By Steve Hodges, M.D.,
The other day I looked everywhere in the car for my sunglasses — under the seat, behind the seat, in the console, in the trunk — only to realize: Duh, my glasses are right on my head!
That’s essentially the same story that plays out daily in my medical practice, when it comes to searching for the causes of encopresis (poop accidents) and enuresis (bedwetting and daytime wetting).
Patients referred to me have undergone myriad medical tests in search of a cause for their bedwetting or daytime pee or poop accidents. Tests for sleep apnea and other sleep disorders. Tests for diabetes, allergies, nutrient deficiencies, rare digestive disorders. MRIs, blood tests, urine tests. Sometimes, psychiatric tests, too — for bipolar disorder, oppositional defiant disorder, and other mental health conditions.
And yet, like the sunglasses on top of my head, the actual cause was obvious and overlooked: a rectum full of poop. In other words, chronic constipation.
In some cases, I do order various tests to rule out the rare causes of enuresis that are unrelated to constipation. (I discuss these exceptions in the M.O.P. Anthology 5th Edition.) However, with virtually every patient, the cause of the accidents is evident from the simplest test of all: an abdominal x-ray. It’s the first test I do and almost always provides the answer.
Yet most my patients had never been x-rayed before landing in my clinic. This is especially true for children with a diagnosis of autism, ADHD, or sensory processing disorder. Many physicians reflexively attribute accidents to these conditions, failing to realize the culprit isn’t the autism; it’s the clogged rectum.
As in my clinical practice, parents in our private Facebook support group report their children have undergone loads of tests that revealed nothing.
A few days ago, a mom posted about her 4 ½-year-old, for whom potty training “never clicked.” Since turning 3, the girl has only asked to use the toilet about five times.
“She has had a lumbar MRI and an abdominal ultrasound, which were both normal, and has been tested for Crohn's, celiac, colitis, and iron deficiency, all negative.” In addition, her daughter is scheduled for an initial evaluation at a well-known children’s hospital next week.
This mom added that her daughter receives OT and PT services for gross and fine motor delays and sensory processing differences and has a diagnoses of mild autism spectrum disorder (ASD).
In this case, the child did have an abdominal x-ray that showed constipation, and the mom wisely started her daughter on M.O.P., our enema-based protocol. However, after a couple months, the child’s symptoms have persisted, which is why, I assume, she is pursuing a hospital evaluation.
But to me, that’s overkill. The child’s x-ray shows exactly why her accidents have persisted and why she does not sense the urge to poop: She began treatment with a rectum that was severely overloaded and impacted.
There is just no way a child with a rectum that clogged and stretched is going to sense the urge to poop. Searching for answers in an iron deficiency test or some of those other evaluations is like me searching for my sunglasses in the trunk of my wife’s car.
For this child, I advised starting with Double M.O.P., a regimen that combines overnight oil enemas, to help soften and break up the crusty old stool, with a morning large-volume enema. From there, she could shift to one of the other M.O.P. variations. It’s just hard to make headway, even on an enema regimen, without first resolving the impaction.
On a related note, this week another member of our private support group posted about her 11-year-old with heavy nightly bedwetting. The child’s urologist would not order an x-ray but the girl did undergo a bladder ultrasound and a sleep study, both of which, unsurprisingly, showed no abnormalities.
Two years ago, the girl had success on M.O.P. — for a time, her bedwetting ceased. But then it came back, as it often does if the rectum has not fully healed. The girl’s previous success alone suggests chronic constipation remains the problem and that a more aggressive version of M.O.P., along with a more gradual taper, will resolve the accidents.
But here’s the interesting part: The mom posted that in the last two weeks, despite only intermittent dry nights, the girl has shown “much more emotional regulation.” In the past, she had a diagnosis of oppositional defiant disorder and showed signs of ADHD and previously underwent therapy for anxiety and emotional difficulties.
Now, I don’t know this child and am in no way qualified to diagnose emotional or psychological conditions. But I do know that plenty of my patients have been referred for behavioral or psychological therapy due to their accidents and that nobody ever considered these kids were constipated, let alone x-rayed them or treated them for a clogged rectum.
Numerous parents have reported to me that their child’s behavioral and/or emotional symptoms diminished or even vanished after they were properly treated for constipation.
One mom posted, “We are seeing a very positive change in our 6 y.o. daughter — sensory issues, meltdowns, anger that we have been treating with therapy for almost a year. Two weeks into M.O.P. and we have a much calmer, happier little girl.”
Another chimed in that her 12-year-old son underwent years of psychological therapy, where he was told that his accidents were “a form of control.” Once his accidents stopped, his behavior and mood improved. “He’s not living in constant anxiety. He is confident, enjoying his friends, it shows in his grades at school, his extracurriculars, homelife, etc. Even take the social stuff away — he feels better, period.”
So many parents in my clinical practice and our support groups have described their wild goose chases in search of an explanation for their child’s accidents — all the testing and inappropriate therapy.
In our free guide, The Mental Health Professional’s Guide to Enuresis and Encopresis, a mom in our support group describes how her 8-year-old was prescribed anti-psychotic medication because a doctor mistook the boy’s poop accidents for bipolar disorder.
Over the years, the boy visited multiple psychologists and psychiatrists who were “100% stumped” by boy’s encopresis and created charts to “try to correlate the accidents to stress and other behavioral issues.”
It took four more years before a doctor diagnosed the boy with chronic constipation. M.O.P. halted the boy’s poop accidents in a week.
My advice: Before you spend loads of time and money on unnecessary tests and treatments for your child’s enuresis or encopresis, have your child x-rayed for stool in the rectum.
Look in the most obvious place first. Chances are, the glasses will be right on your head.