By Steve Hodges, M.D.
A mom in our private enuresis/encopresis support group sparked discussion with this question: “Is enema dependence real?”
Parents ask me this all the time. The short answer is no. Daily use of enemas in children with chronic constipation does not cause “dependence” and, research shows, is the most effective treatment for bedwetting daytime wetting, and poop accidents.
But, this mom says, her doctor disagrees:
Our 7-year-old son’s encopresis resolved with M.O.P.+ [daily large-volume enemas]. We moved to mini-enemas for enuresis. After 24 days, we have 50% daytime dry, and wetness has decreased. Our GI doctor is adamant we stop the enemas and has directed daily Miralax with 1/2 Ex-Lax square. I explained we have not had progress with Miralax in the past. Our doctor claims her practice is full of kids dependent on enemas because they have lost feeling due to the enema usage.
This doctor has things backward. In reality, it is chronic constipation, not enema use, that causes “lost feeling” in the rectum. It is enema treatment, not Miralax, that allows the rectum to fully evacuate, shrink back to size, and regain sensation.
In children with encopresis and/or enuresis, the bowel is already not functioning normally, as it has been stretched by the pile-up of poop. Enemas restore normal function, so these kids no longer need help pooping.
Yet physicians perpetuate the dependence myth and prescribe Miralax for years on end. Heck, the other day, a mom in our private Facebook support group posted that her 17-year-old with nocturnal enuresis has taken Miralax, on and off, for 14 years!
Chances are, daily enema treatment at age 4 would have halted the child’s bedwetting and prevented the need for further treatment. There’s no way this child would have become “dependent” on enemas.
In this post, I will review why enemas are far more effective than osmotic laxatives such as Miralax and why they do not cause “dependence” or “lazy bowel.”
When children delay pooping, stool piles up and stretches the rectum. Over time, this stretching causes the rectum to lose sensation, as well as the tone needed for complete evacuation. Imagine an overstuffed sock losing its elasticity.
Lack of sensation and tone allows even more poop to pile up, stretching the floppy rectum even more, and further compromising rectal tone and sensation. It’s a vicious cycle.
With some kids, this cycle results in encopresis: Poop falls out of the child’s bottom, and the child doesn’t even feel it. With other kids, the result is enuresis: The enlarged rectum aggravates the nearby bladder nerves, causing the bladder to contract forcefully and empty without notice.
Some children, like the 7-year-old described above, experience both encopresis and enuresis. These kids are extremely constipated, harboring more poop than most parents can imagine, until I show them their child’s x-ray.
Halting accidents requires two steps: 1.) fully evacuating the rectum and 2.) keeping the rectum clear long enough (about three months) for the rectum to retract, regain sensation, and stop aggravating the bladder.
By far the most effective treatment is the Modified O’Regan Protocol (M.O.P.), a daily enema regimen pioneered by Sean Oregan, M.D. in the 1980s.
M.O.P. has numerous variations, involving enemas of different sizes and formulations. Some versions add overnight olive oil enemas; others add osmotic and/or senna-based stimulant laxatives such as Ex-Lax. But the key component of all M.O.P. regimens is the daily enema. I advise a gradual tapering off enemas only when the child is reliably accident-free, both daytime and nighttime.
During the tapering period, I often recommend Ex-Lax and/or osmotic laxatives, to help retrain the child to respond to the urge to poop and to keep stool soft so pooping doesn’t hurt. Eventually, the child weans off all laxatives.
At that point — and usually not before — the child no longer needs help pooping. Depending on the child’s symptoms, age, regimen, and plain old luck, this process often takes many months, sometimes more than a year.
But these kids certainly do not use enemas or laxatives forever!
In response to the mom whose doctor claims to have a practice “full of kids dependent on enemas,” another member of our support group — a nurse — posted about her two children, who did daily enemas for a year or more:
They are now both completely healthy poopers with no issues pooping on their own. We had several doctors (including GI) tell us to stop. I was trained that enemas and laxatives are bad and that you'll become dependent. But once I was in this situation for my own kids, this enema program made so much more sense than any other options that doctors were giving us. I would guess that your GI's patients that have ‘lost feeling’ have problems due to the fact that their rectums have been stretched for years. These are probably patients who do occasional enemas when they get desperate to poop, not kids who have done daily enema programs. Once the rectum can heal, the child will have no problem pooping on their own. And what keeps the rectum empty so that it can heal? Enemas.
Another mom posted that her child’s M.O.P. journey, including tapering from all enemas and laxatives, lasted two years. “We developed a routine, went on trips. Kid was okay with this, given that constipation and bedwetting were seen as worse. After two years, we weaned kid off enemas with the use of senna. Now, kid has now been off senna for more than a year. No accidents, no bedwetting, no problems.”
One goal for a child on M.O.P..is to poop “spontaneously” once a day, in addition to pooping after each enema. This is how you make a meaningful dent in the poop pile-up. Pooping once a day tends to maintain the status quo, since the digestive system is constantly cranking out new stool.
Many parents fear that if their child is only able to poop after the enema, the child has become “dependent” on the enema to poop. But this is not a sign of dependence! It is a sign the child’s rectum hasn’t fully recovered. Dependence is something different.
For example, a patient with type 1 diabetes will always be dependent on insulin to live. A child with enuresis and/or encopresis will not always rely on enemas or suppositories to poop, though it may take many months to wean off them.
In the meantime, if enemas are what it takes for a child to fully evacuate, clean out the compromised rectum, and put a stop to accidents, what’s wrong with that?
Certainly, pooping with the help of an enema is a lot healthier than not pooping.