By Steve Hodges, M.D.
When a child is undergoing treatment for both nighttime and daytime enuresis, a frustrating pattern often emerges: Daytime wetting resolves pretty quickly, and then progress stalls. And stalls. And stalls. Only months later does bedwetting finally start to diminish.
The delay period is so common that I’m giving it a name: the Long Lag.
Though I make a point of preparing families for this plateau, many parents become distressed, anyway. I hear two comments in particular:
•”We were doing so well, and now we’re stuck. What are we doing wrong?”
•”This isn’t working. My child’s bedwetting is never going to end.”
Both assumptions are off base! A plateau does not mean parents are doing anything “wrong” or that treatment “isn’t working.” It’s just par for the course with enuresis treatment.
The pattern also applies to children with the “trifecta”: encopresis (chronic poop accidents), daytime wetting, and nighttime wetting. Typically, poop accidents clear up right away, followed by a fairly quick resolution of daytime enuresis, followed by the Long Lag.
In this post, I’ll explain the delay between daytime and nighttime dryness and offer guidance on what additional steps to take, if any, while you and your child ride out this interval. In some cases, I recommend sticking with the regimen that halted daytime accidents. In other cases, I advise adjusting your protocol or adding bladder medication.
One note: This post assumes you’re implementing some form of the Modified O’Regan Protocol (M.O.P.), the enema-based regimen I recommend for treatment of both enuresis and encopresis. By contrast, if you’re treating these conditions only with osmotic laxatives, such as Miralax (PEG 3350), improvement in daytime accidents — if it even happens — may not be followed by a resolution of bedwetting. In my experience, without aggressive treatment like M.O.P., nighttime enuresis may persist indefinitely among children who start with both daytime and nighttime accidents. (As research shows, these kids are the least likely to spontaneously outgrow bedwetting.)
First, let’s review the physiology of enuresis, as this is critical to understanding the Long Lag.
There are, essentially, two patterns of urination — for simplicity's sake, let's call them the "baby pattern" and the "adult pattern."
As a baby, you have no control over urination. When your bladder fills to a certain level, a reflex travels from your bladder to your spinal cord and back to your bladder, which empties automatically. No signal reaches your brain (or, if it does, your brain is too immature to respond). There's no "urge" to pee that you need to react to by finding a toilet.
Eventually, by around age 3, your body transitions to the "adult pattern": The filling of your bladder sends a signal all the way up to your brain, triggering the urge to pee. If you have a healthy, stable bladder, this urge starts out subtle — you think, "Hmm, I'm going to have to find a toilet soon" — and gradually intensifies until you absolutely must heed the signal.
By contrast, children with enuresis are, essentially, stuck in the "baby pattern." Their urination signal has gone haywire, bypassing their brain, and they can't control when their bladder empties. The root cause of the misfiring, as I explain in the M.O.P. Anthology, is chronic constipation. A pile-up of stool has stretched the rectum to the point where it's aggravating the nearby bladder nerves. So, the bladder contracts and empties randomly, before it's actually full. The child does not get "notified" — in other words, the kid has no opportunity to sense the urge and then find a toilet.
Now, there are degrees of urinary dysfunction, gray areas between the "baby pattern" and the "adult pattern." A child with mild constipation may experience urinary urgency (the desperate urge to pee RIGHT THIS SECOND) and/or frequency (excessive urges to pee) but not accidents. Because their bladder is only mildly aggravated, their brain is still sensing the urge to pee, but it's happening too often or they don't have much time to react to it.
However, when constipation becomes more severe, the bladder nerves can go on the fritz more often. Maybe it's a 60/40 situation, where the child has enough time to react 60% of the time but can't react 40% of the time. (In cases like these, some parents mistakenly believe their child is wetting their pants "on purpose." Because the child sometimes has control, adults assume the child is ignoring their body other times.) Maybe it's 70/30 or 20/80.
The severity of urinary dysfunction depends on 1.) how enlarged the rectum is and 2.) how sensitive the child's bladder is to the rectal stretching.
About one-third of children with nighttime enuresis also experience daytime wetting. In my practice, x-rays show that compared to the bedwetting-only kids, those with both day and night wetting typically have more stool build-up. In other words, their rectum is even more stretched, so the bladder is more aggravated and prone to spasms.
It takes a mighty aggravated bladder to trigger accidents while the child is awake. Bedwetting is more common because it takes less severe bladder overactivity to cause accidents while a child is sleeping. (No, deep sleep doesn't "cause" accidents; bladder overactivity causes accidents while the child happens to be sleeping.)
In general, the most severely constipated children are the "trifecta" kids. Not only has their bladder gone haywire, but their rectum has stretched to the point of losing tone and sensation. So, poop just falls out the child’s bottom, without the child noticing. The child can’t sense the urge to poop, so even more stool accumulates, further stretching the rectum. It’s a vicious cycle.
These kids can't control either peeing or pooping.
(Encopresis-only kids have floppy rectums but bladders of steel — that is, bladder nerves that withstand tremendous pressure from the encroaching rectum. A small minority of children have daytime wetting but not bedwetting, a scenario that baffles parents. My best guess is the child's sleeping position allows the overactive bladder to stay calm overnight.)
It takes a monumentally clogged rectum to cause poop accidents.That’s why encopresis clears up so quickly with daily enemas. Making a modest dent in the stool pile-up is often enough to keep accidents at bay. Many children even stop having poop accidents after the first or second enema. (This tells you how useless Miralax is. Many of these same children took oral laxatives literally for years with no improvement.)
Sure, halting encopresis takes longer with some children, and accidents will likely recur if you stop the enema regimen before the rectum has regained tone and sensation. (The rectum, once emptied, needs about three months to heal.) However, it’s the rare patient who continues to have poop accidents after a month of daily enemas or, in the tougher cases, twice-daily glycerin enemas.
Daytime wetting often resolves on a brisk timeline, too, though not as quickly as encopresis. That’s because it takes a bigger dent in the stool mass to calm an overactive bladder than to stop poop from falling out of a child’s bottom. Most kids see a significant improvement in daytime enuresis, if not a total resolution, within a month or two of starting M.O.P.
I emphasize to parents of the “trifecta" kids that you can’t expect daytime accidents to diminish, let alone stop, until all traces of poop accidents, including underwear poop smears, have vanished.
This caution comes as a disappointment to parents. Because enemas sound more “extreme” than oral laxatives, folks assume all three symptoms will disappear at once. But that’s just not how the body of a constipated child works. You have to crawl before you can walk and walk before you can run, Once each symptom resolves, you’re essentially re-starting the treatment clock.
I also tell parents of my enuresis patients to expect setbacks in daytime wetting. “Two steps forward, one step back” is more common than linear improvement. Overactive bladders don’t regain stability on a schedule.
OK, this brings us — at long last! — to the Long Lag.
Why do kids who have overcome daytime wetting still drench their pull-ups overnight? Because the bladder hasn’t yet regained enough stability to go all night without emptying.
Before, the bladder was totally cattywampus, so even while awake, the child had no chance to react accordingly (i.e. get to the toilet). Now that the bladder nerves are on the mend, the child can sense the urge to pee while awake, but reacting while asleep is too steep a hill to climb.
In my experience, nighttime wetting doesn’t even begin to improve until every last daytime urinary symptom has disappeared. This includes both urinary urgency and frequency. In a child with constipation, these symptoms are the first to surface and the last to disappear. Often, parents don’t notice these symptoms because they’re so thrilled their child's daytime wetting has stopped. Children themselves may not notice the symptoms or report them to Mom or Dad.
OK, but what if all daytime symptoms are long gone and your child still wakes up wet every morning? Why is the Long Lag so darned long?
There are two explanations. It’s important to distinguish between them, ideally with an x-ray, because the solutions are different.
Scenario 1: The rectum is still harboring stool.
Parents are often incredulous when, after months of daily enemas, an x-ray shows their child’s constipation persists. It seems impossible. Yet it happens fairly often.
As one mom in our private support group put it, “I feel like I am chipping away at a cement block with a garden hose!”
Another mom posted: “I thought if we can put a man on the moon, we can get impacted stool out of my child and move on. My biggest surprise has been that for my son, this is a long process.” She added: “Be emotionally prepared for M.O.P. to take longer than you expect.”
Sometimes, a follow-up x-ray even will show more constipation than an earlier film, a demoralizing situation, to be sure. It could be that the family, weary of daily enemas, backed off on treatment, figuring the resolution of daytime wetting signaled that dry sheets were on the horizon. But with less pooping, the child’s rectum gradually began to refill, delaying improvement.
In other cases, the family has diligently maintained the enema regimen, but the rectum simply will not empty.
Geez, if an enema every day won’t clean out a rectum, what will?
Two enemas every day. For many kids, the regimen I call Multi-M.O.P. does the trick. (As I explain in the Anthology, Multi-M.O.P. can be done with liquid glycerin or docusate sodium but not phosphate (Fleet) or Microlax.) I have many patients whose daytime symptoms cleared up on Standard M.O.P. but who needed two enemas per day to get empty enough for bedwetting to stop.
Remarkably, even Multi-M.O.P. doesn’t suffice for some kids. The x-ray shows stool seemingly plastered to the rectum. For these patients, I recommend adding overnight oil enemas to the daytime regimen (either the Double M.O.P. or J-M.O.P. regimens described in the Anthology). Oil-retention enemas can be a game-changer, softening the hardened stool overnight, so it can be washed away with the morning’s enema.
If the latest x-ray shows improvement from a previous x-ray, you may not need to change your regimen at all. Your child may simply be on a super slow trajectory and need more time to empty. Sometimes, an x-ray will reveal progress that just hasn't translated yet into less bedwetting, and all that is required is persistence (and patience).
READ: Olive Oil Enemas for Childhood Constipation: An Old-School Treatment Gets Scientific Validation
Scenario 2: The rectum is empty but still stretched.
Sometimes, when I x-ray a child mired in the Long Log, I see a rectum that has been cleared of stool yet remains enlarged. No wonder the bladder is still spasming!
In virtually all cases, the rectum, given enough time, will shrink back to normal and stop aggravating the bladder nerves. But many kids don’t have that much time. Teenagers become especially demoralized by persistent bedwetting, especially after investing so much effort into daily enemas. Some are depressed, anxious, and feeling down on themselves. Their parents are tired of it all, too.
READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
For families stuck in this situation, I recommend adding bladder medication to the M.O.P. regimen. (I explain the three medication categories in the Anthology.) In a child with stool in the rectum, bladder medication is usually ineffective — that’s why drugs are a poor first-line therapy. However, in a child with an empty but dilated rectum, meds often can provide dry nights, buying the child confidence and peace of mind until dryness occurs naturally.
I advise my patients on medication to continue with M.O.P. and periodically take a break from the meds to test whether dryness holds. At some point the “fake dry,” as one mom called medication-induced dry nights, becomes a genuine dry. At that point, the child tapers from the enema regimen.
What if the medication doesn’t work or the dryness doesn’t hold without meds?
In these situations, I recommend bladder Botox, a short surgical procedure that is highly effective in children whose rectum has emptied. By the time the Botox wears off, the child’s rectum has fully healed, and the dryness will persist.
The most accurate way to distinguish between scenarios 1 and 2 is, of course, an abdominal x-ray. For children who plateau after daytime wetting stops, I recommend an x-ray one or two months into the “long lag” period. (This advice assumes the child has made zero progress; if you see even slight improvement, forego an x-ray and continue the regimen.)
What if you live in a country where x-rays are not available? You can make an educated guess as to the state of your child’s rectum by looking for the “soft” signs of improvement.
For example, if your child’s pull-up is less soaked in the morning or if nighttime accidents happen further into the night, like at 4 a.m. instead of midnight, the rectum is likely empty and on the mend. (A bedwetting alarm can provide clues, as explained in the Anthology).
As long as you detect progress, continue with the enema regimen — dryness is likely around the corner. If you don’t see improvement, try adding overnight oil enemas.
I wish I could speed up this process!
In the meantime, if your child is stuck in the Long Lag, think back to where you started. Many parents report feeling “defeated” when their child has plateaued. They use terms like “failed” and “unsuccessful,” forgetting how far their child has progressed from the days when they had accidents at school or couldn’t go to day camp — when the whole family’s lives were upended by daytime accidents.
I recently received an email from a mom frustrated that her 6-year-old was stuck in the Long Lag despite staunch adherence to Multi-M.O.P.
This was a girl who, at age 4, had suffered greatly from the “trifecta,” including 3 or 4 poop accidents per day. Back then, the mom said, her daughter’s daytime accidents were “affecting her confidence and ability to go to school and majorly having an impact on my mental health.”
A Miralax "clean-out,” recommended by the girl’s doctor, had done nothing to reduce the accidents, and neither had 7 months of laxative treatment. When this mom posted her daughter’s x-ray in our private support group, I responded, “This is a significantly dilated and expanded rectum. This will take a while.”
I know that's not what any parent wants to hear! And when it proves true, parents feel discouraged.
I urged this mom to continue her daughter’s M.O.P. regimen, get an x-ray, and look at the big picture. She took the advice to heart and conceded that she’d forgotten how bad things had been two years earlier.
“It’s hard to keep going some days,” she responded, “but seeing how far we’ve come definitely gives me motivation to keep going.”