By Steve Hodges, M.D.
Did you know teenage bedwetting is more common than autism?
The average high school in the United States has about 750 students, which means there are probably 15 kids with enuresis in a typical school. In a big-city high school, with 2,000 to 4,000 students, there are probably 40 to 80 students with enuresis.
But no one ever talks about enuresis because of the stigma attached. Instead, teens with bedwetting shoulder an immense amount of shame and blame. And they’re offered nonsensical, unsupported explanations for the persistent wetting.
Here are some of the explanations my teenage bedwetting patients tell me they’ve heard from doctors:
“You’re a deep sleeper, but don’t worry — no one goes to college wetting the bed.”
“You have a small bladder. Just pee every 2 hours.”
“You must like greasy foods. You need to eat healthier.”
“Your bladder is underdeveloped.”
“Your bladder muscles are overdeveloped.”
“You’re allergic to wheat.”
“You probably have a hormone imbalance.”
“It’s probably stress — see a therapist.”
All these explanations are off base, as I explain in my new book, M.O.P. for Teens and Tweens: The Science-Based Way to STOP Bedwetting and Accidents for Ages 10 to 18, written for middle-school and high-school students.
Here’s what these kids should have been told instead: Enuresis (both bedwetting and daytime wetting) and encopresis (chronic poop accidents) are caused by chronic constipation. In other words, a pile-up of poop in the rectum.
Here’s how I explain things to my patients: When you poop, your rectum is not completely emptying. Some poop ends up in the toilet, but some remains in your rectum. Gradually, the remaining poop piles up. This accumulation stretches your rectum — a lot. In fact, your rectum might be twice as wide as a typical rectum. Or wider. We can measure this on an x-ray.
When your rectum is enlarged by excess poop, it presses against and aggravates your bladder nerves. Instead of calmly alerting you to find a toilet sometime in the near future, your bladder goes nuts, squeezing and emptying before it’s full, without bothering to inform you in advance. You can’t stop an accident any more than you can stop a sneeze or a hiccup.
As for encopresis, a stretched rectum loses tone and sensation, so you can’t feel the urge to poop, and your rectum doesn’t have the oomph to fully evacuate. So, poop drops out of your bottom, and you don’t even feel it.
In otherwise healthy kids, a stretched rectum is responsible for all cases of encopresis and virtually all cases of bedwetting and daytime pee accidents. Yet the American Academy of Pediatrics maintains the fiction that enuresis is caused by a “delay in the development” in the bladder, kidney, and/or brain.
In an additional list of 8 “risk factors” for bedwetting, the AAP does list constipation — fifth on the list, below deep sleep and stress. But under “treatment for older children and teens,” only alarms, medication, and treatment of stress are mentioned as remedies. In reality, by far the most effective remedy is resolving the constipation, so the stretched rectum can shrink back to size and stop aggravating the bladder nerves. In cases where bedwetting persists because the emptied rectum remains stretched and the bladder nerves remain aggravated, bladder Botox or the InterStim device, two highly successful surgical procedures, can stop the wetting.
And yet, among the “tips” the AAP offers parents: “Limit intake of food or drinks with caffeine and avoid salty snacks and sugary drinks, especially during the evening.” As if there is a shred of evidence that any of these steps is an effective treatment for enuresis! (As if every teenager with enuresis has not already tried those strategies!)
The AAP also advises parents: “If bedwetting has not stopped in the late teenage years, your child should be seen by a doctor.”
The late teenage years!!
Meanwhile, these kids avoid sleepovers, endure teasing by peers, and live in fear that their friends will learn their secret and the accidents won’t stop before college.
Before landing in my clinic, my teenage patients have been subjected to years of useless remedies, including liquid restrictions, hypnosis, gluten-free diets, dairy-free diets, sugar-free diets, chiropractic, midnight wake-ups, bribery, rewards, counseling for anxiety — and, of course, medication and alarms. I’ve even had patients who were sprayed with water in the middle of the night as part of a very misguided treatment.
Nothing works, and yet these kids continue to be assured, year after year, “Don’t worry, you’ll outgrow it.”
How is a teenager in diapers not supposed to worry?
So many of my teen patients have become depressed over their endless bedwetting. One mom told me her 16-year-old son was repeatedly hospitalized for suicidal ideation due to enuresis and encopresis.
This notion that all kids eventually outgrow bedwetting is pervasive in our culture. Even Kristen Bell of Frozen fame tweeted: “I’ve never met a high-schooler who pees their pants all day. It’s going to stop at some point."
False! I’ve met countless high-school students with enuresis, right in my clinic, and without aggressive treatment for the underlying constipation, you absolutely cannot assume the wetting is going to stop.
When I explain to parents and teens that constipation is the cause of virtually all cases of enuresis, many of them don’t believe me. They’ll say, “But she poops every day — she can’t be constipated.” Or, “Our doctor never mentioned constipation.”
I explain that many kids with constipation poop every single day. But they don’t fully empty, which is what matters.
Also, the methods doctors are taught to detect constipation are useless. When a doctor feels a child’s belly, there’s no way to tell if the rectum is harboring large amounts of stool. In many kids, even the skinniest kids, you just can’t feel anything. That’s why I x-ray all my enuresis patients. X-rays don’t lie!
I recently received an email from the mom of a 15-year-old who’d never had a dry night. The boy had been evaluated for constipation at age 10 and deemed not constipated. “Honestly,” the mom wrote, “we don’t believe constipation is the cause of his bedwetting.” I suggested the boy get x-rayed. She reported back: “Turns out his colon is full of poop!” She went on: “I am feeling a sense of disappointment that in 5 years of treatment at a major hospital, no one offered us an x-ray.” This happens all the time.
Another mom told me she was shocked to learn her 17-year-old was constipated: “My daughter never demonstrated symptoms of constipation, and exams with her pediatrician have never given any indication otherwise. She was on medication for years with no success. Lots of laundry and self-confidence issues. Her X-ray revealed her rectum measured over 7.5 cm+!”
Here’s the good news I tell my teenage patients: You have a medical condition that can totally be fixed. With the right treatment, a stretched rectum will shrink back to its regular size and stop causing accidents.
But, there’s a catch: For accidents to stop, the rectum must be fully cleaned out every day for several months. Cleaning out the rectum is not a simple or quick process. You can’t just drink capfuls of Miralax and expect this pile-up of stool to dissolve and make a grand exit from your bottom. Not even colonoscopy-type clean-outs will do the job. If oral medications or alarms did the trick, I would not have a bedwetting clinic packed with patients.
The single most important treatment for enuresis and/or encopresis is a daily enema. I am well aware that this does not sound like fun. But my patients tell me that it sucks a lot less than wetting the bed or having accidents at school. They also tell me the process becomes routine. After a while, it’s just not a big deal. Some of my teen patients even do enemas on sleepovers, and their friends are none the wiser.
The enema regimen I recommend is called M.O.P, short for the Modified O’Regan Protocol. It’s named after Sean O’Regan, M.D., the pediatric kidney specialist who developed the regimen back in the 1980s for his own son and then tested it on hundreds of patients in the Montreal area. His published studies can be found on my website.
I recently received an email from the mom of the 16-year-old who was hospitalized for suicidal ideation. She wrote:
“M.O.P. was literally life saving for my son. He was on board to try enemas because nothing else had worked, and we had nothing to lose. It still shocks me how much resistance we got from everyone — the GI doctor, the pediatrician, the mental healthcare providers, his dad. But we did it anyway, and it worked. So much ignorance from the health care system. Lots of grieving on our part once we implemented the program. My son is 16 ½, and I was finally able to buy him underwear.”
In the The M.O.P. Book: Anthology Edition, I explain in great detail how to implement the regimen. M.O.P. for Teens and Tweens is intended as a supplement to the Anthology. In the teen guide, I answer the most common questions I get from teens. Among them:
Why didn’t I outgrow this when other kids did?
How did I end up constipated in the first place?
How long will it take for my accidents stop?
Do I really have to stick an enema up my butt?
M.O.P. is not a quick fix. The protocol takes commitment, patience, and experimentation. But it works.
The mom of the 17-year-old with the 7.5-cm rectum recently posted this update on her daughter in our private Facebook support group for parents of teens and tweens:
“We are finally making progress. She has only had one accident in the last three months and is still getting a significant amount of stool with her nightly enemas. Her last X-ray showed she was cleaned out! She leaves for college in two months! We are so relieved to have found M.O.P. just in time.”
M.O.P. for Teens and Tweens is available as an instant PDF download or as a paperback on amazon. The M.O.P. Book: Anthology Edition is available as a PDF or as a paperback in premium color or in black and white.