By Steve Hodges, M.D.
In his classic and genius essay on preparing for a colonoscopy, Dave Barry recounts what happens when you consume the two mandated jugs of “nuclear laxative,” which he describes as tasting “like a mixture of goat spit and urinal cleanser, with just a hint of lemon.”
Have you ever seen a space shuttle launch? This is pretty much the MoviPrep experience, with you as the shuttle. You spend several hours pretty much confined to the bathroom, spurting violently. And then, when you figure you must be totally empty, you have to drink another liter of MoviPrep, at which point, as far as I can tell, your bowels travel into the future and start eliminating food that you have not even eaten yet.
I haven’t had a colonoscopy myself, but my co-author, Suzanne Schlosberg, has had two of them, and she confirms the accuracy of Dave Barry’s description — except, she told me, “Dave Barry makes the prep experience sound way more fun than it actually is.”
At any rate, given how monumentally well colonoscopy-prep medication excavates the bowels, many parents of my bedwetting patients have asked me: Why can't I just give my child one of those super-duper, mega-blast laxatives? If constipation is the cause of bedwetting, won’t that solve the problem? Why do we have to endure this daily enema thing?
I’ll get to the answers shortly, but keep this in mind: Shortcuts are tempting but rarely fruitful.
Once in a while you’ll find some back road off the traffic-choked highway that’ll get you to your destination faster. But more often, attempting to speed things up only slows you down, delaying the inevitable.
This is true with weight loss and especially true with bedwetting treatment.
On the whole, parents of my patients are receptive to the notion that chronic constipation causes bedwetting. They understand — especially when I show them X-rays — that their child’s stool-stuffed rectum is pressing against and aggravating the bladder. They nod when I explain that resolving accidents requires cleaning out the rectum and keeping it clear, so it can shrink back to size, regain tone and sensation, and stop bothering the bladder.
But when I explain that a daily enema regimen is by far the best way to achieve this, well, that’s where some folks — quite understandably! — say, “Whoa, hold up! There must be an easier way.”
The oral cleanout vs. enema issue surfaces often in our private Facebook support group. One mom, echoing others, asked if she could empty her child’s clogged rectum with a “swift and thorough clean-out like the doctors prescribe before colonoscopies.”
“I'm still hoping to expedite this process and discard the enema regimen,” she posted.
She noted that daily enemas — specifically, the Modified O’Regan Protocol (M.O.P.) — had resolved her son’s encopresis (poop accidents), but four months into the program, his daytime and nighttime enuresis (pee accidents) persisted. Frustrated by the slow progress and “worried about the chronic use of enemas,” she hoped to find a workaround.
The next day, I received a similar email from the dad of a 12-year-old with both daytime and nighttime accidents. The dad asked me the particulars for a high-dose Miralax clean-out. He was trying to avoid M.O.P., he said, because his wife was concerned about the safety of daily enemas.
I sent him instructions for the Miralax clean-out (they’re on page 54 of It’s No Accident and page 3 of Answers to 52 Questions About M.O.P.), because there is no harm in this process. But I also explained that 1.) in healthy children, a daily enema regimen is perfectly safe, and 2.) any positive results from an oral clean-out, nuclear or otherwise, are likely to be short-lived.
Yes, Enemas Are Safe for Children
I discuss the safety of M.O.P. at great length in “Yes, Daily Enemas Are Really, Truly Safe for Constipated Children.” In short: there is no evidence — or even logical reason — to suggest enemas cause dependence or electrolyte imbalance, the two concerns I hear most, or any of the less frequent concerns I hear.
At the same time, there is plenty of evidence that the Modified O’Regan Protocol, as spelled out in The M.O.P. Book, causes no harm, save the rare cases of colon inflammation in children sensitive to phosphate. (If a child experiences a burning sensation from phosphate enemas, just switch to a liquid glycerin or high-volume sodium enema; problem solved.) I’ve used the protocol with thousands of children and had the same experience Dr. O’Regan reported in his research: lots of success, no complications.
Though the idea of daily enemas may seem unsafe, no one can reasonably argue that M.O.P. actually is unsafe. (You also can’t argue it’s “abusive,” though some doctors have tried.)
Let’s move on to the other reason parents are seeking a shortcut: M.O.P. takes too long.
Absolutely, progress on M.O.P. can be slow — maddeningly slow — especially in older children and in any child who has both daytime and nighttime symptoms. I certainly don’t blame parents for seeking a shortcut! For the toughest cases, it can take many, many months for accidents to resolve. As I state in The M.O.P. Book, “This protocol is not a magic cure but a process that involves trial and error.”
Progress is slow for good reason: It took years for a child’s rectum to stretch to the point of losing tone and encroaching upon the bladder. A rectum stretched to that extent — typically more than twice its normal diameter — is not going to spring back in a few weeks, even if it is completely emptied day after day.
But when you only empty it just once, via a Miralax power wash or a nuclear pre-colonoscopy shuttle launch, it’s likely to fill right back up, even if followed by a daily maintenance dose of Miralax.
That’s because, in kids who have accidents, the rectum has been so stretched it no longer works normally. Even if a fire-hydrant-level hose-down managed to empty your child’s rectum completely (and that’s a big “if”), the child won’t feel the urge to poop until the rectum fills up again; the filling of the rectum is what triggers the urge to poop. In a child with a stretched-out, floppy rectum, it takes an extra-large poop pile-up to trigger that urge. And that poop pile-up is going to continue to aggravate the bladder.
That’s why some kids achieve dryness a few days after a clean-out, only to have wetting a return a few days later. It took that long for the rectum to refill.
Also, the holding habit dies hard in children. “Our kids' constipation and holding are a vicious cycle,” as one mom in our group noted. Just because a child’s rectum was cleaned out doesn’t mean he’s going to suddenly relax his pelvic floor muscles and poop immediately upon feeling the urge to poop (and that is key!). Daily enemas are necessary to keep the rectum clear long enough for sensation to return and good pooping habits to kick in.
And here’s a critical point: High-dose oral clean-outs often fail to evacuate the rectum completely. The liquid cleanse often washes right past the impacted mass of stool, so the child ends up with diarrhea and constipation.
Think about it: When you, an adult, prepare for a colonoscopy, your rectum isn’t harboring impacted old stool. The prep solution doesn’t have that difficult a task ahead. And yet it takes an insane amount of this nuclear laxative — stuff so potent that “we must never allow it to fall into the hands of America's enemies,” writes Dave Barry” — to even clean out soft, fresh poop!
I’m guessing that parents who ask about giving colonoscopy-prep medication to their kids have not undergone a colonoscopy themselves. One mom in our Facebook support group, a veteran of the procedure, posted: “I can say that the prep is extremely unpleasant for me — forget about getting my kid to do it!”
She did get her 7-year-old to do three high-dose Miralax cleanouts over many months, but reported that “the encopresis always returned eventually.” She also notes: “We found weekend cleanouts burdensome in many ways. My son was reluctant to drink the laxatives and liquids that were required.” Depending on the child’s weight, a clean-out involves drinking 7 to 14 doses of Miralax (PEG 3350), in 32 to 64 ounces of liquid, over 24 hours.
Only when this mom implemented M.O.P.+, the more aggressive version of M.O.P., did her son’s encopresis resolve for good.
Which brings me to another key point: Even daily enemas can fail to clean out the rectums of chronically constipated children. That’s right! You can give a severely constipated child an enema every single day for 30 consecutive days, or longer, and this kid could be just as clogged up on Day 30 as she was on Day 1.
Many parents are stunned when I show them follow-up X-rays after a month of M.O.P. They assumed, quite reasonably, that their child would be thoroughly hosed out after all that trouble. And yet, the child remains stuffed.
That’s why 15% to 30% of families on our protocol have to switch from M.O.P., which uses store-bought pediatric enemas, to the more aggressive M.O.P.+, which uses high-volume enemas with stimulants such as glycerin or castile soap.
When M.O.P. fails to resolve accidents, it’s not because the child wasn’t constipated; it’s because the enemas did not completely empty the impacted stool.
This phenomenon was demonstrated in our clinic’s published study on daytime wetting. In this study, accidents resolved in 85% of the kids on M.O.P., compared to 30% of the kids who took daily Miralax. (The Miralax kids didn’t do high-dose clean-outs; that wasn’t the point of the study). Most relevant here: in the 15% of kids whose accidents failed to resolve on M.O.P., X-rays showed their rectums were still chock full of stool. Their rectal diameters averaged 6 cm to at the start of the study, twice normal size, and remained stretched to 6 cm after three months of daily enemas! Among the 85% of children on M.O.P. whose accidents did resolve, rectal diameter was reduced to 2 cm on average.
As one mom in our support group posted: "'Clean-out’ can be a misnomer: You think they are cleaned out because lots of stuff emerges, but it is still there — the hard stuff, that is.” Another mom wrote: “I feel like I am chipping away at a cement block with a garden hose!”
In our support group, some of the most stubbornly constipated kids are on Double M.O.P., a regimen of overnight olive oil or mineral oil enemas (in addition to regular enemas). The oil can help soften the oldest, crustiest stool. It’s also important to experiment with different enema solutions, to see which ones empty your child’s rectum the best.
Even if I had a magic wand and could instantly and completely empty every one of my patients, unless these kids continued on daily enemas (allowing the rectum a chance to recover), they would just fill right back up. In children who are constipated enough to have accidents, a clean-out with a nuclear laxative might fully empty the rectum — I would need to see proof on an X-ray — but that’s still not likely to suffice.
I used to suggest laxative clean-outs as an alternative, albeit an inferior one, to daily enemas. That’s why you’ll find the clean-out instructions in It’s No Accident, my first book, published in 2011. However, long ago, after many more years of research and experience, I changed my mind.
I don’t think any oral approach — nuclear or otherwise! — will come close to matching a daily enema regimen. Some families do find occasional laxative clean-outs useful as an adjunct to M.O.P. Clean-outs may have a role, in particular, in children whose poop is more evenly distributed throughout the colon (instead of all piled up at the end) and as a kickstart to M.O.P.
But remember: in a constipated child, the problem isn’t just the rectal clog; it’s the stretching. You just can’t expedite the healing process. Any search for a shortcut is likely to end in disappointment.
I know daily enemas are a drag. But for the child, they are a heckuva lot more pleasant — and more effective — than the nuclear option.