By Steve Hodges, M.D.
I’m an epic procrastinator. I avoid tasks that aren’t totally pressing, in hopes I can get away without tackling them at all.
So, I’m plenty sympathetic when parents put off treatment for their child’s enuresis (wetting) or encopresis (poop accidents), in hopes the accidents will spontaneously disappear. I get it: Accidents are not life-threatening, and it's easy to tell yourself: I'll deal with it next week. Or sometime soon.
Often, this delay is encouraged by a physician. “Don’t worry, she’ll outgrow it,” the doctor will say. Or: “Accidents are normal. Nobody goes off to college in diapers.”
While this counsel may be comforting, it’s also misguided, giving parents license to further defer treatment and leaving children without help for conditions that are distressing, embarrassing, and totally fixable.
In truth, accidents are not normal. Both pee and poop accidents are caused by chronic constipation: A clogged, stretched rectum presses against and aggravates the bladder nerves and loses the tone and sensation needed to prompt a complete bowel evacuation.
Left untreated, enuresis and encopresis, like countless other medical conditions (and like the piles of work on my desk), often worsen rather than vanish. I’ve had plenty of teenage patients who delayed college because their bedwetting was never properly treated — not at age 4, age 7, age 10, or age 15.
When families land in my clinic or join my private online support groups, they’ve reached the breaking point.
“My son was having terrible poo accidents at school and emotional difficulties with it all, so I was pretty desperate,” posted the mom of a 9-year-old. “We had been stuck for years in a quagmire of not knowing what to do about his accidents.”
Another mom wrote: “My daughter was 11 and had recently had some embarrassing sleepovers. It was heartbreaking to see how bedwetting was affecting her.”
Some of these folks had not tried any previous treatment, simply heeding the doctor’s advice to wait it out. Others had “tried everything.”
“We tried regular clean-outs with lots of Miralax, bedwetting medications, dietary changes, dietary elimination, waking at night, bed alarms (four to be exact), chiropractic care, scheduled sitting on the toilet three times a day,” posted the mom of a 13-year-old. “I’ve spent thousands of dollars!”
What these families hadn’t tried is the approach most likely to work: the Modified O’Regan Protocol (M.O.P.), a regimen that combines daily enemas with daily laxatives, before gradually tapering.
Yes, I realize M.O.P. sounds “extreme” and “overly invasive,” perhaps “unsafe” and “traumatic.” At least that’s what some physicians have told families I work with. In reality, M.O.P. is none of those things, as I explain extensively in The M.O.P. Book: Anthology Edition: A Guide to the Only Proven Way to STOP Bedwetting and Accidents.
What the regimen actually is: the most effective way to unclog a child’s rectum and keep it clear. This process allows the rectum — greatly stretched by a persistent mass of stool — to shrink back to normal size, regain tone and sensation, and stop aggravating the bladder nerves. (It is this nerve aggravation that triggers the bladder to hiccup and empty without warning, day or night.)
Still, the regimen isn’t a breeze! Treatment can last many months and requires perseverance and experimentation with products and dosages. What’s more, the “aggressive” nature of the protocol often scares folks off, prompting them to delay treatment even further.
Parents think: There must be something easier. No way are we doing this.
I could, and often do, talk all day long about the benefits of starting M.O.P. now — not 5 months or 5 years from now. I don’t know of any child who has benefited from an extra 5 years wearing pull-ups, but I’ve seen countless lives changed for the better when the accidents stop. The confidence kids regain, the relief they feel — it’s priceless.
“I am thankful for my son being happier, more confident and having less anger issues,” one mom posted, upon “graduation” from our support group for parents of kids ages 3 to 10. “And I am thankful for not cleaning poopy underwear.”
A member of our support group for parents of teens and tweens posted: “My son feels so good when he wakes up dry. The rest of us take that for granted, but it’s a big deal for an almost 14-year-old.”
Below, I discuss 5 common obstacles to starting M.O.P., along with advice from parents who overcame these barriers and got their kids started on the path to dryness.
•Obstacle #1: My child will never agree to enemas.
That’s what everyone thinks! But it’s rarely true. Children are usually amenable to enemas for two reasons: 1.) They feel so much better afterward, and/or 2.) They understand enemas are the ticket to dryness and very badly want to get there.
“The process isn’t as complicated or icky as it seems,” the mom of a 12-year-old posted. “Don’t assume your child will be upset about doing enemas. I was surprised to find that my daughter is totally OK with them.”
Another mom, worried her son would refuse enemas, offered him $1 per day. She soon realized he didn’t even need the reward.
“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, and I don’t think he did either because he had grown up feeling that way. I was so amazed how easy it was once we got on a routine.”
Certainly, adjusting to enemas is easier for some kids than others. One mom with three constipated children has started M.O.P. with two of her kids and is gently encouraging her third to get on board.
“We had very little drama with my first two children,” she posted in our M.O.P. support group. “My third is a highly sensitive child, and he finds it really overwhelming. We’re going to try again with him soon. Even when the kid strongly resists, it doesn’t have to be a big deal. Just wait and try again a bit later.”
Her advice to parents who assume their children will object to M.O.P.: “Chill out about the whole enema thing. Put the enema tip into the child’s hand and let them insert it if they’re old enough. Letting them have control solves a lot of problems.”
What if your child does resist enemas? Our blog post “13 Ways to Overcome Your Child’s Fear of Enemas” is full of practical suggestions.
•Obstacle #2: I don’t believe my child is constipated.
“I wish I’d started M.O.P. earlier, but I didn’t actually believe my daughter was constipated,” posted the mom of a 6-year-old.
I hear this all the time! Parents tell me: “My kid poops every day. There’s no way he’s constipated.”
Guess what? Tons of severely constipated kids poop every day. The real issue is: Does your child fully evacuate with each bowel movement? Many kids don’t, so stool piles up in the rectum, while fresh poop just oozes around the hardened mass of old crusty stuff.
In fact, many constipated kids poop two or three times a day, a sure sign of incomplete emptying.
The number-one sign of chronic constipation is XXL poops, aka toilet cloggers! If you find yourself shocked that a kid that small could bust out a poop that large — well, your child is constipated. Our infographic 12 Signs Your Child is Constipated lists other red flags. Some of them may surprise you.
But don’t take my word your child is constipated; the proof is in the x-ray. I x-ray all my enuresis patients and measure their rectal diameter, so families can see exactly what’s happening. A normal rectum is no larger than about 3 cm in diameter; in my typical enuresis patient, the rectum measures at least 6 cm.
“My daughter never demonstrated symptoms of constipation, and exams with her pediatrician have never given any indication otherwise,” the mom of a 17-year-old told me. “She was on bedwetting medication for years with no success. Lots of laundry and self-confidence issues. Her x-ray revealed her rectum measured over 7.5+ cm!”
After several months on M.O.P. — and just before she left for college — this teenager was reliably dry at night.
“Her last x-ray showed she was cleaned out!” her mom posted. “We are so relieved to have found M.O.P. just in time.”
The M.O.P. Anthology provides detailed explains what kind of x-ray to order and how to ensure your physician interprets it accurately.
•Obstacle #3: Our doctor opposes enemas.
Any physician experienced with M.O.P. will tell you daily enemas are safe and highly effective, and published research confirms this. But doctors without this experience may rattle off a list of objections to enemas: They’re traumatic. They cause dependency. There’s a risk of electrolyte imbalance.
I tackle each of these false claims, and several others, in the M.O.P. Anthology. There is literally no evidence to suggest enemas are harmful and lots of evidence to the contrary.
Yet doctors typically prescribe high doses of Miralax, a treatment that is usually inadequate and sometimes makes accidents worse. When that fails, they prescribe even higher doses.
Should you avoid M.O.P. if your doctor disapproves? I don’t think so. While it’s always reassuring to have your doctor’s support, implementing M.O.P. requires no medical expertise. Most families in our private support groups implement the regimen without the blessing of a doctor.
One mom who recently moved on from the group posted these final words of advice:
Our doctor told me not to do enemas because it would be too traumatic. So we spent over 2 years following her recommendation to do Miralax, which at times made my son’s accidents worse. Once I was fed up, I went out in search for an answer/treatment myself and found M.O.P. My advice is: Don't let keep doing treatments that aren’t getting you anywhere. And if your doctor won’t get on board with M.O.P., it's OK. You really don’t need them. My only regret is that I followed our pediatrician's recommended treatments for 2 years.
While some doctors refuse to even consider M.O.P., in the end, this child’s pediatrician turned out to be open-minded. As this mom recounted:
We went in for an annual check-up recently. I had my son talk to her about how happy he is now not pooping in his pants. She was very receptive this time and was extremely interested in learning more.
If your doctor balks at enemas, print out The Physician’s Guide to M.O.P.. The packet includes scientific studies and a “Dear colleague” letter from me explaining why I recommend enemas over other treatments.
Obstacle #4: My spouse won’t agree to enemas.
I say “spouse,” but what I really mean is “husband.” In 99% of cases reported to me, when a spouse resists M.O.P., that spouse is Dad. I will not speculate as to why, but fathers, far more than mothers, seem certain that enemas are . . . just wrong. This is such a common phenomenon that the Anthology includes a section titled, “Help! My spouse thinks M.O.P. is crazy!”
The topic also comes up periodically in our private support groups.
“One of the biggest things for me starting M.O.P. with my 3.5 year old was (is!) getting my spouse on board,” one mom posted. “He was hesitant, but I spend way more time changing our daughter and seeing what her poop is like, cleaning up the messes, so I am more in tune with the problem than he was.”
In light of her husband’s objections, this mom second-guessed herself and continued with Miralax treatment. Increasingly discouraged, she began tracking her daughter’s accidents.
“That was very telling. I had evidence that she was having 10 to 12 poop accidents a day. My advice to other parents would be to trust your gut if something seems wrong and start a chart.”
In addition, she encouraged her husband and daughter to read Bedwetting and Accidents Aren't Your Fault together. “That has been really helpful for getting my daughter used to the idea of enemas, and it’s helpful to have my husband read it too, because it gives him an overview.”
Another mom appealed to her husband’s science background. “I wanted to do M.O.P. 3 or 4 years ago, but my husband was not on board, and neither was our pediatrician or GI doctor. “The fact that our son is now 10 and dealing with social pressure and mean kids finally helped convince my husband to read the Anthology, and since he is a scientist, he was on board.”
X-rays are often persuasive to dads, in my experience.
“My biggest obstacle was the husband,” another mom posted. “Getting the x-ray totally helps to know and see exactly what’s going on. I would advise any parent to follow your gut and don’t delay. The sooner you help your child the better.”
•Obstacle #5: M.O.P. sounds too overwhelming.
There’s a reason bladder medication and oral laxatives are so commonly prescribed to enuresis patients: powders, syrups, and chewable tablets are easy for both parents and kids to deal with.
But if treating enuresis were easy, my clinic would not be full of 10-year-olds with enuresis and encopresis!
Many folks are put off by M.O.P. because it sounds too hard. Indeed there are several moving parts: You need to choose among the various types of enemas and osmotic laxatives. In some cases, stimulant laxatives — senna-based medication such Ex-Lax — are warranted, too, and overnight oil-retention enemas can help.
M.O.P. is more of a process than a strict protocol, and you may need to keep tweaking the regimen, based on the guidelines spelled out in the Anthology, until you hit on what works for your child.
Understandably, all this scares off some parents at first.
A mom with two children on M.O.P. — one 7 and one 9 — recalls: I was overwhelmed with finding the supplies and figuring out how to incorporate it into our nightly routine. There’s no way to overcome that other than to just jump in and do it. Give yourself two evenings to read the Anthology, a few days to find the supplies, and just get going. Within a few weeks you’ll have tackled most of the difficult bits, and you’ll be into a routine. After that, it’s just a long process of fine tuning. The logistics of that are easier than you think. And the results are SO WORTH IT!
If you or your child need time to warm up to M.O.P., that’s fine! But keep the protocol on your radar.
When it comes to treating enuresis and encopresis, nothing is gained by waiting, and so much is gained by taking action.