By Steve Hodges, M.D.
Won't a Miralax clean-out help a child who's chock full of poop? If a child on the Modified O'Regan Protocol (M.O.P.) stops pooping spontaneously, is that cause for concern? Can bedwetting medication help a 15-year-old?
Below, I address these and other good questions posed by parents in our private enuresis/encopresis support group.
Q: Your M.O.P. Anthology expresses a lot of skepticism toward oral laxative clean-outs. But when x-rays show a kid to be systemically full of stool, wouldn’t it be better for his health to clear him out, rather than have all that ancient poop clogging him up?
A: Good question! If a laxative “clean out” were guaranteed to actually evacuate all that crusty old stool, I would be all for it. However, the term “clean out” is largely a misnomer. Typically, this process results in one of three scenarios:
1.) The liquid cleanse washes right past the impacted mass of stool. So, the child ends up with diarrhea and constipation — “a big, poopy mess,” as parents describe it.
2.) The laxative propels poop downstream, further clogging and stretching the rectum and causing pee and poop accidents to worsen.
3.) The rectum actually does empty — temporarily. If the only post-clean-out treatment is a daily dose of laxative, the child is likely to fill right back up.
That said, periodic oral laxative clean-outs can be useful in conjunction with M.O.P. I sometimes recommend this approach for stubbornly clogged children who are shown via x-ray to have a dense mass of upstream poop. A high-dose clean-out can push the poop downstream, and then enemas can flush out the rest. Taking a weekend off M.O.P. to do a laxative "clean-out" does help some children with stubborn cases of enuresis.
I delve into the limitations and benefits of high-dose oral clean-outs in our free guide Helping Your Child Exit the Miralax Merry-Go-Round.
Q: My 7-year-old son with encopresis has been doing Standard M.O.P. for 2 weeks. He has had no accidents since starting but also hasn’t pooped other than after the enemas. Should I be concerned that he’s not spontaneously pooping? Should we change our protocol? He’s not taking laxatives, and I’d prefer to avoid them.
A: That’s great accidents have stopped. However, it’s way too early to expect spontaneous pooping. Children with encopresis have significantly compromised rectal sensation and tone, and that can’t be reversed in two weeks.
With encopresis, stopping accidents is the easy part. Healing the rectum, so that accidents don’t recur, takes time and continued treatment. Most kids need a good three months for their floppy rectum, once emptied, to shrink back to size and regain full tone and sensation. At that point, they consistently feel the urge to poop and are able to stop what they’re going and find a toilet.
I’d stick with your regimen. There’s no need for your son to start laxatives at this point, but I suggest adding an osmotic once he starts tapering off enemas, as described in Phase 4 of Standard M.O.P. Also, if your son has a deeply ingrained tendency to delay pooping (aka "withholding"), it may help to introduce a stimulant laxative such as senna (Ex-Lax) on the enema-free days. When dosed properly, senna stimulates the urge to poop within 5 to 8 hours; this helps retrain kids to respond to the urge to poop. Then, your son would gradually wean off senna and the osmotic.
FREE DOWNLOAD: Treating Encopresis with M.O.P.
Q: My 15-year-old just cannot make it beyond a few dry nights. He suffered with the “trifecta” (bedwetting plus daytime wetting and encopresis) for years and started M.O.P. at age 11. Thankfully, encopresis stopped almost immediately, and daytime wetting stopped within a month, but bedwetting has persisted. Taking a low dose of DDAVP (desmopressin) worked very well for my son, but our urologist said it’s unsafe to take for more than two weeks. She also said there is no bedwetting medication she can prescribe, and he just needs to pee more frequently (every two hours) during the day. She said frequent peeing is like “physical therapy for the bladder.” Your Trifecta Algorithm says that if bedwetting persists at this point, we should try adding meds. What do you recommend? I’m feeling lost.
A: You are almost there! If your son stays dry on a low dose of DDAVP, that’s a sign he is close to being dry on his own. Desmopressin doesn’t work at all in children who are clogged up. The dose you describe is perfectly safe to take daily as long as needed, though your son could also try two other types of enuresis medication.
If peeing every 2 hours were an effective strategy for halting bedwetting, M.O.P. would not exist! Your doctor is mistaken: It’s not that easy — not by a long shot. Certainly, frequent peeing helps keep the bladder healthy, as I explain in the M.O.P. Anthology, but it’s hardly “physical therapy” for the bladder and is no cure for enuresis.
I recommend your son take DDAVP nightly while continuing his M.O.P. regimen, and once a week, have him skip the medication. If the dryness holds, he can start weaning off enemas, using one of the Slow Taper regimens described on page 68 of the M.O.P. Anthology.
Q: My 7-year-old started with encopresis and nocturnal enuresis. Nearly a month ago, she switched from M.O.P.x to Multi-M.O.P., and the poop accidents completely stopped, which is awesome. But bedwetting hasn’t changed much. She only has dry pull-ups 1-2 times a week, no different from when she was on M.O.P.x. Do I just need to stay the course for longer?
A: Yes, stay the course! It’s normal for kids to experience a lengthy delay between the end of daytime accidents and the end of bedwetting. In fact, this delay is so common that I’ve given it a name: the Long Lag.
It takes a monumentally clogged rectum to cause poop accidents. That’s why encopresis clears up quickly with daily enemas: Making a modest dent in the stool pile-up is often enough to keep accidents at bay. But it takes a lot more rectal emptying and healing — that is, more time — for the bladder to regain enough stability to go all night without hiccupping and emptying.
Since your daughter’s encopresis did not completely halt with M.O.P.x, that suggests her rectum was pretty darned clogged and stretched to begin with. She may need several more months on Multi-M.O.P. before her bedwetting stops.
If she start having more dry nights in the next two months, I suggest asking her doctor to order an abdominal x-ray. A film will help distinguish between two scenarios: 1.) The rectum is still clogged, in which case adding overnight oil enemas can help (see pages 83-84 of the M.O.P. Anthology), or 2.) The rectum is empty but still stretched, in which case enuresis medication may provide dry nights while she waits for her rectum to retract to normal size.
Since your daughter is already having periodic dry nights, my guess is that she’ll start seeing more improvement soon.
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