"Medical Groupthink Gone Awry": Why Doctors Get Bedwetting Treatment All Wrong
By Steve Hodges, M.D. with Suzanne Schlosberg
The irony is terrific.
A panel of 42 medical experts has published a new “consensus” on bedwetting treatment, issuing 18 recommendations with 90% agreement on each.
The paper, published in the World Journal of Pediatrics, is billed as an “updated, evidence-based, and practical framework.”
Updated? Eh, it's a rehash.
Evidence-based? Only selectively.
Practical? Not if your goal is to stop wetting accidents.
The consensus, issued by experts in China, repeats the same erroneous theories and misguided recommendations that have dominated bedwetting treatment for decades — in the United States and globally — and left countless families in despair.
To me, the new guidance is a perfect example of “medical groupthink gone awry.”
I borrowed that phrase from Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health, by Marty Makary, M.D., a Johns Hopkins surgeon before he became (and resigned as) FDA commissioner.
If your child has been wetting for years despite alarms, medication, timed voiding, Miralax clean-outs, behavioral therapy, treatment for stress, or assurances they’ll “outgrow it,” you've experienced the consequences of this groupthink firsthand.
For decades, medicine has operated on the premise that bedwetting is fundamentally a bladder, brain, and/or urine-production problem (well, except when it’s attributed to emotional distress). Meanwhile, the evidence pointing elsewhere — to chronic constipation, i.e. an enlarged rectum aggravating the bladder — has been overlooked, downplayed, or dismissed altogether.
Even when constipation is recognized, doctors don't appreciate the magnitude of the poop pile-up or the intensive measures needed to reverse it. Children are dismissed as untreatable when the treatment they received was never up to the task. Meanwhile, they avoid sleepovers and summer camps, retreating inward as their confidence erodes.
When I first read Blind Spots, I was struck by how closely the epic medical failures Dr. Makary chronicles — from the explosion in peanut allergies to the opioid-addiction crisis — paralleled what I’d witnessed during my three decades as a pediatric urologist.
Dr. Makary explores how medical beliefs become entrenched despite contradictory evidence. Each generation of doctors inherits the assumptions of the previous. Flawed studies reinforce those assumptions. Medical organizations codify them into guidelines. Eventually, the assumptions harden into dogma: “Everyone believes it, so it must be true.”
That is what I see happening in the field of enuresis.
Effective treatment for virtually all children has existed since the 1980s, back when I was in middle school. For the minority of cases that don't resolve with intensive constipation treatment, I add bladder medication to the mix — as a stopgap, not a fix. For the true outliers, I inject Botox into the bladder — a quick, safe surgical procedure that medicine also misunderstands.
Yet appropriate treatment remains elusive for countless children. Hundreds of thousands of U.S. kids still wet the bed as tweens and teens. Many land in my clinic as high school seniors, panicked about waking up wet in a college dorm.
A number of physicians in our private support group — doctors in other fields whose children have enuresis and/or encopresis — have posted about years of frustration before finding a treatment that finally moved the needle. These folks had consulted specialists and tapped their professional networks, including online physician groups with tens of thousands of members.
If parents with medical degrees and ready access to vast expertise have this much trouble finding help for their own children, imagine what other families are up against.
Medicine doesn't have a monopoly on misreading bedwetting. On TV, the bedwetting kid is anxious or troubled (often with an absent mom in the backstory). In politics, “bedwetting” is shorthand for pre-election panic (“Democrats Need to Quit Bedwetting”). The diaper industry invests heavily in normalizing the condition, assuring preteens with enuresis that all they need is XXL “nighttime underwear” and “more time” — rather than, say, treatment.
Consensus tells us what experts agree on. It doesn't tell us whether the premise they all began with was sound.
When it comes to bedwetting, medicine has missed the boat.
Theories Upon Theories
Medicine has cycled through many explanations for bedwetting. Once attributed to psychological problems or willful behavior, nighttime enuresis is now typically described as “multifactorial” — arising from some combination of biological, developmental, and sometimes psychological factors.
The American Academy of Pediatrics (AAP) and the new Chinese consensus point to three main culprits in otherwise healthy children: urine overproduction at night, reduced bladder capacity, and difficulty waking from sleep.
Emotional distress — from a new school, parental divorce, loss of a loved-one — remains in the mix, too, particularly when bedwetting surfaces after a period of dryness. According to the AAP, “Treating the stress can stop the bedwetting,” a remarkably confident claim with no evidence behind it.
Lately, though, medicine has doubled down on another idea: that children who wet only at night have a fundamentally different condition from children who also wet during the day.
The new Chinese consensus mandates a “clear clinical distinction” between these two groups, stating: “This classification drives all subsequent treatment decisions.”
This is presented as progress — a more precise way to diagnose and treat enuresis.
In reality, this distinction sends us backward.
The experts acknowledge constipation is common in children with daytime wetting and recommend treating it before tackling nighttime accidents. But for children who wet only at night, constipation largely vanishes from the picture, and the recommended treatments — both with high failure rates — are bedwetting alarms and medication that suppresses urine production.
In other words, an accident at 2 p.m. and an accident at 2 a.m. can send children down entirely different treatment paths.
This is a mistake.
Daytime and nighttime accidents involve the same organ, the bladder, doing the same thing: contracting involuntarily. The bladder doesn't know — or care — whether the child is asleep or awake.
Medicine has amassed quite an elastic collection of explanations for nighttime wetting:
Your child wets because she sleeps too deeply.
Your child wets because she’s stressed.
Your child wets because her “bladder hasn’t caught up with her brain.”
Your child wets because she produces too much urine.
Your child wets because she has a family history of bedwetting.
Your child’s bedwetting is normal — she just needs time to outgrow it.
All these explanations comfortably coexist under the umbrella of “multifactorial.” All sound plausible.
But if you scrutinize the research, you’ll see these supposed causes aren’t causes at all.
In Blind Spots, Dr. Makary notes that many medical recommendations “fly directly in the face of both science and wisdom.”
That is the case here.
Hidden in Plain Sight
What all the usual explanations miss is the actual culprit: a mondo mass of poop.
When kids delay pooping, as they often do, stool piles up and the rectum bulges into the territory of the bladder, just millimeters away. This isn't just a real-estate problem, though the enlarged rectum can flatten the bladder, reducing its capacity. More to the point, the bulge aggravates the bladder nerves, causing the bladder to “hiccup” forcefully and empty without warning.
Oddly, medicine already recognizes part of this picture: the link between a clogged rectum and daytime wetting. According to the AAP, “almost ALL children with voiding dysfunction also have some form of constipation.” True.
Medicine also largely accepts that chronic stool accidents, known as encopresis, are caused by constipation. Though not everyone got the memo — encopresis accounts for 3% to 6% of psychiatric referrals among school-aged children, and kids with this condition are commonly referred for behavioral therapy.
Fact is, a chronic poop pile-up changes the rectum, stretching it until it loses sensation and tone — imagine a sock that's lost its elasticity. The child no longer reliably feels the urge to poop, and the floppy rectum doesn't fully empty, so stool keeps accumulating. With encopresis, the buildup eventually reaches the point that poop drops out of the child’s bottom, without the child noticing.
Medicine grossly underestimates how constipated these kids are, so treatment falls short or even makes accidents worse. But at least the dots are connected.
With bedwetting, constipation is barely on the radar.
The Chinese consensus does speculate that “earlier attention to constipation . . . could improve response rates” to drugs and alarms. But at best, constipation is treated as an obstacle to successful treatment, not the root cause of the wetting.
Meanwhile, 2026 European and North American constipation guidelines identify "fecal incontinence" as a symptom of constipation but don't mention urinary incontinence at all.
So, here’s roughly where medicine stands: A child who poops in her pants is constipated. A child who pees in her pants probably is constipated. But a child who wets the bed — well, that child makes too much urine, sleeps too deeply, has a small bladder, is stressed out, and/or just needs more time to mature.
This division makes even less sense when you consider how often these symptoms overlap. About one-third of adolescents with nighttime wetting also have daytime wetting. In my own practice, I’d estimate 85% of nocturnal enuresis patients have at least one daytime symptom — wetting, urinary urgency or frequency, encopresis, or “skid marks.” I see plenty of kids with what I call the “trifecta”: nighttime wetting, daytime wetting, and encopresis.
These aren't three unrelated conditions that happen to afflict the same unlucky child. They're just different symptoms of clogged pipes.
Which symptoms show up depends on the amount of stool piled up in the rectum and how sensitive the bladder is to the bulge. It takes a mighty large load of poop to cause encopresis; a much smaller mass can set off a sensitive bladder. Some kids with severe constipation seem to have bladders of steel and never wet. The unluckiest get both enuresis and encopresis.
So why does bedwetting research keep missing the link?
One reason: We have a definition problem.
Most folks think constipation means not pooping often enough. Medicine uses a more elaborate definition but has the same basic blind spot.
Most enuresis studies that consider constipation rely on the Rome criteria, the “gold standard” for diagnosis: How often does the child poop? Are stools hard, painful, or toilet-cloggers? Does the child have stomachaches or poop accidents? Other studies rely on physical exams or transit-time testing, basically a medical version of the corn test.
But none of these tests reveals how much poop has piled up in the rectum.
A physical exam can miss a rectum packed with poop. I routinely see “no mass palpable” in referring physicians' reports — then look at the child's x-ray and see a giant poop clog. Even in a lean, wiry child, a mass of stool can hide in plain sight. And a digital rectal exam can miss poop sitting higher in the rectum, beyond the reach of a finger.
The typical constipation checklist is like a net with big holes. It catches the obvious cases but misses many kids stopped up enough to have severe bladder problems.
For one thing, the criteria rely heavily on information families can't provide accurately. How many 10-year-olds know — or are willing to report — how often they poop or whether their stools are abnormally large or firm? (I was constipated my entire childhood and had no clue.) How many parents routinely peer into the toilet before their school-age kid flushes?
One study of the Rome questionnaire found an astonishing 45% of kids ages 11 to 18 couldn't follow the instructions well enough for their answers to even be analyzed. Among the kids who could, many answered the same questions differently just two days later — enough to change whether they qualified as constipated.
But the problem goes beyond unreliable reporting: The Rome criteria focus largely on what comes out of a child. With enuresis, the key is what remains inside.
A child can poop every single day, even multiple times a day, and still have a rectum packed with poop. Constipation is all about incomplete evacuation. The child poops but doesn't fully empty. Newer, softer stool squeezes around the retained mass, so the child appears perfectly “regular” while stool continues to pile up.
This happens all the time.
One mom in our support group posted that her son, with nighttime enuresis, was not diagnosed with constipation until age 13, when she insisted on an abdominal x-ray. “He pooped regularly, didn’t have large stools, didn’t clog toilet, and didn’t have encopresis or complain of stomach aches,” she wrote. For years, the family was assured, “He'll grow out of it eventually.”
Another mom, whose daughter struggled with the trifecta for years, posted that her daughter had “VERY regular BMs (daily if not more),” so her constipation was overlooked — until the girl was x-rayed.
“I was told her accidents were behavioral,” the mom posted. “It was mind blowing how she could be so regular and still be so backed up.”
Here’s where a diagnostic problem becomes a research problem.
When bedwetting studies rely on the usual criteria, they risk classifying chronically clogged children as “not constipated.” Researchers then conclude constipation isn’t the culprit.
So, the studies end up reinforcing the assumption they began with.
In my clinic, I remove the guesswork by x-raying all my enuresis patients and measuring the widest part of the rectum. (I’ve compared enough x-rays with ultrasounds of the same patients to know x-rays are far more reliable for this purpose.) A normal, empty rectum measures less than about 3 cm across. Most of my enuresis patients measure at least 6 cm. Sometimes I see a stool mass the size of a Nerf basketball.
Another obstacle to accurately diagnosing constipation: an x-ray is only useful if the person reading it knows what to look for.
“Moderate stool burden” may be the three most common, and misleading, words I see in radiology reports. To a parent, that sounds like no biggie. But I routinely review those same x-rays and see a giant poop clog — overlooked because the report focused on the entire colon, not the rectum, the part that matters for enuresis.
What’s more, radiologists are trained to look for serious abnormalities — hence comments like “no free intraperitoneal air” — not necessarily a rectal poop pile-up.
None of this is new — not the definition problem, the diagnostic problem, or the observation that constipation directly causes bedwetting.
An Irish doctor practicing in Montreal figured it out over 40 years ago.
The Bedwetting Breakthrough Medicine Forgot
In the early 1980s, Dr. Sean O’Regan, a pediatric nephrologist, went searching for an explanation for his own son's bedwetting.
Dr. O’Regan’s 5-year-old son wet the bed nightly, sometimes twice a night. Self-conscious about his accidents, the boy wouldn’t sleep anywhere but home, and the situation was stirring tension in the family. Dr. O’Regan’s wife made note of the fact that the good doctor was unable to help his own son.
At the time, bedwetting was largely attributed to psychological problems or abnormalities of the urinary tract. Certain his son had neither, Dr. O’Regan sought answers at the renowned McGill University Medical Library.
He was intrigued by what he found: medical reports dating to the 1890s that linked constipation with urinary problems.
To assess the state of his son’s rectum, Dr. O’Regan asked a colleague to perform anorectal manometry, a test that measures rectal sensation and function.
Using a catheter, the colleague inserted a small balloon into the boy’s rectum and gradually inflated it, waiting for him to report pressure.
But the boy felt nothing.
“The kid’s got no rectal tone,” Dr. O’Regan’s colleague reported.
That was the Eureka moment that changed the course of Dr. O’Regan’s career and, ultimately, my own.
Dr. O’Regan reasoned that chronic stool retention had stretched his son’s rectum, compromised its sensation, and triggered the bladder contractions. He wondered: Would the accidents stop if the boy’s rectum was cleared out and kept empty long enough to recover?
To find out, Dr. O’Regan devised a three-month regimen: one month of nightly enemas, followed by a month of enemas every other night, followed by a month of enemas twice a week.
Each night, the O’Regan boy would read Winnie-the-Pooh on his bed while waiting for the urge to kick in. Within weeks, he experienced his first dry nights. During the second month of treatment, his bedwetting stopped.
Next, Dr. O’Regan set out to test the treatment in other children, tapping local pediatricians to recruit a substantial group of French Canadian children with urinary problems.
His first study, published in 1985, tracked 47 girls, average age 8, with recurrent urinary tract infections (a condition also caused by chronic constipation). Nearly all the girls also had encopresis, daytime wetting, nighttime wetting, or some combination. Anorectal manometry confirmed severe constipation in all of them.
After three months on Dr. O’Regan’s enema regimen, UTIs ceased in 44 of the 47 girls. Among the 21 girls with encopresis, 20 stopped having poop accidents. Among the 32 with daytime or nighttime enuresis, 22 stopped wetting.
Think about it: The same treatment that stopped poop accidents in nearly every child with encopresis also stopped wetting in more than two-thirds of the children with enuresis.
Dr. O’Regan saw no reason to distinguish daytime from nighttime wetting. To him, they were clearly different symptoms of the same problem, so his studies included children with either or both.
In the ensuing years, Dr. O’Regan published additional research documenting the link between constipation — which he defined as chronic stool build-up — and enuresis, as well as the effectiveness of his enema regimen.
He delighted in helping children whose accidents had been misunderstood. “Those kids were told it was all in their heads, that they were psychologically disturbed,” he once told me.
Yet somehow, his work largely faded from view.
Certainly, I never learned about it in medical school.
I did learn that constipation can cause enuresis. But I was taught to identify constipation by feeling the child’s belly and giving parents a questionnaire and to treat it with Miralax.
But my success rate was lousy. Plenty of my patients kept wetting despite Miralax “clean-outs” followed by a maintenance dose, and I didn't understand why.
Then I had my own a-ha moment.
Some years into my practice, I had a 6-year-old patient with a urological condition that made her prone to UTIs. Preventing constipation was key to her treatment, since retained stool can harbor bacteria that trigger infections.
But the usual approach wasn't working. She took Miralax, pooped like a champ, and passed a constipation questionnaire with flying colors. Yet the UTIs continued, and I ended up performing surgery that shouldn't have been necessary.
During the procedure, I discovered the problem: A grapefruit-size mass of stool was squishing the girl’s bladder.
I had totally missed it.
Intrigued, I began comparing pooping questionnaires with abdominal x-rays. Again and again, kids who were “regular” on paper turned out to have a rectum packed with poop.
I thought I’d made an epic discovery and could finally prove to my wife I was a genius!
Then I discovered that my “discovery” had been made decades earlier, by one Sean O’Regan.
I was so amazed by his research that I tracked him down in retirement. Dr. O’Regan didn't sound shocked to hear from me.
“It’s the rediscovery law of medicine,” he said. “Things are often lost and recovered again.”
I began using O’Regan’s regimen in my own clinic, with far better results than I’d ever achieved with Miralax alone.
But some kids didn’t get dry. Others improved, only to relapse. So I started pushing the envelope, often following the lead of moms on a mission. We tinkered with Dr. O’Regan’s regimen, extending the daily enema period and adding Miralax and/or Ex-Lax.
Later, we added olive-oil enemas, a remedy shown in a 2021 Japanese study to be highly effective for both disimpaction and maintenance I contacted the lead author, a surgeon in Kobe, to learn more. A paper trail led me to an 1892 medical journal that described oil enemas as a top-notch treatment for “even the most obstinate cases of spasmodic constipation.”
O’Regan’s rediscovery law strikes again.
Over time, I learned which symptoms responded best to which variations of O’Regan’s regimen. I also found that many kids needed additional months of intensive treatment and, to prevent relapse, a far more gradual weaning period.
I dubbed the evolving approach the Modified O’Regan Protocol, or M.O.P.
Dr. O’Regan seems to find that amusing.
How Medicine Lost the Plot
How did research this compelling fail to change the way enuresis is treated?
Dr. Makary offers an explanation that fits well: “Published studies get lost in a sort of research Bermuda triangle. Medical specialties can live in silos, and silos can stifle progress.”
That is essentially what happened to O’Regan’s work.
Enuresis became the domain of urology, where researchers focused on the bladder, urine production, sleep arousal, and brain development. Constipation became the domain of gastroenterology, where researchers focused on bowel movements, stool consistency, and fecal incontinence.
The rectum-bladder connection fell into the void between.
That disconnect persists today. Earlier this year, the UK's Royal College of Nursing sounded the alarm about a 60% increase in hospital admissions for childhood constipation over the past decade. Yet in discussing the costs of undiagnosed constipation, enuresis wasn't mentioned.
The bedwetting experts aren't seriously looking at the rectum. The constipation experts aren't looking at the bladder.
Even research that connects the two can veer off track.
A Swedish bedwetting study illustrates the problem.
To their credit, the Swedish researchers asked the right question: If a clogged rectum contributes to daytime wetting, could clearing the rectum stop bedwetting, too?
They studied 66 children and classified just 23 — 35% — as constipated, using Rome IV criteria and/or ultrasound.
There's the first problem. Both methods have shortcomings.
The bigger problem: They assessed the results after just two weeks. The 23 children received mini-enemas daily for three days, then every other day for a week, followed by daily Miralax.
The kids kept wetting, so the authors concluded fecal disimpaction “does not alleviate nocturnal enuresis.”
Two weeks! That’s like prescribing two weeks of exercise and concluding exercise “does not improve fitness.”
But here’s the kicker: The researchers never determined whether they’d disimpacted the children.
They even admitted this. “We do not know whether the constipation treatment actually worked against the constipation.”
“Maybe they were still constipated,” they added.
Maybe? That’s the whole ballgame.
If the children were still constipated — and I’d bet a million bucks they were — the study didn't actually test whether emptying the rectum stops bedwetting.
But what will stick with the MDs and PhDs who read the paper? The title: “Fecal disimpaction in children with enuresis and constipation does not make them dry at night.”
Then they really jump the gun, labeling as “false hope” the very idea that resolving constipation will, on its own, stop accidents.
And this study appeared in the Journal of Pediatric Urology, not some obscure publication.
A hasty conclusion like that shapes what researchers study, what expert panels recommend, and how doctors treat patients.
Parents I work with would get a good laugh out of that study.
One mom, surprised it took months of daily enemas to clear out her son, told me: “I thought if we can put a man on the moon, we can get impacted stool out of my child and move on.”
Another described the process as “chipping away at a cement block with a garden hose.”
What the Swedish researchers failed to appreciate is that resolving chronic constipation is a three-part process: First, empty the rectum. Then, keep it clear for months, so it can regain tone and sensation and shrink enough to stop bothering the bladder. Finally, help the child relearn to act on the urge to poop rather than override it.
That simply can’t happen in two weeks.
And medicine routinely falls short at every step.
Why the “Nuclear Laxative” Fails
If you've ever prepared for a colonoscopy, you can probably relate to humorist Dave Barry's description of the prep beverage as a “nuclear laxative.” Personally, I felt like I'd had my colon power-washed.
But a laxative blast doesn’t work the same way in kids with enuresis or encopresis.
Instead, the liquid washes past the impacted stool, leaving the child with diarrhea and constipation — “a big, poopy mess,” as one mom put it. Or the Miralax propels poop downstream, further clogging and stretching the rectum.
Or the clean-out actually works. Briefly. Then the floppy, desensitized rectum fills back up.
Some kids get dry after a clean-out only to start wetting again a week or two later. Then it’s another clean-out, more daily Miralax, more accidents, then another round.
I call it the Miralax merry-go-round.
As one mom posted: “For three years, our pediatrician and GI specialists did nothing but recommend more Miralax and clean-outs, which would help for a couple of days, then she would regress again. It was emotionally draining.”
Another wrote: “Oral clean-outs have never really helped us, but we have done them, anyway, to appease our GI.”
Needless to say, appeasing your doctor should not be the goal of treatment.
So why is medicine so reluctant to move beyond oral laxatives?
It wasn't always this way.
Though Miralax didn’t exist in Dr. O’Regan’s day, other oral remedies, including senna and magnesium, did. But to him, enemas were a no-brainer: “We knew the root cause of bedwetting was incomplete rectal emptying, and enemas were the only way to solve the problem.”
Back then, enemas weren't regarded as a barbaric treatment of last resort.
In fact, the same year Dr. O'Regan published his first paper, a team affiliated with Johns Hopkins University published a study using enemas to treat children with severe encopresis.
The results were striking.The 58 children went from an average of 13 poop accidents per week to just 0.5. (It wasn’t a daily enema regimen, like Dr. O’Regan’s; after an initial clean-out with enemas enemas were given whenever a child went two days without pooping.
The Hopkins team called its regimen “highly effective,” “easy to perform,” involving “minimal risk,” and “the treatment of choice for encopresis.”
Fast-forward to 2017. In a textbook about encopresis, a psychologist describing that very study reported that the children “were made to use enemas.” (Italics are mine.)
Same study. Same treatment. Very different lens.
I understand “effective” is not the same as “a good idea.” The concept of giving a child an enema every day just sounds ... wrong.
And that assumption is deeply ingrained.
Parents have told me their doctors called daily enemas “unsafe,” “traumatic,” “overly aggressive,” even “borderline abusive.”
One mom told me her doctor said, “There’s no way I would do that to my child.”
But where’s the evidence children are being harmed?
When I asked Dr. O’Regan whether any of his patients had ever suffered complications, he said: “Our only complication was a 7-year-old girl who clogged the toilet at our hospital after an enema,” he told me. “She was legendary.”
Note: The damage was to the plumbing, not the patient.
Parents are often surprised by how well their kids handle enemas.
One mom posted: “Our GI went on and on about how enemas are so traumatic. My 10-year-old looked at her like she was crazy and said it was no big deal. You know what’s traumatic? Wearing diapers to school every day in 5th grade.”
Another wrote: “Before the first week was over, my son was begging for enemas because they made him feel better. I never realized how bad he felt. My only regret is that we wasted two years on Miralax.”
Even my neurodiverse patients — and I have many — typically do well with enemas. One
mom said her autistic, minimally verbal 7-year-old came up to her after his third enema and said, “Bum.”
She added: “I actually found him trying to open a Fleet enema and use it on his own.”
(Many of my patients that age actually do self-administer their enemas; they like the autonomy.)
Incidentally, autistic kids are among those most harmed by medicine’s misreading of enuresis and encopresis, because their accidents are often chalked up to autism rather than constipation.
When enemas and oral laxatives are put head-to-head in scientific studies, medicine’s anti-enema bias becomes obvious — and particularly hard to justify.
For example, a Dutch study of fecal impaction that compared enemas with high-dose Miralax found that enemas had a higher success rate (80% vs. 68%), caused significantly fewer poop leaks, and were just as well tolerated.
The researchers had hypothesized that enemas would be less well tolerated. They weren't. Yet the researchers concluded that the two approaches “should be considered equally” and that enemas “should not necessarily be withheld to prevent anxiety.”
Talk about damning with faint praise.
Then there’s this gem: An Italian study comparing enemas with PEG for maintenance treatment aimed to determine whether enemas were “non-inferior” to — in other words, not worse than — the laxative.
Why not just ask: Which is better?
As it turned out, the numbers favored the enemas. In the enema group, 72% of children responded well, compared with 56% taking PEG. During the follow-up period, the enema group also needed treatment on about one-third fewer days.
Yet the takeaway remained: Enemas were “non-inferior” to PEG.
That particular study matters: It was the only study of enemas for maintenance treatment cited in the 2026 European and North American constipation guidelines. This consensus described PEG as “the only treatment with a strong recommendation.”
The guidelines do say enemas have a “therapeutic role in select children” but also caution, “It should always be considered that per rectum therapy may be burdensome for the child and/or caregiver.”
Should it also be considered that years of Miralax may be burdensome? Notably, the guidelines cite no evidence showing that enemas actually are burdensome.
What happens when an enema regimen goes head-to-head with standard treatment for wetting accidents?
Once again, enemas aren't just “non-inferior.” They're better. Much better.
At Wake Forest, we studied 60 children with daytime wetting. Most also wet at night, but we studied daytime accidents because we felt three months was long enough to gauge improvement, whereas bedwetting typically takes longer to resolve.
Our study wasn't randomized; parents chose between Dr. O’Regan’s step-down enema regimen (plus Miralax if needed to keep poop soft) or standard treatment: primarily Miralax and timed voiding.
X-rays showed both groups started with an average rectal diameter over 6 cm, twice normal size.
After three months of treatment, 85% of the enema group had stopped wetting, compared with just 30% of the standard-treatment group.
But the x-rays told the more interesting story: In the enema group, average rectal diameter had shrunk to about 2 cm — totally normal. In the standard-treatment group, it was 5 cm. The rectum had barely shrunk.
What about the children in the enema group who continued wetting? Their rectums hadn’t shrunk at all.
That's the information the Swedish researchers never collected: Did the treatment actually empty the rectum?
Our results also put their two-week treatment period in perspective. Daytime wetting typically resolves much faster than bedwetting, yet even after three months of enemas, not every child in our study had achieved daytime dryness.
Dr. O’Regan’s results reinforce the point: In his three-month study, several children were still wetting at the end, while all but one case of encopresis had resolved.
Expecting two weeks of constipation treatment to stop bedwetting — a much steeper hill to climb — is preposterous.
But here's the real head-scratcher: The researchers stated that extending enema treatment was “not defensible” unless the child also had encopresis or “bothersome bowel complaints.”
As if bedwetting itself isn’t bothersome? Why should a child also have to poop in his pants before more intensive treatment for enuresis becomes “defensible”?
In their paper, the researchers estimate that “perhaps 25%” of children with nighttime enuresis are “resistant to all therapies.” That’s way off base.
In nearly all my patients, resolving constipation does stop the wetting, if you give the rectum enough time to shrink. So much for “false hope.”
For the small percentage who continue wetting, we still have options. And these options provide even more evidence that an enlarged rectum is what causes the bladder to go haywire.
I've prescribed bladder medication for years and have performed well over 100 Botox surgeries on kids with enuresis, and here’s what I know: When the rectum is clogged, meds fail, and Botox wears off within weeks. When the rectum is empty, as confirmed by x-ray, meds can buy a child dry nights and Botox lasts for months.
Think about what Botox does: It blocks the nerve signals that make the bladder contract. It doesn't make a child sleep less deeply, reduce urine production, relieve stress, or somehow mature an “underdeveloped” bladder.
So if any of those things actually caused bedwetting, why would the amount of poop in the rectum determine how long Botox works?
It wouldn't.
That's awfully hard to square with the idea that the rectum is just a bit player in bedwetting.
Medication follows the same pattern. Desmopressin reduces overnight urine production, while other drugs calm bladder overactivity. In general, these medications perform no better than a placebo.
But that poor track record obscures a clear distinction I see in my practice: When the rectum is empty or nearly so, medication tends to work. When it’s clogged, drugs are pointless. The bulging rectum places more force on the bladder nerves than medication can counteract.
Yet drugs are routinely prescribed as “first-line” enuresis treatment without regard to the state of the rectum. Meanwhile, Botox is underused. Parents in our support group whose children are excellent candidates are told Botox is risky and may leave their child needing a catheter.
Nonsense.
If every child with enuresis received intensive constipation treatment, bladder medication when appropriate, and Botox when needed, I’d venture to say almost no case would be “refractory.”
Yet that word — meaning “resistant to treatment” — surfaces all the time in studies.
It’s not that bedwetting is resistant to treatment. It’s that medicine is resistant to the evidence.
And the fallout is more damaging than most folks realize.
Bedwetting: Your Fault, But Totally Normal
Not long ago, around the time Netflix released a new crime series, an article landed in my inbox listing “three disturbing childhood traits linked to future serial killers”: animal cruelty, an obsession with arson, and . . . bedwetting.
Why are we still doing this?
In part, because medicine still hasn’t fully let go of the idea that bedwetting is somehow “all in your head.”
Sure, the serial-killer article appeared in a trashy British tabloid. But it’s not such a huge leap from what appears in staid medical sources, including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
For all the talk of urine overproduction and bladder capacity, the idea that enuresis has roots in emotional or behavioral disturbance persists. And as long as medicine lends credibility to that idea, popular culture will keep recycling it.
Enuresis and encopresis remain listed in the DSM-5, which states that the accidents “may be voluntary or involuntary.”
A chart from the U.S. Substance Abuse and Mental Health Services Administration lists enuresis and encopresis alongside disruptive behaviors, psychosis, and attachment disorders in estimating the prevalence of “serious emotional disorders.”
While the serial-killer theory may be debunked, the thinking behind it lives on.
And kids pay the price.
One mom in our support group posted that her son — who’d struggled for years with the trifecta — had visited multiple doctors and mental-health professionals, all “100% stumped” by his accidents.
“They made charts to try to correlate the accidents to stress and other behavioral issues,” she recalled. “Of course, none of the theories ever seemed to fit.”
When the boy was hospitalized after a bad reaction to ADHD medication, the psychiatrist on duty, aware of his accidents, prescribed an antipsychotic.
Eventually, a urologist diagnosed chronic constipation. Daily enemas stopped his poop accidents in one week — the week before he started middle school. Five months later, his bedwetting stopped.
“We literally went through torture for years,” his mom told me.
For some kids, the torture is even more literal.
Google “bedwetting” and “murder,” and you’ll find headlines like “Father sentenced to 28 years for beating 3-year-old son to death over bed wetting” and “Georgia couple killed 6-year-old for wetting the bed.”
Plenty of kids endure less extreme forms of punishment.
A 15-year-old track athlete with enuresis emailed me: “My dad wants me to sleep in a wet mattress to learn what ‘discomfort is’ and how disgusting I am. He has tried taking away my electronics and my breakfast.”
A 19-year-old asked if I would advise her university health center on treatment, since her parents had mocked her for bedwetting.
Blame takes subtler forms, too.
Even parents who repeatedly assure their child, “This isn’t your fault,” are up against a culture that keeps sending the opposite message.
Schools have turned this medical misunderstanding into policy. I’ve written numerous letters on behalf of patients suspended from school for accidents. Multiple states have pursued or enacted policies requiring children to be toilet trained before entering kindergarten.
Of course, accidents have nothing to do with “training,” and a stretched rectum won’t respond to legal mandates.
The message to kids is unmistakable: You should be able to control this.
But they can’t.
The 15-year-old track athlete blamed himself: “It just makes me so mad at myself that I can’t outgrow it.”
And here’s where medicine gets cause and effect backward. The anxiety, stress, and stubbornness that often accompany enuresis are treated as possible causes of the wetting. In reality, they’re the result of living with an embarrassing medical condition that hasn’t been properly treated.
In her book The Bedwetter, comedian Sarah Silverman recalls sobbing on a school camping trip at age 12, diapers hidden in her sleeping bag. The episode marked the beginning of a three-year depression.
Silverman’s dad, who meant well, sent her to a hypnotist and a psychiatrist. By age 14, she was taking 16 Xanax a day.
One mom told me her son was repeatedly hospitalized for suicidal ideation after a decade of fruitless treatments for his enuresis and encopresis.
When she learned about enema treatment, her son was game to try it.
“It still shocks me how much resistance we got from everyone — the GI doctor, the pediatrician, the mental health care providers, his dad,” his mom told me. “But we did it anyway, and it worked.”
Her son was 16½ when she was finally able to buy him underwear.
But Wait — Bedwetting Is Normal!
Strangely, kids wearing XXL pull-ups receive two messages at once: Your accidents are somehow your fault. But they're also totally normal — don’t worry, you’ll outgrow it.
The diaper industry has enthusiastically embraced the second message, with an assist from doctors.
In a series of Pampers Ninjamas videos, a smiling doctor assures children with enuresis, “Don’t fret. It’ll stop eventually.”
He trots out the usual explanations — immature bladder, deep sleep, anxiety — and concludes that bedwetting kids simply need more time.
Pampers didn't invent these explanations. Medicine did.
Constipation isn't mentioned in their campaign. Instead, while everyone waits for the child's bladder and brain to mature, “Ninjamas are here — they're saving the day.”
Goodnites ads take a similar tack, comparing preteens with enuresis to adults who took extra time to finish college or get over a breakup.
“
Some people need more time,” an AI-generated tween-age voice says. “The only other thing I need are Goodnites Nighttime Underwear.”
But there's a vast difference between destigmatizing a child and normalizing an untreated medical condition.
And there’s an obvious commercial conflict. Medicine supplies the misconceptions; the diaper industry packages them into reassurance that sells more pull-ups.
Breaking with Bedwetting Dogma
So, what would it take to get bedwetting treatment right?
For starters, healthcare professionals should read Dr. O’Regan’s studies — and stop going on wild-goose chases for the cause of enuresis.
Medicine should recognize that bedwetting, daytime wetting, and encopresis all have the same root cause. Constipation should be diagnosed via x-rays, not checklists. Clinicians need to understand the limits of Miralax and know when enemas are the better tool. And urologists and gastroenterologists need to start talking to each other.
Researchers should stop labeling constipation or enuresis “refractory” when a child doesn’t respond to treatments that never had a chance of working.
Above all, medicine should stop mistaking consensus for fact.
In Blind Spots, Dr. Makary recounts how scurvy killed some 2 million sailors during the Age of Exploration.
By the 1700s, physicians had proposed all sorts of causes and useless remedies. Royal Navy surgeon James Lind wasn’t satisfied with any of them.
So, he conducted an experiment. He divided 12 sailors with scurvy into pairs and gave each pair a different treatment — vinegar, seawater, cider, and so on. One pair ate two oranges and a lemon each day.
Those two sailors got better fast.
Lind had found an effective treatment for one of the great scourges of seafaring.
He published his findings in 1753, but almost nobody paid attention. It took another 40 years for the Royal Navy to stock lemon juice on its ships.
Four decades have now passed since Dr. O’Regan questioned the conventional wisdom about bedwetting.
He published his results, but medicine moved on without them.
I hope it doesn't take another 40 years to catch up.