By Steve Hodges, M.D.
When I explain to parents that their child’s bedwetting and daytime accidents are caused by constipation — not an underdeveloped bladder, deep sleep, or behavioral issues — folks tend to have loads of questions. Such as;
How can you be so sure the cause is constipation?
How can a kid who poops every day be constipated?
Why do some constipated kids wet the bed while others stay dry?
How can a child not even notice they’re having an accident?
At what age should you treat bedwetting?
What’s your opinion on Miralax?
Good questions! As it happens, these are also among the questions I was recently asked on the Brainy Moms podcast. Dr. Amy Moore, a cognitive psychologist, and Sandy Zamalis, a cognitive specialist, really nailed the issues that surface most often at my clinic. During the interview, we also touched on enemas (aren’t they too aggressive?), bladder Botox, potty training, the gut microbiome, the connection between autism and constipation, and my theory on a possible connection between childhood constipation and IBS in adulthood.
In this blog post, I will supplement their terrific interview with additional information on several of the topics we covered.
Question: How can you be so sure constipation causes bedwetting and daytime accidents?
Answer: Because I x-ray all my enuresis patients to confirm constipation, and I know from 20 years of practice that when a child’s clogged rectum empties and shrinks back to normal sizes, the wetting stops. Plus, the connection between constipation and enuresis has been confirmed by several published studies.
When it comes to diagnosing constipation, you can’t argue with an x-ray. The film of an enuresis patient will clearly show a rectum enlarged by a pile-up of stool, often to two or three times the normal rectal diameter. The oversized rectum, in turn, presses against and aggravates the bladder nerves, trigging sudden contractions that empty the bladder. I’ve seen patients have pee accidents right in my exam room, and they don’t even know it. Parents find that hard to grasp!
There are handful of rare medical conditions that can cause wetting in the absence of constipation, and if an x-ray shows an empty rectum, I know to look elsewhere for the culprit. However, I can’t emphasize how rare these conditions are (I discuss them in the M.O.P. Anthology). In nearly all enuresis cases, the rectum is chock full of stool, and the child has a garden-variety case of chronic constipation.
My motto is: Constipated until proven otherwise. You cannot rule out constipation by feeling a child’s belly or asking how often the child poops. In my experience, there are only two reliable methods of diagnosing constipation: x-ray and anorectal manometry, which involves inserting a balloon into the child’s rectum and inflating it until the child feels pressure.
Anorectal manometry was the method used by Dr. Sean O’Regan, the pediatric kidney specialist whose published studies in the 1980s demonstrated that a rectum enlarged by stool is the root cause of enuresis, encopresis, and chronic urinary tract infections. A plain x-ray is a lot easier on the child than anorectal manometry and is plenty safe, so that’s the method I use.
In the Anthology, I tell the remarkable story of how Dr. O’Regan, on a mission to solve the mystery of his own son’s bedwetting, came to discover constipation is the culprit. It was Dr. O’Regan’s research that changed my career. The enema-based treatment approach I recommend to my patients, the Modified O’Regan Protocol (M.O.P.), is named for him.
Question: You’ve said that even kids who poop every day can be constipated. How can that be? Doesn’t constipation, by definition, mean “infrequent pooping”?
Answer: The conventional understanding of constipation, such as “pooping less than 3 times a week”, doesn’t fit the scenario we’re talking about. A better definition is “incomplete emptying of the rectum.” Not too catchy! I wish I could come up with better terminology.
Certainly, a child who poops infrequently is constipated. After all, the digestive system never stops, so any day you don’t poop is a day that stool piles up in your rectum. However, many children with a clogged rectum poop daily or even multiple times a day. The problem is that their rectum doesn’t fully evacuate, so stool accumulates, and nobody is the wiser.
The stool mass sits there and dries out, further stretching the rectum and making pooping even more painful. So, kids further delay pooping, and a vicious cycle ensues.
As I explain in the Anthology, the rectum was designed as a sensing organ — once stool travels through the colon and arrives in the rectum, you feel that urge to poop. But in constipated children, the rectum is transformed into a storage organ, a job it was not intended for. The enlarged, floppy rectum loses sensation and tone. The child no longer receives the signal to poop and the rectum loses the oomph to shovel out poop.
In the case of encopresis, the rectum has become so stretched and desensitized that stool just falls out of the child’s bottom, without the child noticing. Many children have both enuresis and encopresis.
Question: Many children with enuresis end up in the care of mental health professionals because it is often assumed that accidents are behavioral or psychological. What is your message to counselors and parents on that topic?
Answer: Yes, I’m on a mission to educate folks that enuresis and encopresis are not caused by stress, anxiety, attention-seeking, laziness (some people believe that!) or any other issues related to mental health or behavior.
Many adults think kids “should know better” than to have accidents and offer rewards to kids when they stay dry. But as I often tell parents, an overactive bladder does not respond to the prospect of earning M&Ms! Incentives suggest to the child that stopping accidents is within their control. But it’s not, so kids who are offered rewards feel like failures when they have an accident.
My key message is: Accidents are never a child’s fault. When the bladder contracts and empties, the child simply has no control. It’s like when the doctor hits your knee with a reflex hammer and your knee kicks — there’s no stopping it. Similarly, an overactive bladder will squeeze and empty on autopilot.
To stop accidents, you need to resolve the underlying constipation. The rectum will shrink back to size and stop bothering the bladder, and the child’s signals to pee will be restored. Kids will automatically stop what they’re doing and go to the bathroom right away. They won’t need any bribery or reminders. Once the normal physiology is restored, the child’s “behavior” returns to normal. In fact, kids not only pee and poop without delay, but many parents report an improved mood and demeanor. This is hardly surprising; carrying around a belly load of poop is uncomfortable and can make anyone feel cranky and miserable.
Unfortunately, none of the above is widely known, and many kids are punished, shamed, and physically abused for having accidents. I have a large collection of news articles about parents sentenced to prison for harming or murdering their children for bedwetting or daytime accidents. That really breaks my heart.
Even adults who would never scold a child for accidents tend to believe there must be some psychological component involved. The term “bedwetting” has seeped into popular culture as a synonym for “excessive worry.” People in politics — well-meaning, educated people — use the term “bedwetter” in a derogatory way all the time. That’s my pet peeve! There are many words in the English that have become unacceptable to use because society has advanced, but somehow people continue to use “bedwetter” as an insult.
Question: You’ve said bedwetting and accidents are “not a normal part of childhood,” but you’ve also said 15% to 20% of 5-year-olds wet the bed, and most kids do eventually outgrow it. How do you reconcile that?
Answer: “Common” is not the same as “normal.” Lots of conditions are common — high blood pressure and obesity, for example — but they are not healthy and, like enuresis and encopresis, they’re treatable and preventable. Chronic constipation is plenty common, for reasons pertaining to life in the 21st Century. But this doesn’t mean all constipated kids will have accidents. Many are lucky enough to have a bladder that is not particularly sensitive to rectal stretching. In some children a slightly enlarged rectum will cause an overactive bladder, whereas in other kids, it takes a mondo-sized rectum to trigger bladder contractions.
That’s why, with treatment, some kids will see quick progress — a small reduction in bladder size will do the trick — whereas others take months and months to see improvement.
You can’t predict which kids will improve quickly, though it’s clear that children with the “trifecta” — bedwetting, daytime wetting, and poop accidents — are in for a long haul. Encopresis usually resolves quickly, but there’s typically a long lag between the resolution of daytime accidents and nighttime accidents. The trifecta kids are also the least likely to spontaneously outgrow accidents, research shows.
In general, you can’t predict which kids will stop wetting without treatment and which won’t, which is why I start treating bedwetting at age 4. Enuresis is a lot easier to treat in preschool than in high school, and I don’t see any benefit to a child to spend years waiting for the magic day they will wake up dry — a day that may never come.
I have a large caseload of teenagers with enuresis, and all of them were told, year after year, “Don’t worry, you’ll outgrow it.” Believe me, they wish they’d been treated in kindergarten. Wetting the bed in high school is monumentally stressful, especially with college on the horizon.
READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
Question: Why do you favor enemas over oral laxatives for treating enuresis and encopresis? What happens if your child refuses enemas?
Answer: It was Dr. O’Regan who proved, back in the 1980s — before Miralax even existed — that enemas are highly effective at resolving enuresis and encopresis. In that era, enemas didn’t carry the stigma they do today. Dr. O’Regan told me it was no big deal when he prescribed them to his patients. Today, unfortunately, many parents and doctors have gotten the impression that enemas are “traumatic” for children or “overly aggressive.”
Parents of my patients tell me the opposite: You know what’s traumatic? Having accidents in 4th grade. Or having to postpone college because you’re still wetting the bed. In my experience, kids are relieved to learn there’s a treatment that actually works. Even kids who are apprehensive about enemas at first tend to get used them pretty quickly. Kids as young as 5 or 6 can do the insertion themselves, and many like that sense of control. Once kids start enema treatment, they often ask for enemas because they feel so much relief. They can feel they are emptying out.
For mild cases of wetting, Miralax can sometimes work, but there’s no question an enema-based regimen is far more effective at emptying the rectum and keeping it clear. My own research has confirmed that, and so has all my years of experience. If oral laxatives worked well, M.O.P. would not exist, since most kids have already gone down that route before their parents find M.O.P. Heck, many parents in my private Facebook support group have had their children on Miralax, including monthly “clean-outs,” for 3, 4, even 5 years. Their doctors seemed to think it was fine to continue with a useless treatment.
What happens with laxatives like Miralax is that the soft poop just oozes around the hard mass that’s causing the problem, so the rectum never empties. Our Enema Rescue Guide, included in the M.O.P. Anthology, offers loads of advice on how to help a child get on board with enemas.
I would never suggest that a parent force an enema — the child certainly must agree to the treatment. But gaining buy-in from a kid usually is not as difficult as parents expect. I explain to kids that enemas are a medical treatment like any other treatment. Adults usually have more apprehension than their kids and often project their fears onto the child. I ask parents to keep an open mind.
Question: What if a child’s bedwetting doesn’t resolve with enema treatment? Where does bladder Botox fit in?
Answer: In nearly all cases, an aggressive enema regimen, in conjunction with laxatives, will get the rectum empty enough to resolve accidents, but in some children, the rectum remains enlarged and the overactive bladder nerves just won’t calm down. In these cases, bladder medication can tide the child over, stopping accidents and giving the child a psychological boost until the bladder shrinks back to normal size. There are new types of bladder medication that are less constipating than the older ones. Bladder meds tend to be ineffective without a bowel-emptying program but often help when a child has been on M.O.P. for a while. I discuss the different medication categories in the Anthology.
In the most intractable cases, I recommend bladder Botox, a highly effective and quick surgical procedure I’ve used for over a decade. Botox isn’t a first-line treatment because it won’t last if the child is constipated. The underlying constipation must be treated. However, if an x-ray proves the child’s rectum is empty but still dilated, the child may be a great candidate for Botox.
For a discussion of all these topics and more, listen to my podcast interview with the Brainy Moms!
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