By Steve Hodges,M.D.
The internet is a vast repository for misinformation about bedwetting causes and bedwetting treatments.
I sometimes think of it as a sinkhole — a giant, perilous cavity caused by the collapse of reasoning and scientific rigor!
Unfortunately, parents who are eager to help their children get trapped in this sinkhole, and kids miss out on treatments that will resolve their accidents for good.
As a pediatric urologist specializing in enuresis (bedwetting and daytime wetting), I’d like to help hoist you out of the sinkhole, so you can get you child on the path to dryness.
Every day I answer parents’ questions about bedwetting, both in my Wake Forest University clinic and the private online support groups I run for parents, including a group for parents of teens with enuresis.
Here are the most common questions I get, along with answers that may surprise you.
Q: What causes bedwetting at age 10? Age 12? Age 13? Age 17?
A: The child’s age doesn’t matter: The cause of bedwetting is the same: chronic constipation. I discuss the rare exceptions, primarily neurological conditions, in "Medical Conditions to Rule Out," on page 40 of the M.O.P. Anthology.
What typically happens: When kids delay pooping, as they often do, stool piles up in the rectum, forming a large, hard mass. The rectum stretches to accommodate this mass, the way a snake’s belly stretches to accommodate the rat it ate for lunch. Over time — months, years — this stretching can wreak all kinds of havoc on the child’s ability to control peeing, as well as pooping.
In the case of bedwetting, the poop-swollen rectum irritates the nerves feeding the bladder. The bladder randomly spasms, emptying before the child can feel the urge to pee, let alone wake up and dash to the bathroom. By encroaching upon the bladder, the enlarged rectum also creates a real-estate issue: a squished bladder is a smaller bladder. It may not have the capacity to hold enough urine overnight.
This is not the same as an “underdeveloped bladder” — that is not a thing.
The same rectal stretching that causes bedwetting also causes daytime pee accidents. That’s why so many kids have both types of enuresis. An accident comes on like a hiccup or sneeze — there’s no stopping it.
Here’s what doesn’t cause bedwetting: deep sleep, urine overproduction, stress, anxiety, laziness, attention-seeking, or delayed communication between bladder and brain. I discuss each of these debunked “causes” the M.O.P. Anthology.
What about heredity? Well, it’s true that kids with parents who wet the bed are more prone to bedwetting themselves, and I treat many, many families with multiple kids who have enuresis. However, you can’t make the leap that bedwetting is hereditary. What’s passed on, I believe, is the propensity toward constipation and the propensity of the bladder to spasm when aggravated by an enlarged rectum. Some bladders are just more susceptible to the effects of constipation.
The problem with focusing on the heredity connection is that it prevents families from taking action. A parent will say, “Well, I wet the bed until I was 10, so I’m sure my son will come around.”
In reality you can’t assume a child will outgrow bedwetting, especially if your child wets nightly or nearly so and/or if your child also has daytime pee or poop accidents. And why wait until 10 to take action when, with a treatment, he could be dry at 4?
In my experience, no one is served when a child spends six additional years in pull-ups. I have heard many parents of my teenage patients say, "I wish we'd started treatment 10 years ago." I've never heard a parent say, "Thank goodness we bought pull-ups for the last 10 years."
Many parents are shocked to learn that constipation is the cause of their child’s bedwetting or accidents. Sitting in my clinic, they’ll say: “But wait! My child isn’t even constipated! He poops every day!”
Nonetheless, in virtually all cases, these kids are indeed clogged. The proof is in the x-ray.
I x-ray all my enuresis patients, and the images almost always confirm these kids are chock full of poop. A normal rectum measures less than 3 cm. My enuresis patients have rectums stretched to 6 cm, often 7 or 8 cm. I routinely see hardened masses of poop the size of a softball in kids declared “not constipated” by their pediatricians. In the Anthology, I explain how to get an accurate reading from an x-ray.
Q: At what age is bedwetting a concern?
A: Bedwetting and accidents are very common, but that is not the same thing as normal. Bedwetting should be treated starting at age 4. Potty-trained kids of any age, even as young as 2, should be treated for daytime accidents (pee and poop).
Children with both daytime and nighttime symptoms are the least likely to outgrow bedwetting. However, you cannot assume that any given child, even one with only nocturnal enuresis, will outgrow the condition. My clinic and private Facebook support groups are filled with families who were assured their child would stop wetting eventually. But that day never came.
The holding habit is deeply ingrained, and left untreated, many children will experience worsening symptoms over time. The earlier you treat these issues, the better.
Q: When will bedwetting stop?
A: Without treatment, there’s no guarantee bedwetting will ever stop. I treat many high-school students who are panicked about heading off to college with pull-ups. I often receive emails from bedwetting adults who never received treatment as children.
It's true that bedwetting rates decrease with age, and most children do eventually stop wetting. But many kids don't. A child who's bedwetting at age 9 has about a 70% chance of bedwetting at 19. If a child is bedwetting at age 12, this child is unlikely to spontaneously stop wetting into adulthood. Think of it this way: about 2% of 12-year-olds wet the bed — the exact same percentage of adults who wet the bed.
Maybe 2% doesn’t sound like a lot, but in the United States, there are about 25 million kids ages 12 to 17, so that means more than half a million of them have nocturnal enuresis. About one-third of those have daytime accidents too.
That is a ton of kids — in fact, more teenagers have enuresis than have autism. With bedwetting, it’s about 1 in 50. With autism, it’s 1 in 54. You hear about autism all the time, but no one ever talks about enuresis.
As I tell kids in my book M.O.P. for Teens and Tweens, the average high school in the United States has about 750 students, which means there are probably 15 kids with enuresis in a typical school. In a big-city high school, with 2,000 to 4,000 students, there are probably 40 to 80 students with enuresis.
I believe all children with enuresis should be treated. Waiting around in hopes that bedwetting will stop isn't helpful.
Q: What is the best treatment for bedwetting?
A: Bedwetting will resolve when the clogged, stretched rectum is fully AND remains empty every day for several months, so it can to shrink back to size and stop aggravating the bladder nerves. This is a more challenging task than even most doctors realize.
Based on my the research and my 15+ years of experience, an enema-based regimen such as the Modified O’Regan Protocol (M.O.P.) is far more effective than the usual oral laxative treatment, such as a high-dose Miralax (PEG 3350) "clean-out" followed by a daily maintenance dose of Miralax.
In the most challenging cases, I turn to surgical procedures such as bladder Botox, but this works best in children on M.O.P.
I wish laxative powders and pills and syrups and chocolate-flavored squares would do the trick. But in most kids with enuresis, these remedies aren’t nearly powerful enough to clean out the rectum. Many of my patients have spent years and years on Miralax, to no avail.
Also unlikely to fix the situation are weekend “clean-outs” — where the child drinks glass after glass of laxative powder mixed with water and spends the entire weekend pooping or waiting to poop. The problem with clean-outs, besides ruining your weekend, is that the freshly softened stool just oozes around the hard mass of accumulated stool. So, you can end up with both diarrhea and constipation!
And even when oral clean-outs “work,” the effect is usually just temporary. No one wants to hear this, but bottom-up treatments, aka enemas, are far superior to top-down treatments (swallowing medication).
My own research confirms this. In a published study of 60 kids with daytime enuresis, conducted in my clinic, some kids did M.O.P. and others used laxative powder. About 85% of the enema kids were dry within 3 months, compared to just 30% of the laxative kids. This study focused only on daytime accidents, which resolve more quickly than bedwetting, and these patients were ages 6 to 11, so teens can expect to be on M.O.P. longer. Still, you can see the big difference!
As for the 15% whose daytime accidents did not resolve within 3 months, x-rays show these kids still had enlarged rectums, so they needed more powerful enemas to clear them out.
Cleaning out the rectum is only half the battle. What’s critical is to do so daily, so the rectum has a chance to regain the tone and sensation to fully evacuate and to retract to normal size. This process typically takes many months.
Here’s what does not work to treat bedwetting: restricting liquids, hypnosis, chiropractic, midnight wake-ups, bribery, rewards, counseling for stress and anxiety. I’ve even had patients who were sprayed with water in the middle of the night as part of a very misguided treatment.
What about bedwetting medication and alarms? In general, bladder medication has about the same success rate as a placebo. In some circumstances, I do prescribe medication, but only in conjunction with M.O.P., not as an alternative. Medications do not get to the root of the problem — constipation — and some bedwetting drugs actually cause constipation.
In the M.O.P. Anthology, I discuss the three categories of bedwetting medications and when they are warranted. I also discuss how bedwetting alarms can be useful — again, as an addition to M.O.P., not as a substitute.
Q: Is bedwetting a symptom of diabetes?
A: Parents often assume a child who wets the bed and/or pees incessantly has type 1 diabetes, and indeed, excessive urinating is a symptom of diabetes. However, I’ve examined thousands of kids whose parents feared diabetes, and exactly one tested positive for the disease.
The same process that causes bedwetting — chronic constipation, rectal enlargement, a bladder gone haywire — also causes urinary frequency (incessant peeing) and urinary urgency (the overwhelming need to pee). On M.O.P., both frequency and urgency will resolve before the accidents do; that’s a sign of progress.
Q: Is bedwetting a sign of stress or a mental disorder?
A: No! Enuresis is a physiological problem, not a psychological one. Yet I have loads of patients who have been referred to mental-health counselors for stress and anxiety.
Kids with enuresis, especially teens, often are stressed, but that is because bedwetting causes stress, not the other way around. Middle-school and high-school students with enuresis live in a state of distress — avoiding sleepovers, worried that friends will learn their secret, terrified the accidents won’t stop before college. For years, these kids have shouldered shame and blame for a condition beyond their control. So yes, they are stressed!
Countless parents have reported they were told by doctors, “She’ll stop wetting when she wants to” or “He’s being lazy or trying to attract attention.” Nothing could be further from the truth.
When the accidents resolve, so does the stress!
I recently received an email from a bedwetting 13-year-old asking who asked, “How can I stop the bedwetting so I can live a normal life?”
I really felt for this kid, as I do for all the children I treat. I wish the actual cause of bedwetting — constipation — was well known and that physicians would treat enuresis earlier and more aggressively, so that 13-year-olds wouldn’t have to search the internet for help.
I’m glad that kid had the wherewithal to email me and didn’t fall into the internet sinkhole of misinformation!