By Steve Hodges, M.D.
A mom in our bedwetting support group, who is implementing the Modified O’Regan Protocol (M.O.P.) with her 6-year-old twins, posted an excellent question about treating chronic constipation and incontinence in children. In short, she asked: Will it ever end?
Here’s more from her post:
Once the colon has been stretched to the point where M.O.P. becomes necessary, what is the likelihood of a full recovery for the child?
Is this a lifelong condition/vulnerability with periods of health and regression that they will need to grow up with and then learn to manage as adults? Or is it more like something that we can help them through and then put behind us?
I feel that I may have been approaching the whole thing the wrong way: as something to be attacked and conquered, rather than a new normal to be accepted and adjusted to.
I have been focused on getting towards that moment when we can be “out of the woods,” instead of learning to make our home in the woods, so to speak.
Do most children recover from chronic constipation and incontinence relatively uneventfully with the right treatment?
The short answer: Yes. With aggressive treatment such as M.O.P., almost all children recover completely. The rectum, even when stretched for years, does shrink back to size. You won’t be buying enemas forever.
But . . . there are two “buts.”
1.) Children constipated enough to have accidents are, by definition, highly susceptible to relapse. The holding habit dies hard. Cleaning out the rectum is only half the battle. Keeping it clear is the other, trickier half and requires long-term vigilance and lifestyle changes.
2.) Even with daily enemas, some children don’t overcome accidents within the typical 3 to 6 months. This does not mean their incontinence will never resolve. It means they haven’t yet found the right type of enema (or enema/laxative combination) to completely empty and shrink the dilated rectum. I’ll discuss this scenario later in the post.
Life After M.O.P.
M.O.P. is a four-phase process: 1.) daily enemas + osmotic laxative, 2.) enemas every other day + laxative, 3.) enemas twice a week + laxative, and 4.) maintenance (first with laxatives, then without).
Phases 1 through 3 clear out the child’s stretched, stool-stuffed rectum and keep it unclogged. This process allows the rectum to bounce back to size, regain tone and sensation, and stop aggravating the bladder. That’s when accidents stop.
But that’s not when you’re out of the woods.
Maintenance with osmotic laxatives lasts at least 6 months, and during this time, you and your children have a lot to monitor: how often they poop and pee, poop size and consistency, their eating habits, school bathroom access, and so on.
I don’t recommend weaning from a daily osmotic laxative until a child is spontaneously pooping a nice pile of mush every day. Kids who achieve dryness without achieving the daily “spontaneous poop” are ripe for relapse.
Once a child has weaned from laxatives, you’re still not out of the woods! You need to maintain all the monitoring and react immediately to any sign that constipation is creeping back, such as large or hard poops, a skid mark, or a day without pooping.
As one mom in our support group posted, “When we started seeing huge logs of poop again, we were all, ‘Oh no you don't!’ Immediately we knew we had to use enemas for a little while, plus an osmotic laxative.”
Her 4-year-old’s encopresis (poop accidents) resolved quickly on M.O.P., but, she says, maintenance has lasted more than a year. Her post continued:
After reading The M.O.P. Book, I understood that stopping accidents was no longer the only objective; a healthy colon was.
So we did “active M.O.P.” for around 8 months, completing all the milestones: no accidents, pooping during potty sits, occasional spontaneous poops, daily spontaneous poops, and, finally, spontaneous poops without laxatives.
We remain now in a sort of perpetual maintenance stage, where we still monitor daily poops and assess whether he needs a stool softener, an Ex-Lax or an enema. We use one to three enemas per month, to be sure there’s no backed-up poop when his diet has been not so great.
I applaud this mom’s emphasis on the spontaneous poop, because that’s really the most important sign of a full recovery. After all, delayed pooping is the root cause of accidents. To escape the woods for good, children must unlearn the holding habit.
Most kids who go through M.O.P. do get to this point — eventually. Laxatives keep stool soft, so pooping no longer hurts, and these kids stop associating pooping with pain.
Maintenance Gets Easier
With age, kids are better able to notice when they’re getting constipated and are more willing to comply with the maintenance regimen.
As one mom in our Facebook group posted:
When we started my son was almost 7, and he would try to get out of every single potty sit, pill, special drink, what have you. (Though he never minded the enemas. Huh.) Now he is almost 10 and understands how important maintaining a schedule is. We are done with regular enemas but still very regimented with Ex-Lax, stool softener, and potty sits.
Another mom reports that two years after completing M.O.P., her 9 ½-year-old will sometimes ask for an enema if he hasn’t pooped in a day or two. “I think he knows how to care for himself if he feels himself getting constipated.”
Yet another mom says that after 2 ½ years on this road, her daughter “can easily slide back into accidents” if they’re not vigilant about her pooping habits and diet. "But we've come a long way, and the older she gets, the more she's willing to do what she needs to do, like potty sits and eating healthier."
The more you can educate your child about the importance of daily pooping, frequent peeing, healthful eating, and staying active, the more successful you’re likely to be in the aftermath of M.O.P.
All our children’s books — Bedwetting and Accidents Aren’t Your Fault, Jane and the Giant Poop, and Dr. Pooper’s Activity Book and Poop Calendar for Kids — reinforce the messages that are so crucial to maintenance.
The calendar in Dr. Pooper’s Activity Book (also included in the M.O.P. Anthology) is especially helpful for kids who don’t want to summon Mom or Dad to the toilet or report their poop consistency verbally. They can just fill in the calendar and hand over the pages.
When Accidents Persist
As folks in our support group know, some kids continue to have accidents despite very aggressive treatment on M.O.P.
This doesn’t mean these kids will never reach the maintenance phase. They will. But it means we have not hit on an effective way to clean out these kids’ rectums.
You’d think 30 consecutive days of enemas would unclog any child, but you’d be wrong.
In a small minority of kids, even months of large-volume enemas with stimulants (the M.O.P.+ regimen) has virtually no effect. Parents are, understandably, shocked when an X-ray shows their child’s rectum is just as stuffed as it was when they started.
I really feel for these families and continue to work with them in finding a solution that will work for their child. I discuss numerous solutions in The M.O.P. Book: Anthology Edition.
But let’s get back to the question that prompted this post: Do most children recover from chronic constipation and incontinence relatively uneventfully with the right treatment?
Children’s rectums have tremendous resilience. Even when a child’s rectum has been stretched by stool build-up for years on end, a complete recovery is possible — and highly likely.
But keeping constipation at bay takes work — "time, effort and mindspace," as one mom lamented. And, possibly, a different mindset than you had at the get-go.
“I don’t think it would benefit us to think in terms of 'he's cured,' reflects one mom, who keep different types of laxatives and enemas handy, in case her son starts to backslide. “I think in terms of ‘When you know better you do better.'"