Bedwetting Not Improving? Have poop Accidents Come Back? What Next?
By Steve Hodges, M.D.
When does a Miralax clean-out help? What can you do if your child has accidents at school but won’t use the school restroom or change out of wet clothes? What if poop accidents come back a month after they stopped? And what if encopresis resolves but bedwetting doesn’t?
These questions recently surfaced in our private support group, and they’re scenarios that come up often. Here’s how I responded.
Q: My 5½-year-old has never reliably pooped in the toilet and has always had a wet pull-up overnight. In pre-K, he had poop accidents almost daily. Since starting Standard M.O.P. three months ago (with pediatric liquid glycerin suppositories), he hasn’t had a single poop accident — life-changing for us. But he still wets at night and doesn’t poop on his own.
We’re doing Multi-M.O.P. on weekends, but sometimes he doesn’t poop at all after the morning enema and then has an accident later in the day. Any suggestions?
A: Yes. First, I’d switch to an enema with more volume. A pediatric LGS is just 4.5 ml, probably not enough to trigger a full evacuation. Though the 7.5-ml “adult” size is intended for children 6+, I think it’s fine for a 5½-year-old, whether store-bought or DIY (much cheaper!). I think he’ll poop faster, evacuate more fully, and avoid those later accidents.
Second, I’d do Multi-M.O.P. every day. A single daily enema is often enough to keep poop accidents at bay but not enough to fully empty the rectum so it can regain sensation and shrink enough to stop aggravating the bladder.
I bet he’ll make faster progress if he poops twice a day, every day, not just on weekends.
At this stage, I wouldn’t expect him to poop on his own, let alone stay dry overnight. He hasn’t regained sensation yet; he’s still in the emptying phase.
But he’ll get there! Bedwetting typically takes much longer to resolve than encopresis. Keep it up, and I think you’ll start seeing progress.
Q: I’m wondering if an oral clean-out would help my 8-year-old. She wakes up wet most mornings and still needs reminders to pee and poop. Her x-rays show she’s full of poop from top to bottom. She’s taken Miralax for more than two years and done enemas off and on for over a year, but we haven’t been consistent.
Two weeks ago, we committed to daily enemas (Standard M.O.P.). She’s having fewer poop accidents, but we clearly have a long way to go. What now?
A: I wouldn’t add an oral clean-out. The stool softened by the Miralax will likely just ooze around the hardened mass and create a mess. (See Why Miralax Clean-Outs Fail.)
Instead, I’d step up to Multi-M.O.P. so she’s reliably pooping twice a day. Given how packed her rectum is, you could also start with overnight oil enemas followed by two daily 50% glycerin/50% water enemas — the J-M.O.P. regimen described in the M.O.P. Anthology.
I’d drop the daily Miralax for now, too. Most kids on a twice-daily enema regimen don’t need an osmotic laxative. But if her poop is firm on the new regimen — it happens — start by adding back ½ cap rather than a full cap.
And remember: After years of chronic constipation, her rectum isn’t going to empty and start healing in just two weeks. The “What to Expect from M.O.P.” section in the Anthology explains the timeline in more detail.
Q: My kindergartner with daytime and nighttime enuresis made great progress over the summer on Multi-M.O.P., but for two weeks she’s been having daily accidents at school. She just won’t use the toilet at school, not even the private restroom across from her classroom. She won’t change clothes at school, either, and often comes home wet. Help!
A: This issue comes up periodically in our private support group, so I’ll defer to parents who’ve been in the same situation. They’ve offered some really helpful suggestions.
Teaming up with the school nurse is at the top of everyone’s list. The nurse can get to know your child, make bathroom visits feel routine, help with changing after accidents, and serve as a liaison with her teacher.
As one mom put it, “The nurse needs to be her pal and normalize talking pee and poo with her.”
She suggested cards your child can point to if she’s uncomfortable saying what she needs.
Another mom suggested having the nurse come up with occasional “errands” for your child, “just so that every time she goes in there it’s not to do something she doesn’t like.”
A few practical changes can help, too. Keep extra clothes and wipes in the nurse’s restroom, along with a footstool so your child’s legs aren’t dangling when she pees or poops. If the flushing noise bothers her, noise-cancelling headphones may help.
Rewards can be useful, too — not for staying dry, of course, but for specific actions, such as using the school restroom or changing clothes after an accident.
As another mom put it: “You can’t incentivize a biological process that they can’t control, but you can incentivize the effort.”
You’ll find more ideas in “The M.O.P. Parent’s Guide to Advocating for Your Child at School,” included in the M.O.P. Anthology.
Q: My daughter with encopresis had a couple of smears this week after dropping to Standard M.O.P. 10 days ago. She’d been completely accident-free for a month on Multi-M.O.P. Does she need more time before tapering, or just a slower taper?
I also gave her ½ an Ex-Lax square twice this week because she was only getting pebbles out with her enema. I’m not sure whether the smears are from the Ex-Lax or from getting backed up again.
A: The pebbles and smears tell me she’s getting backed up again, a common scenario with encopresis. I’d return to Multi-M.O.P. and wait until she’s been 100% accident-free, including smears, for at least 30 days. Then start a much more gradual taper.
Even after the rectum is fully emptied, it takes a good three months to regain sensation and tone. During that healing period, kids are especially prone to relapse, so going slowly matters.
Rather than jump from two enemas a day to one, follow one of the Slow Taper plans in the M.O.P. Anthology.
For example, with a 3:1 taper, the first month, do two enemas a day for three days, followed by a single enema on the fourth day. Then repeat. The next month, alternate between two enemas a day and one. The third month, drop to one daily enema, then start a new 3:1 pattern — three days with one enema, followed by one enema-free day.
On the enema-free days, add senna (Ex-Lax) to ensure a bowel movement and help her learn to respond to her newly restored urge to poop. Finally, gradually replace the senna with an osmotic laxative, as shown in the Senna Taper Plan.
However, I wouldn’t use Ex-Lax to address her current pebble issue. We use senna to trigger a bowel movement, not to soften stool. If her poop is too firm, add an osmotic laxative.
I know the slow taper sounds tedious, but I’ve found it’s really effective at keeping accidents from coming back.