By Steve Hodges, M.D.
Enemas are not a popular bedwetting treatment — no question there! And X-raying children for constipation is not a common practice. It’s tough for me to persuade my own colleagues that enemas work much better than MiraLAX and that X-rays are warranted for enuresis patients.
I recently attended the American Academy of Pediatrics international conference in San Francisco and talked to hundreds of pediatricians. While most most agreed constipation can cause bedwetting, quite a number were unaware of this fact, and a few considered bedwetting primarily a psychological problem. Very few doctors I spoke with used X-rays to diagnose constipation — most relied on exams and parent reports. And none had heard of treating bedwetting with a month of enemas. I saw more than a few eyes popping out of heads! Most of the doctors I met defined “aggressive” constipation treatment as a high-dose MiraLAX cleanout, a week of Ex-Lax, or few days of enemas followed by daily MiraLAX.
Given all that, I’m hardly surprised when parents tell me their doctors are not on board with M.O.P. (the Modified O'Regan Protocol) or won’t order X-rays. But what does surprise me is the intensity of the resistance that some parents report.
Posting on the It’s No Accident Facebook page, one mom wrote: “My son’s first pediatrician said an X-ray ‘wasn’t the standard of care’ and that it would expose my son to radiation that could later cause cancer.”
In an email, another mom quoted her pediatrician as saying, “Enemas will emotionally scar your daughter for life.” A commenter on our Facebook page wrote: “When I brought enemas up to our doctor, he said, ‘There's no way I would do that to my child.’”
When another mom reported positive M.O.P. results, she told me, her doctor told her to “stop that right away.” This mom continued: “The most upsetting thing was her language around the trauma that the enemas would create for him, which has not been our experience at all. He enjoys his book or iPad time, and it's just part of our evening routine like brushing teeth.” The doctor recommended more MiraLAX.
Another doctor, describing enemas as “dangerous,” suggested a mom reward her daughter for dry nights and advised her daughter to wear cotton underwear underneath pull-ups so she would “feel the wetness more and wake up.”
This woman asked me: “How is a mom supposed to stand up to a pediatrician who doesn't know anything about this?”
Good question!
Yes, It’s Awkward to Disagree With Your Doctor
I realize it’s not easy to disagree with your doctor. I’ve read the studies showing that even confident, assertive people become timid when faced with the prospect of challenging their doctor’s opinion.
In one study, published in the Archives of Internal Medicine, only 14 percent of 1,340 patients surveyed said they’d be willing to tell their physician they disagreed with his or her advice. Most feared they’d be labeled a “difficult patient” or damage their relationship with the doctor.
In another study, published in Health Affairs, researchers conducted focus groups with highly educated patients, and most said they felt awkward, anxious, or intimidated about expressing disagreements with their physicians. Even folks who described themselves as having confidence in other settings, like at work, found themselves tongue-tied in the doctor’s office. They didn’t want to “rock the boat.”
I understand this concern. If you show up at your appointment armed with studies and printouts, you may worry your doctor will think: Hey, I went to medical school; you didn’t.
And, the doctor may have a point. When patients find studies on the Internet, they may not have the background to put these studies in context. Maybe a study contradicts two dozen other studies published on the topic, or maybe it was poorly designed, so the results are suspect.
Hey, we doctors did learn a few things in medical school! But in reality, when it comes to bedwetting and accidents, most of us did not learn a ton.
Pediatricians, as jacks of all trades, learn about more conditions than I’ve probably ever heard of, but most receive little training on treating an overactive bladder. Urologists, meanwhile, tend to specialize in conditions requiring surgery; for many of my colleagues, potty accidents don’t rate, despite the misery their patients experience. They often prescribe an ineffective drug and call it a day.
When I was in med school, bedwetting treatment was barely discussed. I was taught: Don’t treat these kids before age 7, and then use a bedwetting alarm or DDVAP (a drug that suppresses urine production overnight). End of story! Bedwetting is simply an area that falls through the cracks. As I explain in It’s No Accident, it’s a specialty that I accidentally stumbled upon.
I mention all this in hopes of boosting your confidence as you approach your physician about M.O.P. While your doctor is no doubt steeped in the research on countless medical topics, bedwetting may not be one of them.
With luck, your fears about discussing M.O.P. with your doctor will prove to be unfounded. Some parents have told me their doctors, acknowledging that traditional treatments weren’t working, said, “Sure, let’s give it a try!”
Still, I tend to hear more from parents who’ve gotten pushback. For parents in this boat, I offer the following ideas.
•Describe the toll accidents are taking on your family. Doctors who suggest waiting for your child to “outgrow” the problem or who push MiraLAX may not recognize the extent of your family’s distress and how urgent the problem feels to you. So explain: Your child is losing self-esteem, getting teased by peers, or shamed by teachers, or the whole family is exhausted. Try: “This is difficult for our family. We are brainstorming different possibilities. In our research, we came across this. . . ”
•Bring published research. Doctors, understandably, may not be eager to read our books or blog posts, but they might be willing to consider published scientific studies.
If your doctor pushes MiraLAX, download “Daily Enema Regimen Is Superior to Traditional Therapies for Nonneurogenic Pediatric Overactive Bladder” from the Research page of BedwettingAndAccidents.com.
If your doctor insists enemas are dangerous, point to this study: "Systematic review: the adverse effects of sodium phosphate enema." Reviewing 39 studies conducted over 50 years — 50 years! — the researchers found a total of 15 cases of electrolyte imbalance in children ages 3 through 18. In nearly every case, the child had a chronic disease, was severely dehydrated, or received multiple enemas in one day. In reality, phosphate solution spends little time in the colon and thus has little influence on the body’s electrolyte levels.
If your doctor disagrees that constipation causes virtually all cases of bedwetting, download Dr. O’Regan’s studies from my website. I also recommend the Journal of Urology comment by Angelique Champeau, RN, director of the Children's Continence Clinic at UCSF Benioff Children’s Hospital. Angelique: “After 16 years of managing urinary tract dysfunction in children, I would hypothesize that the number [of cases caused by constipation] is closer to 90-100%. Using a prevalence of 50% can cause gross under treatment."
You might let your doctor know that our approach and our books are endorsed by the pediatric urology departments at UCSF Benioff Children's Hospital and Mayo Clinic, organizations that are highly regarded.
•Ask for research. Flip things around: If your doctor insists that enemas are traumatizing or dangerous, that X-raying for constipation is risky, or that bedwetting drugs work well, mention that you’d like to read up on that. Ask the doctor to recommend research you can download. At the very least, you will learn where your doctor is coming from.
•Ask lots of questions. There’s no need to interrogate your doctor, but as a paying customer, you certainly should be inquisitive. For example: Do you have experience with enema therapy? Have other patients found enemas traumatizing? What, specifically, do you feel are the risks of enemas? Why do you feel a “top down” approach is more effective than a “bottom up” treatment?
If your doctor pushes DDVAP, ask: What is the long-term success rate of this drug? Does my child overproduce urine? If so, how do you know? If not, why is it a good idea for my child to produce less urine? (Here's my take on DDVAP.)
•Take the “humor me” approach. If your doctor assures you that your child is not constipated, insist on an X-ray, and indicate you’ll try a different approach if your child’s rectal diameter proves to be under 3 cm.
If your doctor doesn’t approve of enemas, say, “Well, how about if I try this for a month and then check in with you? If it doesn’t work, we’ll try something else.”
What if you still get nowhere? You just may need to find another physician.
With some doctors, no amount of scientific research, case studies, or positive reports from parents will prompt them to budge. As one mom posted, when she reported her daughter had gone from five accidents per day to one or zero while on M.O.P., her pediatrician said it was “just coincidence” and the girl was “growing out of it.”
The mom wrote: “She has been a great pediatrician up to this point. We’ve been with her since my daughter was a newborn, and I hesitate to switch. But we may have to.”