By Steve Hodges, M.D.
When parents discover the Modified O’Regan Protocol (M.O.P), it’s usually after they’ve “tried everything” to fix their child’s bedwetting and/or daytime accidents — laxatives, probiotics, medication, alarms, nighttime fluid restriction, overnight wake-ups, fiber, bribes, potty sits, and, of course, years of waiting for the accidents to spontaneously resolve.
Compared to those approaches, a daily enema regimen seems so radical, so extreme, so outlandish that parents expect it to stop the accidents immediately, or at least within a month.
When that doesn’t happen, many get discouraged.
As one mom posted on Facebook: “My son is almost 9, and we have been doing M.O.P. for a good two weeks now. I thought we were getting a handle on the daytime accidents, but I just got done dropping off new clothes for my son at school due to him having bad accident. I just feel so hopeless that this will never get any better.”
Hopeless after two weeks?
Expecting M.O.P. to work that quickly is like expecting to lose 10 pounds after two weeks of exercise!
Another mom posted:
“My son (10 years old) has struggled with this since he was about 6 months. Finally started M.O.P. 30 days ago. Have seen huge improvements but have also had a few instances of waking up wet. So easy to think this isn’t working and to stop.”
Think about it: Her son has been struggling with constipation for nearly a decade, and despite “huge improvements,” she’s ready to quit because he’s had a few instances of waking up wet!
In reality, the fact that a 10-year-old has made huge improvements in 30 days is nothing short of phenomenal.
In the same week, another mom posted this:
“We are on day #46 [of M.O.P.] and while my 6 year old is such a good sport about this protocol, I was beginning to lose hope because we haven’t achieved our consecutive 7 dry nights yet. Actually, we haven’t achieved more than 2 dry nights in a row. I keep thinking maybe I’m doing something wrong.”
Clearly, some wires are getting crossed!
In this post, I’ll explain what you can expect from M.O.P., how to define “progress,” and what to do when you’re genuinely getting nowhere. I hope to minimize your frustration and help you recognize — and celebrate! — progress you may have overlooked.
Let’s start with how we describe M.O.P. in The M.O.P. Book: Anthology Edition: “M.O.P. is not a miracle cure.”
We further describe the protocol as a “trial and error process” and “a process that happens in fits and starts and that each child experiences differently.” Several times, we caution families to “expect uneven progress and setbacks.”
Yet when progress is slow and setbacks occur, parents jump to the conclusion that they’re doing something wrong or the process isn’t working!
Parents are easily discouraged, I suspect, because of a misunderstanding about how M.O.P. works. For one thing, it’s not the rectal clean-out that fixes the problem. Fully evacuating the rectum every day is only the prerequisite for resolving accidents.
With enuresis, accidents stop after the stretched rectum shrinks back to a normal diameter, regains its tone, and stops aggravating the bladder. This can be a slow process. As we state in the Anthology:
A rectum clogged for years won’t rebound overnight. Also, when the nerves feeding the
bladder have been chronically irritated, it can take months for them to settle down, even
after the rectum is persistently clear. In a small minority of cases, it takes more than a year for accidents to stop completely.
Yes, more than a year! No one expects their child to be in the minority, but someone’s child has to be.
As I explain in the Anthology, a normal, healthy rectum measures no greater than 3 cm in diameter. Most of my enuresis patients have a rectum that measures 6 cm to 9 cm in diameter — two to three times normal! (We take measurements via X-ray.)
This is no small situation to overcome. A typical scenario is for the rectum to shrink back to size within about three months — three months after the rectum has been fully and continually cleaned out.
But here’s something else many folks don’t understand: the mere insertion of an enema does not guarantee a complete evacuation.
For many families, getting on board with enemas is such a big step — one that may require defying their doctor’s advice — that they overlook the possibility that the enema might not even do the job.
Simply administering enemas day after day guarantees nothing. You can give a child enemas for 80 straight days, even 180 straights days, and get nowhere.
In the Anthology, we alert readers to this possibility:
Parents are often stunned when follow-up X-rays show that even after a month of enemas, their child is still severely clogged. Some children are just so stubbornly and severely constipated that store-bought enemas — the kind we use for the basic M.O.P. program — are inadequate. In fact, a small minority of children remain clogged even after months of daily M.O.P.+ enemas.
Complete evacuation is far more difficult to achieve than parents and physicians typically realize, especially physicians who’ve been advocating Miralax and more Miralax.
When a child does not make progress on M.O.P., it’s because the families have not hit on an enema formula that will clear out their child’s rectum.
The child might need to switch from liquid glycerin suppositories to phosphate enemas, or vice versa. More likely, the child needs to use large-volume enemas (M.O.P.+) with more saline solution and a higher dose of stimulants such as glycerin and/or Castile soap.
How much higher? Who knows? A lot of guesswork is involved.
I recently worked with a family whose 6-year-old daughter simply could not overcome daytime accidents in over a year on M.O.P. and M.O.P.+. We finally decided to do a week of consecutive daily X-rays, taken within 2 hours of the daily enema, to more accurately determine an effective formula.
(Yes, a week of daily X-rays is safe and is warranted in these situations; it’s common practice in the bowel-management programs of major U.S. children’s hospitals.)
Each day, I reviewed the post-enema X-ray and evaluated how well the girl’s rectum had emptied. The child began the week using 280 ml of saline solution plus 15 ml of glycerin; by the end, we’d shifted to 400 ml of saline plus 40 ml of glycerin and 40 ml of Castile soap.
As this mom told me, “If I had given her the final formula a year ago, I wonder where we would be today.”
Fortunately for the child, this mom persisted. Rather than throw in the towel, she went to great lengths to find the formula that worked for her daughter.
In most cases, a week of daily X-rays isn’t necessary; with enough time and experimentation, most folks can find an effective formula on their own. But parents do have to be willing to take the time and do the experimentation.
As we emphasize in the Anthology, it’s critical to change your M.O.P. regimen after any 30-day period of negligible or no progress. We state:
What if your child sees no progress after 30 days? That’s when you switch to M.O.P.+. And if that fails, you try Double M.O.P. or Super M.O.P., outlined on the M.O.P. Progression chart.
(Double M.O.P. involves overnight oil-retention enemas, and Super M.O.P. involves the Peristeen pump, an anal irrigation system that’s like an extra powerful large-volume enema.)
Elsewhere, we state:
While it’s important to give M.O.P. a full 30 days, it is equally important to make a change
if you see no progress after that first month. I’ll say it again: Do not stick with any version of M.O.P. that is not working.
Yet many families use the exact same type of enema for months on end and get frustrated when the child doesn’t improve!
Which brings me to another important topic: the definition of “improvement” or “progress.”
As we explain in the Anthology, progress is “not necessarily the same thing as having dry nights.” It’s only natural for families to measure improvement by the number of dry pull-ups. After all, the whole point of M.O.P. is to resolve the accidents!
However, with many kids, subtle signs of progress precede dry nights. In the book, we list these signs, which include fewer stomachaches, less urinary urgency or frequency, more spontaneous pooping, and fewer underwear skid marks.
We also urge parents to track their child’s symptoms closely. Tracking allows parents to notice these subtle signs or, alternately, to feel certain no progress is happening and recognize when it’s time to tweak the regimen.
Now, one subset of frustrated parents is the group dealing with three issues at once: bedwetting, daytime wetting, and poop accidents (encopresis).
Among these folks, a common scenario is this: the poop accidents stop right within a few weeks, but the wetting, day and night, persists. The end of poop accidents comes as a huge relief, but based on the initial success, parents expect similar results with enuresis.
This is not a realistic expectation! As we state in the Anthology, these kids may need daily enemas for “many months.” In fact, we use all-caps and red type to make this point:
IMPORTANT NOTE: If your child has bedwetting in addition to daytime pee and/or poop accidents, you are looking at a longer haul. Phase 1 may last many months, and you are more likely to need M.O.P.+.
Elsewhere, we state: “[Phase 1] may take additional months, as kids with daytime accidents face a more difficult road.”
In most of these cases, poop accidents diminish and then stop, and then daytime accidents diminish and stop, and only then — perhaps many months later — do nighttime accidents diminish and stop.
So, if your child has no dry nights the first month but has fewer daytime accidents, that is a big sign of progress! It's a glass-half-full situation! It’s something to celebrate rather than bemoan.
However, it is not a sign to start tapering from daily enemas. According to the protocol, you do not shift to enemas every other day until your child has at least 7 consecutive days and nights of 100% clean and dry pull-ups. Even then, you might want to maintain daily enemas for several extra weeks, especially if your child has not a achieved a daily spontaneous poop. As we explain in the book, lack of a spontaneous poop is a red flag for a high risk of recurrence.
Understandably, when families embark on M.O.P., they want to know how long it will take for the accidents to resolve. I’ve even had parents ask if I will “guarantee” success within a certain time frame!
I can only provide data based on my clinical practice. For obvious reasons, I have no data on success rates among parents in the general public who buy the book.
At any rate, below I provide more detail, taken from the Anthology, about the results we see in my clinic. Keep in mind, my patients have the benefit of having frequent X-rays to assess how well their enema formula is working. Not all families on M.O.P. have physicians who are willing to order X-rays for this purpose or are experienced in evaluating the images.
Poop accidents: Encopresis often resolves within a week or two on M.O.P., and nearly all
cases resolve within a month. Children with encopresis are so monumentally clogged that even small improvements make a big difference. Still, to prevent a relapse, it’s important to finish the 90-day program.
Daytime pee accidents: My research shows 85% of children with daytime pee accidents will stop daytime wetting within 90 days on the standard M.O.P. regimen. If a child is having nighttime accidents in addition to daytime pee accidents — which is the case for most kids with daytime enuresis — it will almost certainly take several months for the bedwetting to cease.
Bedwetting: In my practice, about 95% of bedwetting-only patients see significant progress within 30 days on M.O.P., and around 80% achieve dryness in the first month. But for some children, bedwetting can take many months of aggressive M.O.P. or M.O.P.+ treatment to resolve.
Here's another way to look at the above information: The "clock" essentially starts over after each type of accident resolved. So if your child has all three types of accidents, it's highly unlikely bedwetting will stop within three months. It may take a month of daily enemas for the encopresis to stop, another one to three months for the daytime accidents to stop, and then an additional three months for the bedwetting to stop.
When you're evaluating whether your child has made progress in a given 30-day period, make sure you only consider progress across within accident type. In other words, if your child started M.O.P. with both nighttime wetting and daytime wetting, forget about the bedwetting until the daytime accidents have resolved. When making decisions about whether to tweak the regimen, consider only whether the daytime symptoms have improved.
It’s hard to predict which kids will be the unlucky ones who take longer than most. But in general, the older the child, the longer it takes for the wetting to stop. That’s because the rectum and bladder nerves have been stretched for a longer time.
If your child is stalled out on any version of M.O.P., I urge you to re-read the Anthology for ideas on tweaking the regimen or shifting to a more aggressive version. You might also consider joining one of our private support groups (the main M.O.P. group of the Tweens/Teens group), where you can post about the M.O.P. permutations you have tried and receive input from me and other parents in the same boat.
Most members of our support groups started with high expectations and eventually came around to the idea that M.O.P. is not magic.
As one wise mom posted to her fellow parents:
Be emotionally prepared for M.O.P. to take longer than you expect. I am an impatient person, and I thought that if we can put a man on the moon, we can get impacted stool out of my child and move on. My biggest surprise has been that for my son, this is a long process. But I feel very very confident this is the best approach.