By Steve Hodges, M.D.
At what age should bedwetting be treated?
The medical community’s boilerplate answer — around age 7 — is profoundly misguided, unsupported by science, and makes life crummy for countless children.
Seven is not a magic number! And it’s three years later than I recommend. Yes, I treat bedwetting at age 4.
Telling families, “Don’t worry, it’s normal, she’ll outgrow it,” deprives kids of timely treatment, dismisses the distress so many families feel, and allows a fixable condition to worsen.
The advice to delay treatment until age 7 or beyond is based on a misunderstanding of what actually causes bedwetting.
It’s also the reason I have a huge patient load of tweens and teens with enuresis — 6th-graders who not only wet the bed but have accidents at school, middle schoolers who miss out on scouting sleepovers and summer camp, 10th-graders terrified of heading to college with pull-ups, seniors who tell me, “It’s so embarrassing not even my best friend knows.”
Yet “Be patient!” is the advice physicians of all stripes dispense every day, to patients and to the media.
Recently a pediatrician asserted in the New York Times: “In a normally developing child who is younger than 7, deciding to wait it out . . . is completely reasonable.” Also: “Most children need time, not special interventions, to eventually stay dry overnight.”
On the Cleveland Clinic’s website, a pediatric kidney specialist says: “When your child is older than age 7 and still wetting the bed, you might want to talk with your child’s [doctor].”
And this, from the American Urological Association: “If a child experiences bladder control problems during sleep after the age of 7, it's worth looking into.”
Unbelievably, American Academy of Pediatrics (AAP) advises parents: “If bedwetting has not stopped in the late teenage years, your child should be seen by a doctor.”
All this complacency ("worth looking into" and "you might want to talk with" the doctor" — seriously?) echoes what parents I work with, in my clinic and private Facebook support groups, were told.
“Every year, through age 5, 8, 10, 14, the pediatrician kept saying, ‘Don’t worry, he’ll grow out of it,” one mom told me. Her son was 16 when he came to my office.
Another mom said, “A pediatrician told my 7-year-old not to be concerned until age 11 or 12 because there are such great pull-up-type products available nowadays.” (Ten-year-olds love wearing pull-up-type products!)
A mom in our support group for parents of bedwetting teens posted: “I’ve been told consistently, ‘He’ll grow out of it.’ I now have a 16-year-old who wets the bed nightly. Hoping for college. I’m so angry about how long we waited.”
The mom of an 11-year-old posted: “We were told, ‘He’ll grow out of it. There’s medication and alarms if it comes to that.’ Which is frustrating because we waited as a result. We didn’t know any different.”
I’ve heard this thousands of times.
The advice to wait until around age 7 (or beyond) is inevitably accompanied by statistics about how common bedwetting is at age 5.
From the AAP: “Around 20% of children have some problems with bedwetting at age 5.”
From the New York Times: “At age 5, about 15 percent of normally developing children still wet themselves at night.”
The implication: because bedwetting is common, it’s normal.
Bedwetting is indeed common — true enough! For example, a study of 16,000 children in Hong Kong found 16% of 5-year-olds wet the bed — 20.7% of boys, 10.8% of girls.
However! Just because a normally developing 5-year-old has a common condition does not mean that 1.) the condition itself is normal, 2.) the child will outgrow the condition, or 3.) the condition should be left untreated.
The advice to “be patient” is, in part, based on the myth that overnight dryness is a developmental issue — that some kids just have an "underdeveloped bladder," an immature “bladder-brain connection,” or a hormonal shortage that will eventually right itself.
For example, the Cleveland Clinic says, “The underlying issue is usually a bladder that’s not yet matured.”
The New York Times says: “Staying dry at night is a multistep developmental process. First, your child needs to develop increased levels of the hormone vasopressin. . . Your child also needs to recognize their bladder is full and wake up.”
The AAP says bedwetting “is thought to happen because of a delay in the development in at least one of the following three areas at nighttime: bladder (less space in the bladder at night), kidney (more urine is made at night), and brain (unable to wake up during sleep).”
False, false, and false!
Bedwetting has nothing to do with hormones or bladder development or sleep, as I explain here. It’s almost always caused by chronic constipation — in other words, rectal stretching due to a pile-up of stool.
In 99% of my otherwise healthy patients, no other cause exists. (Here, I discuss the rare exceptions, such as posterior urethral valves.) And in most cases, the chronic constipation itself has no underlying medical cause. Exceptions include neurological conditions, such as spina bifida and tethered cord syndrome, and anatomical anomalies such as imperforate anus.
The plain fact is, in a toilet-trained child, bedwetting signals the rectum is stretched by a mass of stool. The poop-stuffed rectum is stretching the nerves that control the bladder, causing the bladder to hiccup and empty without warning.
You can see the pile-up — a poop mass can be larger than a softball — in a plain x-ray. You can quantify its severity by measuring the diameter of the child’s rectum. It’ll be 2 to 3 times wider than normal.
Or, you can conduct an anorectal manometry study, in which case you’ll find the stretched rectum has lost its tone, like a sock that’s lost its elasticity. Anorectal manometry was the preferred diagnostic method of Sean O’Regan, M.D., the pediatric kidney specialist who was the first to scientifically document, back in the 1980s, that bedwetting is caused by constipation.
In our culture, chronic constipation is quite common, for a half-dozen reasons that pertain to life in the 21st century. But this does not mean a mass of stool in the rectum is normal or healthy or that its consequences, including bedwetting, should be shrugged off.
Countless children who outgrow bedwetting nonetheless remained plagued through adulthood by the effects of constipation. That alone is reason to treat the rectal clogging that is at the root of enuresis.
And many children who stop bedwetting at age 10 could have stopped before kindergarten, if they’d been treated properly.
I’ve yet to meet a parent who said, “Good thing we waited! I’m so glad I bought all those pull-ups and changed all those sheets at 1 a.m. I’m especially glad she missed out on all those birthday sleepovers!”
The unluckiest kids are those who struggle with bedwetting as middle-schoolers and high school students or become bedwetting adults. The persistent wetting takes an extreme toll on their self-esteem.
The thing is, all their distress could have been avoided, if only these families had not been told bedwetting at age 5 is normal!
If only they had not been told, “Most children need time, not special interventions.”
Virtually all my patients were wetting the bed in kindergarten and showed signs of chronic constipation years before that. But these signs were missed or disregarded. No alarm was raised, no treatment offered.
So, the rectum stretched further, the bladder nerves became more aggravated, and the wetting persisted — or worsened, progressing to daytime pee and/or poop accidents (encopresis).
A second reason doctors recommend waiting — besides the misguided notion that overnight dryness is developmental — is the data showing a drop-off in bedwetting over time. It’s true, as the Times says, that “eventually” most children outgrow bedwetting.
For example, that large Hong Kong study found bedwetting persists in 13% of 6-year-olds, 10% of 7-year-olds, and 6% of 8-year-olds. At age 10, about 2.6% of kids wet the bed, the same percentage as adults.
I’m not sure why so many doctors think bedwetting is fine in 6-year-olds but not 7-year-olds. There’s not a huge drop-off in that year. Besides, more than half of bedwetting 7-year-olds become bedwetting 8-year-olds, and half of bedwetting 8-year-olds become bedwetting 9-year-olds.
Health organizations like the AAP cite the teenage/adult enuresis figures — 1% to 3% — as some sort of assurance that the condition is destined to disappear. But we’re talking about millions of kids.
In fact, the percentage of teenagers with enuresis is on par with, or slightly higher than, the percentage of kids on the autism spectrum (1% to 2%). No one downplays the autism numbers.
At any rate, the commonly cited enuresis statistics obscure important clues as to which kids are likely to outgrow their condition. It’s clear: the children with the worst odds are those who wet the bed every night and/or have daytime accidents, too.
In fact, as the Hong Kong researchers concluded, the conventional wisdom that bedwetting will spontaneously resolve with age “probably applies only to those with mild enuretic symptoms” — in other words, kids who wet the bed infrequently and don’t have daytime accidents.
No one ever talks about that!
Most physicians with the “don’t worry, he’ll outgrow it” approach fail to inform parents — and perhaps don’t even realize — that daytime wetting and encopresis have the same cause as nighttime wetting.
Kids who wet the bed nightly and kids who have both daytime and nighttime issues are the most severely constipated and the ones who need the earliest and most aggressive treatment.
By “aggressive,” I mean daily laxatives and enemas. The regimen I recommend, the Modified O’Regan Protocol, is based on Dr. O’Regan’s research. (Details are spelled out in The M.O.P. Book: Anthology Edition.)
By “early” I mean this: Any toilet-trained child who has daytime pee or poop accidents should be treated with M.O.P. Yes, this applies to 2- and 3-year-olds. For children who only wet the bed, I recommend treatment starting at age 4, especially if the child wets nightly.
For babies and toddlers who show signs of chronic constipation, I recommend Pre-M.O.P., a regimen that involves laxatives and suppositories, to prevent these kids from ever having to deal with bedwetting and accidents in the first place. (The regimen is explained in The Pre-M.O.P. Plan.)
I’m not sure if enemas and laxatives are examples of the “special interventions” the Times referred to, but I can tell you my patients wish they’d been offered these interventions, rather than empty promises, when they were a lot younger.
Instead, patients are offered bedwetting alarms and medication. Neither of these treatments addresses the root of the problem, delayed pooping and a dilated rectum, and both have high failure rates, as I explain in The M.O.P. Book: Anthology Edition.
Also, neither will help the many kids who have both daytime and nighttime accidents. Among tweens and teens who wet the bed, 32% also have daytime accidents.
Here’s what else won’t help resolve enuresis, even though all are recommended by the AAP: reducing stress, limiting fluids at night, waking the child overnight, avoiding salty snacks, and limiting caffeine and sugary drinks.
If any of those remedies worked, my clinic would be empty!
If Miralax worked, my clinic would be empty, too. Among physicians who recognize that bedwetting is caused by constipation, the vast majority push Miralax and, when that fails, even more Miralax.
I used to do that, too, before I realized — and my research demonstrated — that oral laxatives, while helpful as an adjunct to enemas, won’t suffice to restore normal rectal tone.
Children with enuresis need to be fully cleaned out every day so that the stretched rectum has a chance to shrink back to size, stop bothering the bladder, and regain the function necessary to fully evacuate daily on their own.
M.O.P. will resolve bedwetting and daytime accidents in tweens and teens, but the process usually takes a lot longer than it does 5-year-olds and may require medication (in addition to, not instead of, enemas).
I recently received this email from a mom whose son started M.O.P. at age 16:
"[M.O.P.] was literally life saving for my son, who was repeatedly hospitalized for suicidal ideation with encopresis and enuresis as the primary triggers. My son and I were both on board to try the enemas because nothing else had worked and we had nothing left to lose, but it’s still shocking to me how much resistance we got from everyone — the GI doctor, the pediatrician, the mental health care providers, his dad. But we did it anyway and it worked. He did daily enemas for 18 months. He is 16 ½ now and just recently stopped wearing diapers. I just recently bought him underwear. So much ignorance from every part of the health care delivery system. Lots of grief and grieving on our part, once we read your book and implemented the program."
Next time you hear a doctor say, “Don’t worry, he’ll outgrow it,” think of this kid.