By Steve Hodges, M.D.
At what age should a child be treated for bedwetting or daytime accidents?
Most doctors will tell parents, “Accidents are normal — don’t even worry about it until she’s 7.”
Many will even dismiss bedwetting when a child is 9, 10 or 12, assuring parents, “Don’t worry — he’ll outgrow it” and “No one ever went off to college in pull-ups!”
Of course, parents do worry, because bedwetting and accidents are extremely stressful for families and often damaging to a child’s self-esteem, especially as a child gets older and wants to attend sleepovers and sleepaway camp.
And let me tell you, I’ve had numerous patients delay college, or live at home instead of a dorm, because they were still wetting the bed.
The single biggest regret among parents in our private Facebook support group is that they waited . . . and waited . . . and waited for their child to stop having accidents, delaying aggressive treatment, or any treatment at all, because their doctor kept assuring them dryness was just around the corner.
As one mom in our group recently posted:
We had been going to a pediatric GI specialist at ages 8, 9 and 10. She pretty much just reassured us at each visit and told us it would take just another 6 months, then just another year, then just another few years for things to clear up. But things were not going in the right direction.
So many pediatricians seem to act like it’s not a problem to be concerned about — my son is turning 12 this month, and we could have resolved this years ago!
You will find similar cautionary tales in these two blog posts: “Don’t Assume Your Child Will Outgrow Bedwetting” and “Teenage Bedwetting: Everything You’ve Been Told is Wrong.”
While it’s true that most children eventually outgrow enuresis or encopresis, many children do not — a fact downplayed by the American Academy of Pediatrics. Others wet the bed or have daytime accidents for years and years longer than they would have, if only they’d received appropriate treatment.
As a team of Hong Kong researchers concluded, the “Don’t worry, she’ll outgrow it” adage “probably applies only to those with mild enuretic symptoms” — in other words, children who wet the bed infrequently and don’t have daytime accidents. Children with “more severe symptoms,” such as daily bedwetting, “have a “significantly greater chance of persistent [bedwetting] in adult life.”
It is my mission to prevent as many children as possible from suffering the discomfort and embarrassment associated with prolonged bedwetting and accidents. Our free infographic, “Bedwetting and Accidents: Early Intervention is Everything” spells out four action items for parents:
1. KNOW that bedwetting and daytime accidents are caused by chronic constipation.
The rectum, stretched by stool build-up, presses against and aggravates the bladder, triggering spasms. Deep sleep, anxiety, hormones, or an “underdeveloped bladder” play no role in bedwetting.
In the case of encopresis, the stretched rectum loses tone, making it impossible for the child to fully empty, and loses sensation, so the child doesn’t feel the need to empty. Often, stool just drops out of the child’s bottom, without the child even noticing.
2. CONFIRM constipation via X-ray and rectal diameter measurement.
Feeling a child’s belly, the most common diagnostic method among pediatricians, is highly unreliable — worthless, actually. A baseball-sized mass of stool in the rectum can easily go undetected by a doctor’s hand, even in a tiny 3-year-old.
As one mom in our private Facebook support group posted, “Based on feeling our daughter's belly, our pediatrician declared, 'There is no way this child is constipated' but allowed an X-ray anyway. I brought the photo of her stuffed-full-of-poop film right back, and his attitude towards the seriousness of her problem completely changed.”
How often a child poops also tells you nothing useful. Many severely constipated children poop every day — they just don’t fully empty.
I X-ray all my enuresis patients and measure their rectal diameter, for reasons I explain in The M.O.P. Book: Anthology Edition. Nearly all of these kids prove to be significantly constipated. A normal rectum is no more than 3 cm in diameter; most of my enuresis patients have rectal diameter measurements of 6 or 7 cm.
In some cases, even a plain X-ray can fail to detect a large rectal mass, as I recently described in “An 11-Year-Old Bedwetting Patient, A Lucky Mistake, and a ‘Wow’ Moment.” The episode I describe should hammer home just how useless belly exams are.
Children with encopresis don’t need X-rays, as chronic constipation is the only explanation for their condition.
3. TREAT constipation aggressively.
Daily Miralax, the most common treatment for childhood constipation, fails most kids with enuresis or encopresis. My own research demonstrates that daily enemas — the basis for the Modified O’Regan Protocol (M.O.P.) — are far, far more effective than Miralax. The research of Sean O’Regan, the physician for whom M.O.P. is named, also shows that a daily enema regimen is highly effective for treating enuresis, encopresis, and chronic urinary tract infections.
Yes, daily enemas are safe for children. No, they do not cause dependence or electrolyte imbalance or sphincter damage or emotional trauma, as I explain in detail in The M.O.P. Book: Anthology Edition and in the (free) “Physician’s Guide to M.O.P.”
And no, high-dose oral clean-outs are not a substitute for enemas, as I explain in “Bedwetting Treatment: Why Even the ‘Nuclear’ Option Can’t Replace Enemas.”
In fact, in many children, even daily pediatric enemas do not adequately clean out an impacted rectum, and these children need to move on to high-volume enemas (the M.O.P.+ regimen) and Double M.O.P. (the addition of overnight oil-retention enemas), more aggressive protocols described in The M.O.P. Book.
4. ACT NOW, not later.
I cannot overemphasize the importance of early treatment.
The longer the rectum remains stretched, the longer bedwetting and accidents can take to resolve. Simply getting the rectum cleaned out is not enough; the floppy rectum must also shrink back to size, so it can regain tone and sensation and stop bothering the bladder.
I strongly recommend treating bedwetting starting at age 4 and treating daytime accidents within a few months of toilet training.
When a child struggles to potty train, it’s because the child is not ready to train or because the child is constipated. My approach to potty training is spelled out in “7 Super Important Rules for Potty Training Success: A Guide for Parents.”
To download our free infographic, "Bedwetting and Accidents: Early Intervention is Everything," go to our Downloads in English page.