Bedwetting at 16, Tapering Off Ex-Lax, Preventing Encopresis Relapse: Dr. Hodges Answers Parents' Questions

Parents often have questions about bedwetting, encopresis, and constipation treatment. Dr. Hodges weighs in.

By Steve Hodges, M.D.

Can you tell from an x-ray whether constipation is causing a teenager's bedwetting? What if 2 squares of Ex-Lax is too much for a child but less than 2 squares doesn't produce a bowel movement? What if your doctor won't order an x-ray for constipation? Will bedwetting medication make a child's constipation worse?

These are among the questions I've received recently from parents via email and our private support group for enuresis and encopresis treatment. The answers may help guide your child's treatment.

Q: My 16-year-old daughter has nighttime enuresis 5-6 nights a week. She has done two Miralax clean-outs, but it is hard on her stomach for days afterward. In the past, we’ve tried alarms, waking up at night, Calm magnesium, and desmopressin. She just started Multi-M.O.P. I'm curious to know if her x-ray indicates that constipation could be causing her bedwetting. What else we can be doing?

A : Yes, rectal stool is 100% the cause of her bedwetting. Her x-ray demonstrate the typical pattern that I call the “O’Regan sign": stool in the rectum plus accumulation of stool in the right (ascending) colon. (I named this pattern for Dr. Sean O'Regan, the kidney specialist who proved back in the 1980s that constipation is the root cause of bedwetting). I would focus on clearing out her rectum by continuing Multi-M.O.P.

After a couple of months, she could try demospressin again. As I explain in the M.O.P. Anthology, the medication will be more effective once the rectum has been emptied. While on Multi-M.O.P., she won’t need an osmotic laxative, such as Calm magnesium, unless her stool is firm. Most kids can hold off on the osmotic until they start tapering off enemas.

I do not recommend waking children overnight. While this may help reduce laundry, it does nothing to calm an overactive bladder and only disrupts the child's sleep. Teenagers need all the sleep they can get! Alarms also do not address the root problem of an overactive bladder — chronic constipation — and generally are not worth the effort. However, as I explain in the Anthology, alarms can be a useful gauge of a child's progress.

Q: We’ve been trying to slowly taper my 4-year-old (who started with encopresis only, no enuresis) off M.O.P. but have been struggling to find the right dose of Ex-Lax for the enema-free days. More than 2 squares makes her poop too loose, and she struggles to get to the toilet in time. But if she takes less than 2 squares, she won’t poop. Should we try tapering with just an osmotic instead? She has had a few spontaneous poops on days where she has only taken an osmotic. She is definitely regaining her ability to sense the urge to poop, and I want to encourage that.

A: You have several options. One is to try 1 ¾ squares of Ex-Lax. Some children are extremely sensitive to senna, and adjusting the dose by 1/4 square can make all the difference. Alternately, you could add a fiber supplement to bulk up her stool; This might make 2 squares manageable.

A third option is to skip Ex-Lax altogether and simply follow one of the Slow Taper plans with a daily osmotic, as described in the Anthology. Given your daughter’s recent history of spontaneous pooping, that may work just fine, and anyway, you’ll know soon enough. If she’s not consistently pooping on the enema-free days, try one of the Ex-Lax options.

To minimize the risk of an encopresis relapse, it is important for children to poop every day while tapering off enemas, so make that your goal for now.

Q: My 9-year-old has daytime-only enuresis (no bedwetting) and is following Multi-M.O.P. Her original x-ray, over a year ago, showed a full rectum. Recently, her accidents have been dribbles, with dry undies scattered across the month. Our GP is on board with enemas and has prescribed bladder meds but won't consent to another x-ray. (We are in Australia.) I worry my daughter’s wetting will worsen if she starts medication while still constipated.

A: I’d go ahead and start the medication, anyway. In the absence of an x-ray, medication itself can provide valuable information. If accidents diminish, this is a sign your daughter’s constipation has improved; medication is generally ineffective when a child’s rectum remains clogged. On the other hand, if the mediation brings no improvement, this suggests it’s time change her regimen to achieve more complete emptying.

READ: Bedwetting Medication: When It Works, When It Doesn't

For example, you could add overnight olive oil enemas or rotate the type of enemas she’s using during the day, as explained in the Anthology.

Some bladder medications do have the unfortunate side-effect of increasing constipation, so you could indeed see a worsening of symptoms. However, you’d notice that within a few days, in which case you’d stop the medication right away. A few days of medication is unlikely to set your daughter back significantly.

I’d continue to push for an x-ray. Doctors in Europe and Australia tend to oppose x-rays for constipation but sometimes can be persuaded. You might hand your doctor our Physician’s Guide to M.O.P. (included in the Anthology), in which I spell out my position that x-rays are both safe and extremely valuable for guiding enuresis treatment.

Q: My 4-year-old has daytime and nighttime enuresis. She is on Multi-M.O.P. but doesn’t always have much output after her second glycerin enema of the day. Last year, you recommended overnight oil. We never got around to it but now are motivated because kindergarten is coming up. We finally have a new x-ray. Please let me know what you see here and what you advise.

A: The current x-ray shows a good amount of rectal stool, which tells me we need to switch up the enema type to get more output. For example, you could replace one of the glycerin enemas with a phosphate (“saline”) enema, or try two docusate sodium (Enemeez) enemas per day. Or, try the Japanese-style enemas — 50% glycerin, 50% water — described in the J-M.O.P. section of the M.O.P. Anthology, along with overnight olive oil.