great start! Remember that kids can poop every single day and still be monumentally constipated. Having "good big bowel movements" doesn’t mean anything if accompanied by accidents. Also, I"m not sure how you're defining "big," but extra-large bowel movements are, themselves, a red flag for constipation, signaling that stool has been piling up in the rectum.
I wouldn’t expect spontaneous pooping just three weeks into M.O.P. Children with encopresis typically have a very stretched rectum, due to significant poop accumulation. As a result, the rectum has lost a lot of sensation and tone. The child just isn’t feeling the urge to poop and doesn’t have the capacity to fully evacuate.
Once the rectum is completely cleared, it takes about three months to shrink back to size and fully heal. The urge to poop will return gradually.
In the meantime, if you don’t think the current type of enema is producing enough, you might try a different solution, whether liquid glycerin, phosphate, or docusate sodium. Or, you could stimulate a second daily bowel movement, either with Ex-Lax, as described in the M.O.P.x section of the M.O.P. Anthology 5th Edition, or with two glycerin or docusate sodium enemas per day (Multi-M.O.P.). We are finding that two stimulated bowel movements per day gets kids emptier faster. If a child is pooping just once a day, it's hard to make a dent in the poop pile-up.
Keep in mind that children with encopresis are particularly prone to a recurrence of accidents, so I suggest the “slow taper” approach, described on pages 68-69 of the Anthology.
Q: We are doing M.O.P. for the trifecta of encopresis, daytime enuresis, and nighttime wetting. At this age (she's 5), her wetting doesn’t bother me and doesn’t disrupt our lives — not in the same way that wetting up to 40 times a day did, at our very worst. If we can resolve the encopresis and daytime accidents, I wonder if we will continue enemas “just” for the nighttime wetting. Thoughts?
A: Yes, our thought is: Don’t minimize nighttime wetting! Just because bedwetting doesn't bother you or your child now does not mean that will be the case when she is 7 or 10 or 13, at which point it will be harder to treat (and you will have purchased several more years of pull-ups).
Also, keep in mind you can’t turn off bedwetting like a faucet the moment it feels burdensome to the family or becomes embarrassing for the child.
You may not even know whether or when bedwetting distresses your daughter. Several pelvic floor therapists have told us that accidents, whether daytime or nighttime, take a bigger emotional toll on children than they let on. One physical therapist told us she talks to her patients via Walkie Talkie and from a different room because they'll share their feelings more openly if they don’t have to look an adult in the eyes. “The floodgates open up,” she said. Most patients tell her they’re distressed by bedwetting but don’t tell their parents for fear of disappointing them.
No doubt, bedwetting feels like a minor nuisance right now compared to daytime accidents, but remember that the cause of all accidents is the same: chronic constipation. So, if you stop enemas before nighttime wetting has resolved, not only will you prolong overnight accidents, but your child may be prone to a recurrence of daytime accidents.
At my clinic I treat bedwetting at age 4. If this were standard practice, teenage bedwetting would not be a thing. Yet it is. Most parents in our private Facebook support group for parents of teens wish they had been advised to treat their child a decade earlier, when treatment would have been easier and before their child had missed out on sleepovers and school overnights before the child’s self-esteem had been affected.
Finally, know that in children with both daytime and nighttime accidents, bedwetting is unlikely to disappear without treatment. Research shows the children least likely to outgrow bedwetting spontaneously are those with a history of daytime enuresis and/or encopresis.
Bottom line: In my view, children don’t benefit from delaying treatment or downgrading the regimen before accidents completely cease, day and night.
These blog posts may help:
Q: My daughter, age 13, has urine accidents at night. She has regular bowel movements, but the consistency is hard and lumpy. Her pediatrician does not feel any lumps in her belly, no blockage. She will hyper focus on a game or task, ignore the urge to go, and wet herself. Or not feel the urge to go at all. She takes Miralax, which we call her “poop juice.” What do you recommend?
A: I recommend M.O.P., as Miralax is highly unlikely to resolve her enuresis.
Based on her persistent wetting, I’d bet your daughter is more constipated than her doctor suggests. It doesn’t matter whether a child is “regular” — what matters is whether the child is evacuating completely.
Also, a doctor cannot accurately evaluate a child’s constipation status simply by feeling the child’s belly, as I explain on page 35 of the M.O.P. Anthology 5th Edition. An abdominal x-ray is the most accurate way to assess a child’s constipation status.
For teens, I don’t like to waste time, and I suggest starting with either M.O.P.x (a daily enema plus a daily stimulant laxative ) or Multi-M.O.P. (two liquid glycerin enemas per day). Both variations are detailed in the Anthology 5th Edition.
Finally, I would not attribute your daughter’s accidents to being “hyper focused and ignoring the urge to go.” When children have chronic constipation, the bladder nerves are aggravated, causing the bladder to contract suddenly and forcefully — there is no way the child can stop the accidents, whether it’s daytime or nighttime.
Once her rectum is fully cleaned out and the rectum shrinks back to size and stops bothering the bladder, her accidents will stop, regardless of her focus.
These blog posts might help:
•Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable