By Steve Hodges, M.D.
I’ve known for years that enemas resolve pee accidents far better than any other treatment, whether it’s Miralax, bladder-relaxing medication, or peeing on a schedule.
This isn’t something parents like to hear — understandably. Who wants to place a tube up a child’s bottom? Physicians, on the whole, also are unreceptive to enemas, considering them “too aggressive.”
Nonetheless, it’s true: Enemas work better. A lot better. And now I can point to research that proves it.
The medical journal Global Pediatric Health has published a study I conducted with a colleague, Marc Colaco, M.D., at our Wake Forest University School of Medicine pediatric urology clinic.
Our study tracked 60 patients, ages 4 to 11, who typically wet their pants daily. Forty of these patients followed standard therapies, including Miralax, a pee schedule, and, in some cases, overactive-bladder medication.
Another 20 patients agreed to daily enemas plus daily Miralax, a regimen I call the Modified O’Regan Protocol (M.O.P.). Families were instructed to taper to every-other-day enemas if the child stopped wetting mid-way through the study.
After three months, 30% of the patients treated with standard therapies reported they had stopped wetting. And the enema group? Fully 85% of the patients — 17 out of 20 — had stopped wetting.
Why Enemas Resolve Accidents Better Than Miralax
A closer look at the data explains very clearly why enemas worked better.
At the start of the study, we X-rayed all 60 patients to measure the diameter of their rectums. Research has determined that a rectal diameter wider than 3 cm indicates constipation. In our study, the average rectal diameter in both groups was greater than 6 cm.
Three months later, the rectums of the 40 patients treated with standard therapy remained stretched — to 5 cm, on average.
But the rectums of the enema group had shrunk dramatically — to 2.15 cm, on average.
That’s a completely normal measurement.
So, what does a child’s rectal diameter have to do with pee accidents?
As Sean O’Regan, M.D., demonstrated in his groundbreaking studies, daytime pee accidents (as well as poop accidents, bedwetting, and recurrent UTIs) are caused by constipation.
But Dr. O’Regan was very careful to define “constipation” as a rectum chronically stretched by excess stool — not simply “infrequent pooping,” the common and misleading definition.
A stretched rectum presses against the bladder, reducing the bladder’s capacity and irritating the bladder nerves. So, the bladder hiccups uncontrollably and without enough warning for the child to make it to the bathroom on time.
The reason daily enemas work so much better than daily Miralax alone is twofold: 1.) Enemas clear out the rectum more effectively, and 2.) Enemas keep the rectum clear so it has time to bounce back, regaining tone and sensation.
Miralax alone works for some kids, but it often fails to dislodge the large, hard mass of stool. Poop softened by Miralax oozes around the mass that has been stretching the bladder, so the problem doesn’t actually get solved.
(The reason I use Miralax in addition to enemas is that Miralax keeps stool soft, so pooping isn’t painful for kids, and they are less likely to withhold.)
Putting a child on a regular peeing schedule helps control wetting, for reasons I detail in It’s No Accident. Bladder-relaxing medication is just a temporary fix because it doesn’t get to the root of the problem: constipation.
What about the three children in our enema group who did not stop wetting their pants?
Our data offers a clear explanation for the negative result: Unlike their peers in the enema group, these patients did not show a normal rectal diameter after three months.
In other words, they were still stuffed with poop. Pediatric enemas simply weren’t powerful enough to clear out these kids; so, their poop-stuffed rectums didn’t shrink back to size.
I know it seems nuts that three months of daily enemas aren’t sufficient to clean out a child, but it happens. For these patients, I prescribe a daily regimen of large-volume enemas (the M.O.P.+ regimen).
The results of my study mirror those of Dr. O’Regan’s studies. He, too, found that about 85% of daytime wetting resolves on a daily enema regimen. But the difference in our studies is that I compared enemas to standard therapies. In Dr. O’Regan’s day, back in the 1980s, Miralax was not available; enemas were the only option for treating constipation, so that’s what Dr. O’Regan’s patients used.
In the 30 years since his research was published, enemas have fallen out of favor. I understand why. It’s easy to hand a child a glass of water mixed with a tasteless, odorless powder — simple! It’s less easy to insert a tube up a child’s bottom.
Miralax does play a role in resolving accidents, but only as a supplement to — not a substitute for — daily enemas.
Why Families Come Around to Enemas
Many families are so averse to enemas that they will spend months and months fiddling around with various enema doses and doing periodic high-dose Miralax “cleanouts.” This can be a very messy proposition and, for all the mess, often doesn’t resolve the wetting.
Ultimately, most of these families give up and try the enema regimen they had so staunchly avoided.
That’s when their kids stop wetting.
In our study, not only were the rectal-diameter results dramatically different between the two groups after three months, but so were the children’s scores on a measure called the DVSS, or dysfunctional voiding scoring system. The DVSS scoring range is 0 to 30; the higher the number, the more symptoms of problematic voiding — including frequent accidents, urgency to pee, painful peeing or pooping, and others.
At the start of our study, the children in both groups averaged 14 DVSS score. That’s worse than it sounds! (Nobody scores even close to 30.) Almost all these kids wet their pants daily.
But after three months, the enema group’s average DVSS score had dropped to 4, essentially a normal score. The standard-therapy group’s average score had dropped slightly, to a 12.
Our study demonstrates two facts that the medical establishment, remarkably, does not recognize: 1.) enemas work better than Miralax for resolving wetting, and 2.) constipation is the cause of virtually all wetting.
Search “causes of pee accidents” or “causes of diurnal enuresis” (daytime wetting), and you will — sometimes — find constipation listed among a list of possible causes. For example, the National Institutes of Health lists constipation fourth on a list of five causes:
•small bladder capacity
•pressure from constipation
•drinks or foods that contain caffeine
This list makes no sense. If an abnormally small bladder, anatomical problems, anxiety, or caffeine caused accidents, why did enemas fix the problem in every single child whose rectum shrank back to normal size?
Chronically constipated children do have a small bladder capacity — but that’s only because they are constipated! The poop clog is encroaching upon the bladder. When these children are cleaned out, they no longer have a “small bladder.”
“Anxiety” also does not explain accidents. Many children who have accidents feel stressed and anxious, but that’s typically because they have accidents, not the other way around.
Many websites claim that “we just don’t know” why children have accidents. My study confirms that we do — and that daily enemas are the best way to resolve them.
How to Avoid Pee Accidents in the First Place
Of course, making sure children don’t relapse is critical. To maintain dryness after the hard work of an enema regimen, I suggest children:
•Stay on Miralax for several months so that poop is mush — the consistency of hummus or a milkshake!
•Poop with their feet up on a stool. The genius Squatty Potty "unicorn" video explains why it’s anatomically superior to poop in squatting position.
•Eat tons of fruits and vegetables, and stick to whole or minimally processed foods
•Drink plenty of water.
•Get daily exercise.
As for preventing accidents in the first place, I would add one item to this list: wait until a child is 3 years old to potty train.
As my previous research has shown, kids who train at 24 months or earlier are at the greatest risk for later developing enuresis. They have triple the risk of having accidents down the road than children trained between 2 and 3.
If your child is currently having accidents and your pediatrician is not receptive to enemas or has never even considered enemas as a treatment, show the doctor our study! And let me know how it goes.