By Steve Hodges, M.D.
Normally I wouldn’t blog about the same topic three times, but the Kristen Bell “potty training” saga is such a factual disaster, such a destructive tornado of misinformation, that I feel compelled to keep explaining the medical realities.
To recap and update:
•Bell, star of Frozen and Frozen II, revealed that her daughter, Delta, wears diapers to sleep. She called bedwetting at that age “pretty normal for a 5 yr old whose tiny bladder can’t take the 10 hr challenge yet."
•Psychologist John Rosemond, echoing the Twitter trolls, called Bell “too lazy to toilet train her child.”
•Now, Bell says she and husband, Dax Shepard, are resolving the overnight wetness by waking Delta up around 11 a.m. and placing her on the toilet. Shepard says, “Yeah, we put a wet spaghetti noodle on the toilet once a night."
•The media has headlined this development “Kristen Bell has finally potty trained her five-year-old daughter Delta.”
•Though she appears to have been mom-shamed into taking action, Bell continues to press the notion that it’s fine for kids to wet the bed at age 5 and that bedwetting inevitably disappears. “I’ve never met a high-schooler who pees their pants all day,” she says. “It’s going to stop at some point."
As a pediatric urologist, I’m here to tell you I’ve met hundreds of high-schoolers who wet their pants, day and night. In fact, as I explain in my bedwetting book for older kids, M.O.P. for Teens and Tweens, the typical big-city high school likely has 40 to 80 students with enuresis. No parent should assume “it’s going to stop at some point.”
In truth, Bell has no idea whether she’s met any high schoolers with enuresis because it is a condition that teenagers, very understandably, go to great lengths to hide. These kids live in fear that someone will find out — a fear exceeded only by their fear that they’ll go off to college with pull-ups.
Year after year, these kids were told by their doctors, “Don’t worry, bedwetting is normal,” “Don’t worry, you’ll outgrow it.” And every year, they’d think, “OK, but WHEN?”
Few of these kids were told the real cause of enuresis: chronic constipation. Instead, they were given all sorts of mythical reasons for their wetting. “You’re a deep sleeper.” “Your bladder is small for your age.” “You have a hormonal imbalance.” “It’s your genetics.” “You have anxiety.” “You’re trying to get attention.” “You’re drinking too much caffeine.”
When I x-ray these kids, as I do all my enuresis patients, the actual reason is right in front of me, in black and white: the rectum is clogged! The giant mass of stool has stretched the rectum to two or three times its normal diameter. That stretching has, in turn, stretched and aggravated the nearby bladder nerves. And when the bladder is aggravated, it empties before it’s full, without notice, and at the most inopportune times.
What does work, as I tweeted at Kristen Bell, is fully evacuating the rectum every single day so the stretched rectum has a chance to shrink back to size and stop bothering the bladder. This is best accomplished with a regimen of enemas and laxatives, such as the Modified O'Regan Protocol (M.O.P.), described in detail in The M.O.P. Book: Anthology (4th Edition).
But this is not an easy regimen, and when you start as a teenager, after your rectum has been stretched for 10 or 15 years, it’s likely to take many, many months, at least. I’ve had patients who’ve had to take a gap year, instead of going straight to college, because nightly enemas are not something you can discreetly manage in a college dorm.
I’m all in favor of gap years, but not for the purpose of shrinking a stretched rectum.
None of this has to happen! If physicians were more aware of the signs of chronic constipation and if they recognized that bedwetting, while very common, is not normal and should be treated aggressively starting at age 4, we would not have high-school students wetting the bed.
But these kids fly under the radar. Their condition is not life-threatening, so it’s not taken seriously, despite the monumental distress and embarrassment they suffer as they get older. “Don’t worry, you’ll outgrow it” is of no comfort to a 180-pound 16-year-old who has to sleep in pull-ups and has to invent excuses to avoid traveling with the baseball team.
I realize Kristen Bell doesn’t know any of this — most parents don’t. And to the parents of 5-year-olds, the scenario seems unfathomable. So, I totally get why Bell feels certain her daughter’s overnight wetting “will stop at some point.” But it’s just not an assumption she should make.
Meanwhile, for whatever reason ("The Twitterverse was kind of mom-shaming me”), it seems Bell has become motivated to put an end to the bedwetting.
That’s good, but her method — waking Delta overnight — is flawed. Even if you’re able to keep a child dry this way, hardly a given, you haven’t really solved anything except a laundry problem. As long as the child’s rectum remains stretched, the child’s bladder will remain overactive.
Now let’s consider the term “potty training” as it pertains to the Bells. Kristen Bell believes her daughter has “an irregular pattern for potty training.” The Twitter trolls think Kristen is “too lazy to potty train her daughter.” The headline writers announce that “Kristen Bell has potty trained her five-year-old daughter.”
The fact is, Kristen Bell potty trained her daughter years ago! Probably at age 2 or 3, like most parents. Delta Bell knows how to use the toilet, and chances are, it was her mom who taught her.
The fact that Delta has accidents, whether overnight or during the day, has absolutely nothing to do with potty training. Children with enuresis ARE potty trained. They know darned well to use the toilet when they feel the feel the urge. The problem is, their bladders have gone haywire. The bladder hiccups and empties before the child has a chance to feel the urge, let alone wake up and respond accordingly.
This does not mean the child is not potty trained. This does not mean the parent is lazy or the child needs further instruction on how to use the toilet. What the child needs is treatment for constipation.
In a previous blog post, I advised Kristen Bell to have Delta x-rayed and have her rectal diameter measured. Bedwetting is almost always caused by chronic constipation, and an x-ray is the easiest way to prove it — or, in the rare even there’s another cause, to rule it out. On occasion, enuresis is caused by an anatomical abnormality or neurological condition that went undiagnosed. I see a handful of these cases a year; in the other 3,000 kids I see, the cause is chronic constipation.
Kristen Bell is right about one thing: parents shouldn’t “feel ashamed” if their child wets the bed. Neither should kids. The shame and blame these kids shoulder is significant and devastating. The judgment their parents are subjected to is awful as well.
But attitudes about bedwetting and accidents aren’t going to change until the public understands why they happen in the first place.
Here are some blog posts that can help.