The other day in my clinic I saw a 13-year-old boy who had never had a dry night — despite having spent two years on desmopressin, a medication that suppresses urine production and was prescribed to him by another urologist.
His mom asked, “Do you think he should stay on the medication?”
Also this week, a mom posting in our discussion forum asked about oxybutynin, a bladder-relaxing medication commonly prescribed for bedwetting: “The urologist feels that my daughter's frequent daytime pee accidents are due to bladder spasms. The only downside is that one of the side effects is constipation, which she also struggles with.”
To resolve a condition caused by constipation (those spasms happen when a clogged rectum aggravates the bladder), a urologist wants to prescribe medication that causes constipation.
By the time my patients get referred to me, most have been placed on at least one medication for bedwetting, and I understand why drugs are an appealing choice. Writing a prescription is easy for a doctor and often reassures exhausted, distressed parents that something is being done.
But in almost all cases of bedwetting, drugs that suppress urine production or bladder spasms are not the solution. In limited cases they can help, but they do not address the root cause of bedwetting and accidents: a poop-clogged rectum.
Even when medication “works” — which, for many kids, like my 13-year-old patient, is never — it typically does so only as long as the child takes the drug. When the child stops, countless studies show, bedwetting typically returns.
And yet! Medication is considered by numerous medical organizations, including the International Children’s Continence Society, to be one of two “first line” treatments for bedwetting.
(The other is a bedwetting alarm; as I explain in It’s No Accident, alarms only teach the child to wake up before wetting; yes, that can be helpful, but it doesn’t stop the child from needing to pee in the middle of the night.)
Bedwetting is not a disease, like type 1 diabetes, that needs to be controlled with daily medication. It is a condition that can be fixed — for good — by a) cleaning out a child’s clogged rectum and b) allowing it to shrink back to size so it stops aggravating the bladder.
The drugs commonly prescribed by urologists don’t fix the problem; they just cover it up.
Of course, Band-Aids have their place, which is why, on occasion and purely as a stop-gap measure for sleep-away camp or a class trip, I will prescribe medication. But in no way do I consider drugs a reasonable or effective fix for bedwetting or daytime accidents.
Enemas Resolve Bedwetting
You know what does work? Enemas. (Yes, they are safe, and they work better than MiraLAX.)
Of course, in our drug-focused culture, nobody is researching enema therapy for bedwetting. So, you have to go back to 30 years to the published studies of Sean O’Regan, discussed in detail in It’s No Accident and posted in full on our website.
Let’s quickly review these studies, before I delve into the thoroughly unimpressive results — and unwarranted conclusions — of today’s studies on bedwetting drugs.
All of Dr. O’Regan’s studies were conducted on children at the University of Montreal, Hôpital Sainte-Justine, where he practiced as a pediatric nephrologist. In one study, Dr. O’Regan followed 22 boys and girls with daytime wetting, nighttime wetting, or both.
Parents of 17 of these children agreed to follow Dr. O’Regan’s favored enema-based therapy: nightly enemas for a month, followed by a month of enemas every other day, followed by a month of twice-weekly enemas.
(This is the regimen I recommend in The M.O.P. Book. However, I suggest maintaining daily enemas until the wetting stops and then dialing it back.)
All 17 children improved dramatically — on average they went from wet to dry in 16 days, with a range of three days to six weeks.
And the results lasted! Nine months later, 14 of the 17 (82%) were still entirely accident free. The other three had gone from having daily accidents before the therapy to wetting once a week.
It’s significant that all of these children were shown to be constipated prior to the study. Unfortunately, researchers today typically do not check for constipation when conducting bedwetting studies, because they don’t seem to understand that constipation is the root cause of bedwetting. Even those who concede constipation is “associated” with bedwetting don’t seem to grasp that if you resolve constipation, you will resolve the wetting.
So, we don’t know for sure whether the children involved in more current bedwetting studies are stuffed with poop. However, some researchers do mention that most of their bedwetting patients also are constipated, and my experience tells me that virtually all of these kids are.
In another investigation, Dr. O’Regan tracked 47 girls, average age 8, who had recurrent urinary tract infections; most of these girls also had chronic poop accidents (encopresis) and/or daytime or nighttime wetting. Within three months of starting the enema protocol, 44 of the 47 girls stopped having UTIs. Among the 21 patients with encopresis, 20 (95%) stopped having poop accidents. What’s more, 22 of the 32 (69%) girls with enuresis stopped wetting. What about the girls who didn’t improve? Almost all their parents admitted to not following the enema regimen fully.
It’s nuts that doctors who consider enemas an “overly aggressive” treatment for constipation and bedwetting (I hear that all the time) see no problem with prescribing drugs that don’t work long-term, don’t work at all, or have side-effects that make wetting problems worse.
Let’s take a closer look at the two categories of drugs commonly prescribed for bedwetting: medication that suppresses urine production (desmopressin, sold as DDVAP) and drugs that suppress bladder spasms (such as oxybutynin, sold as Detrol or Ditropan, among other names).
Desmopressin: No Fix for Bedwetting
Mimicking anti duretic hormone (ADH), desmopressin essentially tricks the kidneys into producing less urine at night. ADH is one of the naturally occurring hormones the body uses to regulate fluid levels. The body’s hormones work a lot like the thermostat in your house: You have sensors that measure the fluid levels, and if your fluid level gets too high, your brain releases hormones to cause your body to release more fluid; if fluid levels are too low, you release hormones to retain fluid. So the idea is that demopressin will compensate for kids who overproduce urine overnight.
But wait: Do the kids on desmopressin actually have abrnomally low levels of ADH? Do they need a drug to compensate? That’s a good question to ask your doctor if he or she wants to put your child on this drug.
The human body manages fluid balance very well! If your child’s body produced abnormal ADH levels, you would know it (your child would have uncontrollable thirst and pee incessantly, among other symptoms), and you’d be seeing a doctor for it (trust me). In most bedwetting studies where the patients’ ADH levels were actually checked, guess what? Their levels were normal.
Nonetheless, desmopressin can still “work.” Since the bladder contracts uncontrollably when it reaches a certain urine volume level, decreasing that volume at night (with desmopressin) can keep a child dry that night. The body does such a remarkable job at fluid management that even children who take these drugs chronically suffer few, if any, adverse effects. Their bodies just catch up the next day.
But just as the safety of desmopressin has not been an issue because of its short-acting nature, its usefulness is also short-lived. Several hundred studies have been conducted on desmopressin, with varying results, but the trend is clear: This stuff stops working when the child stops taking it. Relapse rates are generally 60 to 70 percent.
Yet desmopressin is very popular among pediatric urologists. Even researchers who find extremely high relapse rates for desmopressin seem to think it’s a whiz-bang drug.
For example, a 2013 study found that only 26% of kids treated with demospressin stopped wetting completely, and 66.6% of them relapsed after stopping the drug. Yet the researchers concluded desmopressin is “effective.”
Let me tell you: If two-thirds of my bedwetting patients were still waking up with wet sheets after I treated them, I would not consider myself an “effective’’ physician. Twenty-six percent would be terrific success for, say, a drug for metastatic prostate cancer but for bedwetting? Hardly.
This enthusiasm for a drug that doesn’t work amazes me.
Consider this: In an article titled “Practical consensus guidelines for the management of enuresis,” a group of urologists from Harvard Medial School and several European universities conceded that desmopressin is only effective on the night of administration, so . . . “therefore, it must be taken on a daily basis.”
That’s their “practical consensus”? How about this: Desmopressin is only effective on the night of administration, therefore . . . it makes sense to use a treatment that doesn’t require a child taking a drug every night indefinitely? Maybe that’s a more practical solution?
Expressing further enthusiasm, the researchers wrote: “If wetting resumes once treatment is withdrawn, [the drug] should be continued/resumed.”
In other words: If the drug isn’t working, keep taking it!
It may be worth noting that four of the six authors of that “consensus guideline” have been involved in drug trials sponsored by companies that manufacture desmopressin.
The very limited effectiveness of the drug isn’t my only concern. Though desmopressin is generally safe, in rare cases it can interfere with electrolyte levels. At any rate, the idea of altering the hormones that control urine output in children doesn’t sit well with me.
We urologists have a saying: A dumb kidney is smarter than a smart doctor. In other words, if you’re producing a lot of urine at night and are otherwise healthy, there is probably a darned good reason your body is making that pee. We all need to get rid of fluid to maintain our body’s fluid and electrolyte balance, so why mess with that? Especially since desmopressin does nothing to resolve the constipation that causes bedwetting to begin with!
Bladder-relaxing Drugs Don’t Resolve Bedwetting, Either
OK, so what about oxybutynin, the bladder-relaxing drug mentioned in our forum?
For one thing, as a sole therapy, it appears to be no more effective than a placebo, especially for children who have only nighttime, but not daytime, wetting.
Some studies have reported the drug to be somewhat helpful for kids with both daytime and nighttime symptoms and also in combination with desmopressin (great, more drugs!). Ah, but then there’s this slight problem: oxybutynin causes constipation! As researchers noted in the journal Canadian Family Physician, oxybutynin can cause dry mouth, dry eyes, blurred vision, diarrhea, and/or constipation symptoms “in up to 76% of patients.”
But even that doesn’t stop many urologists from prescribing this drug. The doctors simply compensate for the constipation by prescribing MiraLAX! So now you’ve got kids taking three drugs — desmopressin, oxybutynin, and PEG 3360 (MiraLAX) — and still wetting the bed.
Constipation, however, is not among the most worrisome side effects of oxybutynin. Those would include hallucinations, agitation, sedation, confusion, amnesia, and nightmares. The Canadian researchers concluded: “Oxybutynin can cause disturbing adverse effects involving the [central nervous system] and should be used with caution in young children.”
I can see the lure of prescribing bladder-relaxing drugs, or any drug that might work. Bedwetting can be so stressful on families and so damaging to a child’s self-confidence, that folks are willing to try anything. I’m well aware that enema therapy is not fun for all involved and is a lot more cumbersome than taking a pill or nasal spray. And results won’t happen overnight.
But I always like to have a good reason for any therapy I prescribe. And since I the cause of bedwetting is almost always a stretched rectum, I’m going to recommend a therapy that will allow the rectum to shrink back to see. I generally recommend families continue with nightly enemas until the bedwetting resolves.
If you are following the enema regimen and your child is not yet dry, be patient! Some children require two or even three months of nightly enemas before achieving dryness. (Yes, this is a bummer!)
If you are skeptical that your child’s wetting is due to an enlarged rectum — or if your doctor is skeptical and wants to prescribe drugs — insist the doctor perform a contrast enema. This is a study that involves inserting an enema solution with dye that shows up on an X-ray.
Or, request anorectal manometry — a test that involves inserting a small balloon into the child’s anus and inflating it; if the child cannot detect the inflated balloon, the child’s anus is quite obviously stretched. (Dr. O’Regan performed anal manometry on all the patients in his studies.)
If your child has a normal contrast enema or anorectal manometry study and is wetting the bed, I’ll gladly concede the child is an outlier and help you with other therapies.
But I have yet to come across such a patient.