By Steve Hodges, M.D.
For centuries bedwetting and accidents have been attributed to stress, anxiety, and psychological problems. Even today, you read about this alleged link in the popular media and in the scientific literature. I have countless patients who have been referred to psychologists by their pediatricians or schools. So, I was not surprised when a mom in our Facebook support group posted this question:
My 10-year-old started wetting the bed after 5 years of dryness, other than about 5 accidents per year. Could this be a sign of being bullied? He denies this cause. Nothing has changed in his or our lives except we are planning to get a puppy. My son doesn't like to poop away from home.
In medical jargon, bedwetting that starts after a long period of dryness is called “secondary” bedwetting. I have numerous patients whose bedwetting began “out of the blue,” according to their parents, and these parents, understandably baffled, often assume some hidden stress must be triggering this problem in their otherwise healthy child.
But X-rays demonstrate otherwise. Almost invariably, these kids are severely constipated — same as children who have wet the bed all their lives (aka "primary nocturnal enuresis").
The medical literature makes the unfounded assumption that primary and secondary bedwetting have different causes. For example, a 2016 Turkish study states that "secondary enuresis frequently arises from psychological factors," whereas primary enuresis is caused by "genetic predisposition, biological and developmental factors."
The National Kidney Foundation states, "The later the onset of the wetting, the more likely the cause is due to psychological stress."
But where's the evidence?
The research cited to back up these claims is highly dubious. Appalling, really.
Let’s consider the Turkish study, published in the Journal of Pediatric Urology. How do the authors support their claim that secondary bedwetting “frequently arises” from psychological factors?
The study cites one source: the 4th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published in 1994. The DSM-IV was rendered obsolete by the updated version, DSM-V, published in 2013. But the most recent version states: “Enuresis can be triggered by separation from a parent, the birth of a sibling or family conflict.”
And the evidence cited for that claim? One study published in an Indian medical journal, that itself cites zero evidence. Seriously!
Want to follow me down the rabbit hole? Let’s go:
According to the Indian medical journal, “approximately 50% of the children with functional enuresis have emotional or behavioral symptoms due to a variety of causes related to stress, trauma or psychosocial crisis such as birth of a sibling, hospitalization, start of school, parental absence, etc.”
But the authors offer no research in support of that statistic. In fact, the only study cited, a 1986 New Zealand study, concluded the opposite: that bedwetting is “unrelated to a broad range of psychosocial factors including family social and economic background, family life-event measures, changes in parents in the family, and residential changes.”
In short: the notion that psychological stress causes either primary or secondary bedwetting is supported by . . . nothing.
It’s important to note that most studies exploring the bedwetting/stress link have not considered whether the children were constipated. Given the proven connection between bedwetting and constipation, that omission alone renders these studies useless.
But even the rare bedwetting/stress studies that have considered constipation status of children cannot be trusted because their methods of detecting constipation are unreliable.
That Turkish study — the one claiming "secondary enuresis frequently arises from psychological factors" — did consider whether the subjects were constipated, finding "no significant association between nocturnal enuresis and the presence of constipation."
But how did they check these children for constipation? They asked their parents! More specifically, they had parents fill out a questionnaire asking whether their children a) pooped fewer than three times a week and b) strained to poop.
I cannot emphasize how unhelpful these questions are. First of all, pooping frequency is a poor gauge of constipation. MANY chronically constipated children poop every day — even two or three times a day — because they never fully empty. Sure, they may appear to be "regular," but X-rays prove these kids nonetheless have a giant mass of poop clogging their rectums.
Second, how many parents know whether their school-age kids are "straining" to poop? The Turkish study looked at kids ages 6 to 13. I don't know many moms who hang out in the bathroom while their 6th graders have a bowel movement. I was severely constipated throughout childhood and strained plenty to poop. I never mentioned this to my parents.
Furthermore, many constipated children don’t strain to poop. Soft poop oozes around the hardened mass in the rectum — a mass that just stays there. So, these kids are pooping easily but not fully.
Sean O'Regan, M.D., the pediatric kidney specialist who first proved the constipation-bedwetting connection, recognized back in the 1980s that parent reports on constipation did not correlate with reality. In his own studies, he made a point of measuring constipation “not subjectively but objectively," using a test called anal manometry.
As I explain in The M.O.P. Book, anal manometry involves inflating a small balloon in the child’s bottom. The more inflation the child can tolerate, the more the rectum has been stretched by stool buildup. A child with normal rectal tone would notice the balloon inflated with just 5 to 10 ml of air, whereas a severely constipated child might not even detect the balloon until it’s inflated with 40 ml of air. Dr. O'Regan's bedwetting patients could withstand 80 to 110 milliliters of air without discomfort.
Even so, Dr. O'Regan noted, half the parents "denied constipation as a symptom."
At the time of his discovery, Dr. O’Regan was pleased he could help so many children whose accidents had been attributed to psychological problems. “These kids were told that it was all in their heads,” Dr. O’Regan told me when I interviewed him for It’s No Accident. More than 30 years later, many children are being told the same thing.
When I have a patient with "secondary bedwetting," I don't assume the bedwetting actually came out of the blue. And I don't simply ask how often the child poops. I ask a series of more probing questions, such as whether the child has any history of daytime urgency, frequency, or withholding and whether the child has recently been in an environment, such as school, where he or she won't use the bathroom. I also order an X-ray. (Yes, X-rays for constipation are safe.)
In talking with these families, I usually find the child has shown signs of constipation over the years — signs that went unrecognized — and that some relatively recent event has caused the child to use the bathroom less often.
A typical scenario: A kindergartener suddenly starts wetting the bed or having accidents after being dry since age 2 or 3. The parents attribute the accidents to the “stress” of starting a new school. In reality, the child was too intimidated to use the school bathroom (or was restricted by school rules) and started withholding pee and poop.
Something similar often happens in high school, because students encounter stricter bathroom policies, are grossed out by bathroom conditions, or fear being bullied in the bathroom. Many of my patients never use the restroom between 7:30 a.m. and 3:30 p.m. In kids with a history of mild to moderate constipation, that change is enough to trigger bedwetting or urinary tract infections I have several patients who began having UTIs practically every month after becoming severely constipated in high school.
Of course, when a child starts wetting the bed after years of dryness, I always rule out medical causes such as an anatomic or neurological condition or diabetes. On rare occasions, the cause turns out to be something other than constipation.
Let’s go back to the mom whose questions prompted this blog post. She says her son was dry overnight for 5 years, “other than about 5 accidents a year” and that her child has a history of not using the toilet outside of the home. Those are two red flags. I’d bet good money this boy is constipated. An X-ray or anal manometry would provide a definitive answer.
Bedwetting is a common and stressful problem. That Turkish study, surveying parents of 4,250 children ages 6 to 13, found that 9.5% of children wet the bed, consistent with other research.
I wish the medical community would stop treating primary and secondary bedwetting as different conditions and stop perpetuating the theory that “psychological factors” cause bedwetting. Anxiety may cause a child to avoid using the bathroom at school, and that may in turn trigger bedwetting, but drawing a straight line from stress to wet sheets is irresponsible and prevents a lot of children from getting the treatment they need.