Don't overlook signs of constipation during potty training
- Steve Hodges, M.D.
- Sep 30
- 5 min read
By Steve Hodges, M.D.
In my experience, nearly all tween and teen bedwetting cases — I’ve personally treated thousands over 20 years — can be traced back to the potty-training period.
Either the child was constipated before potty training and therefore was destined to have difficulties pooping on the toilet, or the child developed the withholding habit during potty training, for reasons I explain here. Or, the child sailed through toilet training but then developed chronic constipation, which escalated into enuresis (wetting accidents) and/or encopresis (poop accidents) in kindergarten.
The bottom line: Potty-training struggles at age 2 or 3 are a giant red flag for chronic constipation and should not be dismissed ("no worries, she'll outgrow it") or treated as a psychological issue.
READ: What Preschool Potty Accidents and Teenage Bedwetting Have in Common (Spoiler Alert: Everything)
I mention this because of parenting column that recently appeared in the Washington Post: I am trying to potty-train my 3-year-old. I’m running out of ideas! The advice, while well intentioned, misses the boat.
My goal here is to prevent more children from developing enuresis and/or encopresis — stressful, confidence-crushing conditions that are preventable if you know what symptoms to look for and treat those symptoms aggressively enough.
Here’s the question from the Post column:
I have been trying to potty-train my almost 3 -year-old girl. She has done great with #1 but just can’t seem to bring herself to go #2 in the potty. Even if I know she has to go, she will sit and sit and then go find her favorite spot behind a chair and go in her pants! I have also tried giving her some stool softeners because I do think she is constipated! She doesn’t seem to be bothered by it, even with “incentives”! I am out of ideas!
First off, this mom astutely recognizes what the Post columnist downplays: This child is constipated and needs treatment. (Stool softeners won’t cut it, but more on that shortly.)
The columnist focuses on the fact that toilet training can’t be forced — true enough, but not the key issue here. She writes: “There is only so much that can be done from the parent’s perspective. You cannot force eating, sleeping or toileting.”
What the columnist misses is that the child’s toilet-training struggles are a direct consequence of her clogged rectum.
While you can’t force a constipated child to poop, you absolutely can — with robust treatment — resolve the constipation so that the child a) feels the urge to poop, b) heeds that urge in a timely manner, and c) does not feel pain with pooping.
Left untreated, chronic constipation in a 3-year-old tends to worsen. Just as a stopped-up bathtub drain won’t unclog itself, neither will a backed-up rectum. To the contrary, as more stool piles up, pooping becomes more painful, and the rectum stretches, losing the tone and sensation needed for complete evacuation.
This triggers a vicious cycle: The child can’t sense the urge to poop, so even more stool accumulates, so pooping hurts even more, so the child further delays pooping, and the rectum stretches further, and so on.
Parents often don't recognize this cycle because a child can poop every day and still be severely constipated.
The Post columnist misinterprets the child’s hiding, writing: “It is a good sign that she is hiding behind her favorite chair to poop; it means she is aware of the sensation!”
Hiding — behind furniture, in a closet — is not good sign! In fact, it’s among the red flags listed in our infographic 12 Signs Your Child is Constipated.
Hiding signals the child is trying to override the urge to poop — aka withholding. Kids do this without realizing it, typically because the hard, dry mass of stool in their rectum has made pooping painful. Chronic constipation usually begins with an episode of painful pooping and can quickly escalate to encopresis or enuresis if not recognized and treated consistently and sufficiently.
Unfortunately, the columnist veers off in a psychological direction:
“If you believe she is constipated, there could be some unconscious shame tied up in the defecation. I don’t want to become too psychoanalytic, but passing stools can be associated with shame, anxiety and stress, possibly made worse by the negative attention and disappointment from you after her accident is discovered.”
Certainly, children can become stressed when parents push them to poop, and kids do feel shame when they have toileting accidents, especially when they sense their parents are disappointed or frustrated with them.
However, all this is due to chronic constipation, not the other way around. It’s not that the “shame” of pooping brings on constipation; it’s that constipation — more specifically, accidents brought on by constipation — can cause shame.
The solution: Ditch the psychoanalyzing and treat the clogged rectum.
READ; “Potty Regression,” “Potty Refusal,” “Not Fully Potty Trained": Why These Terms Should be Canceled
The columnist wisely advises this parent to report the child’s pooping difficulties to the doctor: “A good pediatrician won’t ignore you; you don’t want to miss a medical need if there’s one there.”
Problem is, pediatricians frequently downplay constipation, recommending inadequate remedies such as prune juice, increased fiber, and occasional Miralax (PEG 3350).
As one mom in our private support group posted, “At 3, my son flat-out refused to poop on the potty. I was told to give him prunes and lots of fiber, and he was on laxatives on and off. I just thought that was the way he was, and he’d grow out of it. Now he’s 5 and has never pooped in the toilet. We’ve both been in tears many times over it.”
I hear this all the time.
What many folks don’t appreciate is that garden-variety constipation is itself a “medical need.” The condition is common, but that doesn’t mean it’s normal or will spontaneously disappear.
Children who have poop or pee accidents need especially aggressive treatment, such as the Modified O'Regan Protocol (M.O.P.), an approach that combines suppositories and laxatives.
"Incentives," like those offered by the mom who wrote to the Washington Post, won't help (and will only cause frustration for parent and child alike). No amount of M&Ms or screen time will trigger bowel movements in a child with a clogged rectum. Lack motivation isn't the problem here.
I agree with the Post columnist that parents should never push potty training, and the toilet-training vibe should be “easy, fun and stress-free.” Preschool potty-training deadlines and early potty training lead to many cases of chronic constipation, enuresis, and encopresis.
However, when the columnist says, “Applying pressure to potty training will make it take longer,” she doesn’t grasp that simply backing off will not resolve the situation.
The columnist adds: “Unless there are medical issues, the timetable of when your daughter will poop in a potty is up to her.”
That’s just not true. Unless the child’s rectum is fully cleared out and kept empty on a daily basis — a process that requires more than stool softeners — she will not have control over her bowel movements. It’s really not “up to her.” It’s up to the child’s parents and doctor to get her the treatment she needs.