By Steve Hodges, M.D.
All day long in my clinic, I remind patients and their families there’s no quick fix for bedwetting.
First, you must tackle the underlying cause of the accidents: chronic constipation. Once unclogged, the rectum must remain clear for months, so it can shrink back to size and stop aggravating the bladder nerves.
That’s the proven, if laborious, way to stop enuresis (bedwetting and daytime accidents) — the approach I’ve taken for 15 years.
But these days, there’s a much faster way. Actually, there are two: bladder Botox and InterStim, essentially a pacemaker for the bladder. Both surgical procedures halt wetting accidents immediately.
I have injected Botox into the bladders of more than 80 children, and I recently implanted the InterStim device, commonly used in older adults, into the upper buttocks of an 11-year-old girl.
I’m excited about both procedures, which have dramatically improved the lives of kids with enuresis, including several teens.
Kids who had avoided sleepovers, whose self-esteem had taken a big hit, were suddenly freed from pull-ups and the stress, shame, and secretiveness of enuresis, a highly stigmatized and misunderstood condition.
“I’m still in shock that it worked,” the mom of the 11-year-old InterStim patient told me a month after her daughter’s surgery. “My daughter has worn pull-ups her entire life and was always nervous her friends would find out. She would never have gone on a sleepover. Now she can. She’s so excited.”
In this post, I’ll describe both surgical bedwetting treatments and discuss which children are good candidates.
I’ll also explain why these procedures, despite being extremely successful and safe, should nonetheless remain a last resort, not a first-line treatment.
Finally, I’ll explain how the success of Botox confirms that chronic constipation is the cause of enuresis — not deep sleep, hormonal issues, an “underdeveloped” bladder, stress, or any of the other fictional causes so widely believed.
Bladder Botox for Bedwetting
With the Botox procedure, we insert a scope, via the urethra, into the child’s bladder and inject the drug into multiple locations, so it’s evenly dispersed.
Yes, this is same drug, botulinum neurotoxin, that cosmetic dermatologists use to temporarily minimize frown lines and crow’s feet. Botox also is used to control migraines, neck spasms, and excessive sweating, among other conditions.
Botox temporarily weakens or paralyzes certain muscles by blocking the nerve signals that cause these muscles to contract. With enuresis patients, the bladder nerves have gone haywire due to the enlarged rectum; Botox halts the random bladder contractions that cause accidents.
One fear among parents is that after the Botox injection, their child won’t be able to pee at all. They imagine a frozen bladder like a celebrity’s frozen forehead. But that doesn’t happen. Experienced surgeons know how much Botox to use. Besides, we’re injecting Botox into a bladder that is already overactive.
A Botox injection, done under general anesthesia, takes 15 minutes, and the aftermath is pain-free. The most common side effect is blood in the urine for a few days after surgery, but that’s not dangerous.
The big question: How long do these kids stay dry? That depends on their constipation status.
My enuresis patients who fare best with Botox are those who’ve worked diligently to empty their rectum with an enema-based regimen such as the Modified O’Regan Protocol (M.O.P.). If an x-ray shows the rectum is empty but remains stretched (suggesting the bladder nerves are still aggravated), Botox usually buys these kids enough time to stop wetting on their own.
By the time the Botox wears off, several months to a year later, the child’s bladder has recovered, thanks to M.O.P.
Botox wears off more quickly if the child is constipated at the time of surgery. The enlarged rectum continues to place so much force on the bladder nerves that even this powerful, nerve-blocking drug can’t counteract it for long. In these cases, kids typically need repeat Botox injections.
Why perform Botox surgery on a child with stool in the rectum? Why not wait until the rectum is totally empty before doing this expensive procedure?
Well, in some cases, the child’s constipation is so stubborn that even with dedication to the most aggressive variations of M.O.P., hardened stool clings to the rectum, as shown by an x-ray. (This phenomenon explains why Miralax is so often useless for enuresis!)
Sometimes, parents will turn to Botox because they and their child are tired of the enema regimen, and the child needs the psychological boost that comes with dry nights. Totally understandable!
Insurance companies typically won’t cover Botox until a child has exhausted all three classes of bladder medications, described in the M.O.P. Anthology 5th Edition. But that’s usually not a barrier; medication almost always fails in constipated kids.
I am willing to do Botox for patients who don't have a clear x-ray, but I make sure families understand the procedure may not provide lasting results. The child may need additional Botox injections, which may or may not be covered by insurance.
On the other hand, I would not inject Botox into the bladder of a child who has both enuresis and encopresis (chronic poop accidents). That's because kids with encopresis are, by definition, massively constipated, and poop accidents are pretty easily rectified with M.O.P. In a child who started with both encopresis and enuresis, I would wait until long after the encopresis has resolved before considering Botox.
For my patients with spina bifida, I inject Botox into their bladders annually. These kids will always have trouble pooping due to a neurologically impaired bowel, and there’s only so much they can accomplish with a daily enema regimen. For them, annual Botox is a great option. Kids with neurogenic bowel do need to maintain their enema regimen after surgery, but by doing so, they are able to stay dry, day and night.
Parents often ask for statistics on the procedure’s success rate in my clinic, and we do have a study, presented at the 2023 meeting of the Society of Women in Urology.
We analyzed all our Botox cases over a 10-year period, excluding children with neurological impairment. The group of 50 patients included 23 girls and 27 boys, average age 11. Nine months after surgery, 94% were either completely dry (29 kids) or having fewer accidents (18 kids).
Among the children whose enuresis had not fully resolved at the 9-month mark, several had achieved total dryness after surgery, but accidents resumed when the Botox wore off. In most of these cases, a second Botox injection halted enuresis, but our study did not extend that far.
When Botox didn’t last, it was because the child remained constipated, as demonstrated via x-ray.
Interestingly, some of my patients report they are able to poop more easily after a Botox injection. I suspect these patients had developed an especially strong tendency to override the urge to poop (what parents refer to as “champion withholding”), and once they didn’t have to worry about accidents, they became more relaxed about pooping.
I don’t know — that’s just a guess. But I’ve heard it enough times to believe it’s worth mentioning.
Given how well Botox works, why don’t I recommend it for all my difficult enuresis patients? For starters, it’s expensive and not easy to get covered by insurance. But the cost isn’t the only issue.
It’s clear to me that emptying a child’s rectum is the ticket to resolving enuresis for good. Calming an overactive bladder requires shrinking the enlarged rectum that’s triggering the overactivity. If you don’t tackle the underlying constipation first, Botox won’t counteract the whacked-out bladder nerves for long.
As always, getting to the root of the problem remains more effective than covering it up.
Incidentally, my experience and data with bladder Botox confirm what research dating back to the 1980s has proved but is often overlooked: a chronically enlarged rectum is, without a doubt, the cause of enuresis.
If deep sleep, hormonal imbalance, stress, behavior issues, or a small bladder caused wetting accidents, Botox wouldn’t work. Botox does not alter a child’s sleep patterns, hormone levels, stress level, behavior, or bladder size. It simply calms bladder nerves.
If constipation were not the cause of enuresis, bladder medications alone would have a strong track record, and Botox would not wear off in kids with neurogenic bowel or significant constipation. But bladder meds have a dismal record, and Botox wears off in kids with spina bifida or a persistently clogged rectum.
There’s no shortage of evidence that constipation is the root cause of bedwetting and daytime wetting, as well as chronic urinary tract infections and encopresis. The success of Botox only adds to the proof.
InterStim: A Bedwetting Breakthrough
I’ve been using bladder Botox for over a decade but only recently implanted my first InterStim device in a patient. I believe this device has great promise and some benefits over Botox, and I imagine I will be using it more, particularly in older kids.
InterStim has been approved by the FDA for adult incontinence since the late 1990s and is commonly used in adults over 50 with overactive bladders. The device is not specifically approved for use in children, but as physicians, we can use it “off label.”
(Off-label use of drugs and devices for children is common. Nearly 80% of hospitalized children receive medications that are not approved for children.)
The InterStim device is small, about the size of an ultra-thin matchbox. While the child is under general anesthesia, the device is implanted in the upper buttocks area, where there’s enough fat padding to hide it.
The gizmo sends mild electrical pulses to the nerves, near the tailbone, that influence the bladder and surrounding muscles. The electrical pulses halt the random, forceful bladder contractions that cause accidents.
How well does InterStim work in children? I don’t know yet.
In older adults, the device has a strong success rate, dramatically reducing urinary frequency, urgency, and accidents in patients diagnosed with overactive bladder. But it’s not full proof.
No studies have been conducted on children, and I’ve only just started using the device, so I have no basis for comparing InterStim to Botox for children with enuresis.
One useful feature of InterStim is that patients undergo a two-week test run before deciding whether to go ahead with the surgery. Prior to the trial period, a thin wire is inserted beneath the skin, and a wire extension is connected to an external gizmo worn discreetly under clothing, held in place by a belt.
My 11-year-old patient called it “my karate belt.”
If the InterStim halts accidents during the trial, as it did with my patient, the device is implanted under the skin in a 30-minute surgery.
The InterStim battery lasts for about 15 years and doesn’t need recharging. Unlike adults, children with enuresis are not likely to need the device indefinitely. (The cause of enuresis in children is chronic constipation, whereas in adults, overactive bladder typically has other, age-related causes, though constipation can contribute.)
InterStim can be turned off and on using a phone app, a handy feature that will allow my patients to test whether they still need the device to stay dry.
You may wonder how I chose the 11-year-old as my first InterStim patient. Well, she was among the few patients for whom Botox wore off quickly, in less than a month. I believe this was because her rectum was not entirely clear, and we just couldn’t do any better with an enema program.
This girl has a life-long history of severe constipation. At age 5, she needed surgery for vesicoureteral reflux (VUR), a condition I discuss in the M.O.P. Anthology. In addition to daytime and nighttime enuresis, she had chronic urinary tract infections (UTIs) prior to enema treatment. Both VUR and chronic UTIs are caused by severe, chronic constipation.
Though this patient was able to achieve daytime dryness with an enema regimen, her bedwetting persisted. Unsurprisingly, several medications failed, and then Botox did, too. The girl's insurance rejected InterStim at first but eventually relented.
For most of my patients, especially small, lean kids, I still favor Botox over InterStim. It would not be easy to hide the device in a skinny third-grader, and why implant a device in a child when a one-time Botox injection has good odds of solving the problem?
However, for certain older kids, InterStim may prove to be the better option. The effect won’t wear off if the child remains constipated; you can just dial up the electrical pulse to counteractive the overactive bladder. However, I recommend patients with the InterStim continue working to keep constipation at bay, so they can eventually have the device removed.
As with Botox, InterStim may even help kids resolve chronic constipation, a happy side benefit.
My 11-year-old patient reports that she’s had an easier time pooping since the device was implanted. Her mom told me, “She used to have big poops, but now they’re more normal.” This means stool is not piling up in her rectum, as it did previously.
(Extra-large bowel movements are the number-one sign of chronic constipation, as explained in our free download, 12 Signs Your Child is Constipated.)
My patient says the device does not hurt and is only noticeable when she pees, according to her mom. “It doesn’t bother her at all — it just feels like a tapping when she uses the bathroom.”
Best of all, this kid is thrilled to have sustained dryness for the first time in her life. “I can see she’s more cheerful now," her mom told me. "She’s happy and excited. She talks about it lot. She’ll say, ‘I don’t have any pull-ups anymore.’”
As thrilled as I am about InterStim and Botox for kids with enuresis, I still would not do Botox or InterStim on a child with an intact spinal cord until the child had first exhausted all the variations of M.O.P.
Most enuresis cases can be resolved with an aggressive enema-based regimen. But for the cases that can’t, I welcome the surgical options.