By Steve Hodges, M.D.
Let’s say an elderly man wets his pants at the park or wets his bed. Or both. Let’s say this keeps happening.
Would you describe this man as “behaving inappropriately”? Would you assume he has a psychiatric disorder? Or that if he felt less anxiety, he could make the wetting stop?
Unlikely! You’d figure he needs to see a urologist.
Yet when children have wetting episodes, adults often assume — erroneously — that the accidents signal psychological issues. Enuresis, a condition that includes bedwetting and daytime pee accidents, has burrowed its way into the psychiatry and psychology literature, with disastrous consequences for children.
The condition rates a 3-page entry in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), described by its publisher, the American Psychiatric Association (APA), as “an authoritative volume that defines and classifies mental disorders.”
Enuresis also has notched a 14-page chapter in the Handbook of DSM-5 Disorders in Children and Adolescents and countless entries in online resources for therapists and parents.
These entries should be removed. Enuresis is no more of a mental disorder than is an enlarged prostate.
In children, the cause is a stretched rectum due to chronic constipation. Enlarged by a pile-up of stool, the rectum aggravates the bladder nerves, causing the bladder to “hiccup” and empty without warning, day or night.
Stress, anxiety, attention-seeking, defiant behavior, trauma, parental depression or divorce — none of that is relevant. When the constipation resolves, the wetting stops.
And yet the characterization of enuresis as, at least in part, a “mental disorder” has seeped into the public consciousness, depriving children of effective treatment and needlessly triggering emotional distress and family conflict.
Children who need enemas and laxatives to evacuate a clogged rectum are, instead, offered sticker charts, referred for play therapy, cross-examined about their “potty refusal.” As the years go by, these kids miss out on sleepovers and sports camps and endure teasing at school. Their self-esteem plummets. Teens with enuresis panic about the prospect of heading to a college dorm with pull-ups.
Heck, just today the dad of a 17-year-old with enuresis emailed me that a “specialist had him doing mind exercises,” but the bedwetting has persisted. “The poor kid is humiliated and feels trapped and stressed about going anywhere overnight, including the future he wants in college.”
Quite often, the anxiety kids feel and the stubbornness they may display are perceived by adults as a cause of their enuresis rather than what these emotions and “behaviors” actually are: the upshot of a medical condition left untreated.
Of course children with enuresis feel stressed and “act out.” That’s inevitable when the symptoms of a dilated rectum are classified as a psychiatric disorder!
This entire sad scenario applies equally to encopresis, chronic poop accidents, a condition that also is caused by a stretched rectum and also somehow rates an entry in the DSM-5 and a lengthy chapter in the Handbook.
In the case of encopresis, the stool-stuffed rectum loses tone and sensation, so poop just drops out of the child’s bottom. These kids literally cannot feel the urge to poop or feel the accidents happening, yet adults often assume they’re “lying,” “REFUSING!!” to use the toilet, “seeking attention,” or showing signs of a psychiatric disorder.
Encopresis accounts for 3% to 6% of psychiatric referrals among school-aged children.
Countless parents in our private encopresis/enuresis support group have described their wild goose chases — and worse.
“When my son was 8 years old, he was medicated with serious anti-psychotic meds because a doctor thought he had signs of pediatric bipolar,” one member of our Facebook group told me. What were these “signs”? “His poop accidents and poop smearing.”
The boy, struggling with encopresis and enuresis, had been hospitalized after a bad reaction to ADHD medication, and the psychiatrist on duty made an utterly unwarranted leap. (Perhaps he referred to the DSM-5?)
Over the years, the boy visited multiple psychologists and psychiatrists, “all of whom were 100% stumped” by the cause of the boy’s encopresis, his mom recalls. “They made charts to try to correlate the accidents to stress and other behavioral issues. Of course, none of the theories ever seemed to fit.”
Eventually, a urologist confirmed the boy’s rectum was clogged and dilated. A regimen of daily enemas plus Ex-Lax halted his poop accidents in one week — the week before the kid started middle school. Five months later, his bedwetting stopped. (Encopresis always resolves more quickly than enuresis.)
“We literally went through torture for years,” his mom told me.
The notion that encopresis and enuresis have psychiatric origins has been around for centuries and is deeply rooted in our popular culture, including film and TV. The term "bedwetting" has even become a political cliche, used by pundits to signify "excessive worry."
Dr. Sean O’Regan, the pediatric nephrologist who proved back in the 1980s that chronic constipation causes both enuresis and encopresis, delighted in helping children whose condition had been grossly misunderstood.
“These kids were told it was all in their heads, that they were psychologically disturbed,” Dr. O’Regan once told me.
Forty years later, the tune has barely changed.
Sure, today’s manuals recognize a physiological component to encopresis and enuresis. The DSM-5, for example, calls encopresis a “biobehavioral” disorder, suggesting that both “physiological and behavioral aspects” may contribute.
That’s still only half right.
The psychiatry resources repeatedly, and without valid evidence, associate encopresis and enuresis with psychiatric disorders.
The Handbook asserts: “In fact, some studies have found psychiatric comorbidity in as high as 74% of children with encopresis.” You might think: Wow! That’s really high! There’s obviously a connection!
In actual fact, it was one study that found a 74% comorbidity, and this study, published in the Turkish Journal of Pediatrics, is laughable: In the majority of cases — 55% — the comorbid “psychiatric disorder” was . . . enuresis!
A guide for psychiatric nurses acknowledges encopresis is caused by constipation yet states that encopresis “is also a psychiatric diagnosis.” Why? Because “anecdotally, [encopresis] may have some association with psychiatric problems.”
Right: “Anecdotally.” “May have.” “Some association."
The U.S. government piles on. A chart published by the Substance Abuse and Mental Health Services Administration, intended to help researchers estimate the prevalence of “serious emotional disorders,” lists enuresis and encopresis in a column with “disruptive behaviors,” “psychosis,” and “attachment” disorders.
It’s not hard to see how an 8-year-old with chronic poop accidents ended up on bipolar medication.
As long as enuresis and encopresis occupy space in the psychiatric literature, no matter how much the entries hedge or qualify their statements, kids will be shortchanged. The die has been cast.
Often, mental health professionals don’t question the “mental disorder” classification until their own children develop these conditions. Over the years, several parents who happened to be employed as therapists have joined our Facebook support group, only to realize their assumptions were off base.
One mom posted: “Part of my experience about learning about this with my own kid has been to feel pretty devastated about how terribly some encopresis situations were managed with kids I worked with over the years. It makes me feel nauseated to think about a sticker chart.”
Another mom recounted that in her decade as a therapist, she and her colleagues treated encopresis “as a symptom under the anxiety or behavioral or trauma umbrellas. We didn’t consider encopresis a medical issue. Until I started dealing with it with my own son, I had no clue.”
That’s understandable! After all, therapists rely on authoritative manuals such as the DSM-5.
I’ve spent many hours reading about encopresis and enuresis in the psychiatry and psychology literature. These resources are packed with fallacies, as are the deeply flawed studies cited in the footnotes and misinterpreted in the texts.
Notably, the accurate sections support the fact that enuresis and encopresis are physiological conditions and only bolster the case for deleting these entries entirely.
It is not my intention to single out the mental health professions for misunderstanding the conditions I treat every day. These folks clearly want to help and are hardly the only health professionals with mistaken ideas about encopresis and enuresis. I write often about my own profession’s undertreatment of these conditions and have urged the American Academy of Pediatrics to update its guidance.
However, my patients, their parents, their school teachers, their therapists, and even their physicians are heavily influenced by the way encopresis and enuresis are characterized by the psychiatry and psychology fields. The DSM-5’s mistake matters.
Ironically, the misclassification of these conditions has created a role for well-informed therapists. Many families I work with desperately need help managing the fallout from years of blame and shame felt by kids (and parents), including poor self-image and a reluctance to comply with treatment. That’s an arena for mental health professionals, not pediatric urologists like me.
This post highlights a sampling of the errors in the DSM-5 and related literature. I urge mental health professionals to learn more about enuresis and encopresis, and I urge the Powers that Be to remove their misplaced entries on these conditions.
“Voluntary” encopresis and enuresis don’t exist
The DSM-5 includes enuresis and encopresis in an entry titled “Elimination Disorders” and asserts both conditions “may be voluntary or involuntary.”
Further, the manual divides encopresis into two types: a subtype “with constipation” and a subtype in which “there is no evidence of constipation on physical examination or by history.”
This second subtype, according to the book, “appears to be less common,” and is “usually associated with the presence of oppositional defiant disorder or conduct disorder.”
Bollocks, as the British would say!
Encopresis is always caused by constipation. I don’t care what behavior disorder a child does or does not have — kids don’t poop in their pants unless they have a stretched rectum and backup of stool. I’ve treated patients diagnosed with conduct disorder or ODD; 100% of them were constipated, and all stopped soiling when treated for constipation.
Over 15 years, I’ve treated thousands of patients with encopresis. I’ve seen everything. If there were a subtype “without constipation,” I’d have seen it at least once.
If a physician can’t find evidence of constipation in a child with encopresis, it’s because a physical examination and pooping history are worthless diagnostic tools, not because the child’s rectum is empty. Want proof? Get the child x-rayed.
The DSM-5 concedes that when a child has poop accidents due to constipation, “the incontinence resolves after treatment of constipation.” Well, yes! Theravive, an online network of licensed therapists, states the case quite well: “It remains a fact that if the bowel is kept empty, soiling cannot occur.”
The Handbook does a good job of explaining the origin of chronic constipation in otherwise healthy kids: “In the majority of cases, encopresis develops from the process of repeated withholding of stool due to history of passing painful/large diameter stool.”
High five! Kids delay pooping because it hurts!
Soon, a vicious cycle develops: Because pooping hurts, kids avoid doing it. So, more poop piles up, and pooping hurts even more. Eventually the rectum stretches to the point where it loses sensation, and kids can’t poop because they’ve lost the signal and the tone to fully evacuate.
Avoiding pain is human nature, not a sign of a “mental disorder.”
The Handbook also refers to “environmental causes” that may lead to encopresis — for example, “premature initiation of toilet training and stressful events occurring during toilet training.” I agree!
My own published research found children who toilet train before age 2 have triple the risk of developing chronic constipation and daytime wetting. And certainly, children pushed to toilet train before they’re ready are more prone to constipation.
If your preschool demanded you ditch diapers by September and the deadline pressure led you to delay pooping, you, too, might end up with a stretched rectum and soiled underwear. This happens all the time. It’s a great reason for preschools to change their potty-training policies. It’s no reason to include encopresis in a manual for diagnosing mental disorders.
The Handbook even does a fine job explaining how kids can fail to notice when they’ve had a poop accident, a scenario that frustrates parents to no end: “Over time with chronic constipation, the colon can become distended, causing children to have reduced awareness or sensitivity to the physiological sensation indicating a need to defecate. They may also become desensitized to the odor from soiling.”
What’s more, the Handbook concedes that “research has not been able to demonstrate a causal relationship whereby mental health conditions cause encopresis.”
So, let’s review: You’ve got a condition that 1.) starts with a painful pooping episode, 2.) causes the rectum to lose sensation, 3.) can be exacerbated by pressure to graduate from diapers, and 4.) is not caused by mental health conditions.
What on earth is encopresis doing in the DSM-5?
My guess: the inclusion of encopresis rests largely on the alleged existence of a subtype of encopresis that’s unrelated to constipation. According to the Handbook, treatment options for this subtype “are sparse due to it being the less common type. Thus, less is known about positive predictors and risk factors related to treatment outcomes.”
Alternately, try this: Less is known about this subtype because it does not exist. It is only assumed to exist based on pure speculation.
The only way to prove this condition exists would be to x-ray a cohort of children with ODD or conduct disorder who also have encopresis. If their rectums measured less than 3 cm in diameter (a normal measurement), then, OK, you could say these kids are not constipated. I guarantee you such a study would disapprove the existence of this mysterious “subtype” of encopresis.
Perhaps another rationale for including encopresis in psychiatry texts is the fact that children with this condition quite often experience psychological distress. The Handbook cites a UK study linking children with encopresis to elevated rates of “bullying behavior (both as a victim and perpetrator), antisocial activities, attention and activity problems, obsessions and compulsion, and oppositional behavior.”
The lesson here? Children suffer when their encopresis goes untreated.
What happens, according to the book, when the underlying constipation is treated and poop accidents resolve? “Improvements in emotional and behavioral functioning,” that’s what.
I hear this often from parents. The mom of a 5-year-old with encopresis posted that prior to treatment for constipation, her son “used to have anger and behavioral problems that we thought were age related.”
The mom of a girl with encopresis and enuresis posted: “My daughter is a different kid than she was a year ago. We went from daily outbursts and heightened anxiety to cooperation and logical discussions. My daughter is happy and grateful for the peace and freedom [treatment] has afforded us.”
Let’s move on to enuresis.
Enuresis: “deep feelings” and “attention seeking” play no role
While psychiatry texts agree encopresis is usually caused by constipation, the same texts do not recognize enuresis has the very same cause. Instead, cited causes for enuresis are all over the map.
The Handbook attributes bedwetting to “the interplay of three elements: defective sleep arousal, lack of inhibition of bladder emptying during sleep, and nocturnal urine production.” The DSM-5 cites notes that bedwetting runs in families.
In fact, deep sleep and urine production play no role in enuresis, myths I dispel here, and no bedwetting gene exists. (What does run in families is the predisposition toward constipation and sensitivity of the bladder to rectal stretching.) But even if these physiological factors actually did cause enuresis, wouldn’t that disqualify the condition from inclusion in a book on diagnosing mental disorders?
Inexplicably, the psychiatric literature defaults to an assumption that enuresis has both physiological and psychological origins.
The DSM-5 cites “predisposing factors” such as “delayed or lax toilet training and psychosocial stress.” (That’s right, according to the DSM-5, “premature” toilet training can lead to encopresis, whereas “delayed” toilet training can lead to enuresis — a confused message that perpetuates the myth that there’s a “window of opportunity” for toilet training.)
Also common is the “attention seeking” explanation for enuresis. As Psychology Today’s “Diagnosis Dictionary” puts it, wetting accidents may signal "a child has deep feelings they’re struggling to express or a need for attention and care that is not currently being met.”
This theme surfaces often in therapy. This week a mom in our Facebook group posted screenshots of texts from a behavioral therapist who insisted her son was having wetting accidents as a way to get his “wants and needs met” and that this mom is “reinforcing” attention-seeking behavior by allowing him to wear pull-ups! She added: “Urinating on his bedroom floor doesn’t have anything to do with constipation.”
The Handbook cites multiple third-rate studies linking daytime wetting to “difficult temperament and maternal depression/anxiety.” Also, the book, like Psychology Today, attributes secondary enuresis — the resumption of bedwetting after a long dry period — to “stressful life events,” particularly separation or divorce of parents.
“The most vulnerable age for secondary enuresis was 5 and 6 years,” the book states.
Enough with the parent blaming!
Do you know why bedwetting commonly returns around age 5 or 6? Because that’s when kids to go kindergarten.
Suddenly, children have less restroom access than they did in preschool and, often, more worries about interrupting the teacher. For a whole host of reasons, kindergarteners and first-graders use the toilet less often than they did in preschool, and they’re typically in school longer hours. As a result, constipation that may have been held at bay reaches a point of critical mass, literally. I see this all the time.
How can I be sure it’s constipation and not divorce or the birth of a sibling that’s causing the accidents? Because I x-ray my enuresis patients.
No enuresis study has validity without verification of a child’s constipation status via x-ray or anorectal manometry, a technique that involves inserting a balloon into the child’s rectum and inflating it to detect rectal sensation.
More than a decade of x-raying patients tells me this: Children simply do not have wetting episodes unless they have 1.) a dilated rectum or 2.) a neurological or anatomical condition such as tethered cord syndrome or spina bifida.
Dr. O’Regan used anorectal manometry, the gold standard technique for diagnosing chronic constipation, and found his enuresis and encopresis patients had monumentally stretched rectums. On average, these kids could not sense the balloons until they were inflated with 80 ml to 110 ml of air. How extreme is that? A child with normal rectal sensation would notice a balloon filled with 5 m. to 10 ml.
“Stressful life events” and “a need for attention” play no role here. Yet this myth pervades the literature and is hard for parents to get past.
Even after an x-ray confirmed her daughter’s rectum was stuffed with stool, one mom emailed me: “I’m not 100% convinced [her enuresis] isn’t just laziness/attention. In the last 12 months we have moved to a new house in a new town, and we’ve had another baby. She’s expressed a lot of jealousy regarding my time with the baby. I try my hardest to give her one-on-one time, and it doesn’t make a difference. Recently she’s been complaining of tummy aches, but she does seem to mention them at really ‘convenient’ times.”
Adults tend to look far and wide for psychological causes of accidents when none exist. A stretched rectum simply cannot be repaired by quality time with Mom.
Whereas parents often gravitate to the “stressful events” theory of enuresis, schools tend to adopt an alternate explanation espoused by the DSM-5: that daytime accidents “may be associated with symptoms of disruptive behavior.”
Kids who have pee accidents in class are often referred by schools for behavioral therapy and some are even threatened with suspension from school. (I’ve known some schools to follow through on the threat.)
All this just makes parents feel crappy for no reason, blames kids for embarrassing episodes that are entirely beyond their control, and diverts the family from seeking appropriate treatment, prolonging the entire family’s agony.
“My biggest regret was how much time I wasted thinking my son’s enuresis was behavioral or cognitive or that if I was a ‘better mom,’ he’d stop having accidents,” one mom in our Facebook support group posted.
The same treatment approach fixes all forms of encopresis and enuresis
The various psychiatry texts fill lots of space dividing enuresis into subtypes — nighttime and daytime, primary and secondary, voluntary and involuntary, and so on, asserting they’re “separate conditions” that require different treatment approaches.
Counseling, relaxation techniques, play therapy, group therapy — all these are suggested to treat certain forms of daytime wetting. Among the recommendations for nighttime wetting: “reward a child for nights without bedwetting and praise efforts to try,” “do nothing,” use a bedwetting alarm, and try bladder medication.
Echoing other resources, Theravive insists that diagnosing the correct subtype of enuresis has a “major impact on the sequence and types of treatment.”
Nonsense! All these so-called subtypes are all just manifestations of the same condition: a bladder aggravated by a stool-stuffed rectum. The same treatment approach will fix all forms of enuresis and all cases of encopresis, too.
What’s needed: an aggressive regimen to 1.) clear the rectum of impacted stool, 2.) fully evacuate the rectum every day for months, and 3.) keep stool soft so pooping doesn’t hurt. Only then can the rectum shrink back to size, regain the tone and sensation needed for complete evacuation, and stop aggravating the bladder nerves.
By far the most effective regimen is the Modified O’Regan Protocol (M.O.P.), an enema-based regimen based on Dr. O’Regan’s research and one I have prescribed, researched, and refined for over 15 years. The protocol also includes the strategic use of osmotic and stimulant laxatives and is spelled out in The M.O.P. Anthology.
Sometimes, even after a child’s rectum has emptied daily for months, the rectum remains stretched. You can see this scenario on an x-ray, and it explains why a child with a clear rectum can still wet the bed. In many of these cases, bladder medication can help. With the most challenging cases, an injection of Botox into the bladder can do the trick.
But the first line of business for any child with any manifestation of enuresis or encopresis should always be cleaning out the rectum and fully evacuating it daily.
Notably, the DSM-5 and related texts observe — very briefly — that many children with enuresis also have encopresis, constipation, and urinary tract infections. However, these resources fail to connect the dots: chronic constipation is the cause of enuresis, encopresis, and chronic urinary tract infections!
Reading these texts is like watching a TV crime show in which detectives overlook obvious clues. You're going: No! You've got the wrong guy! Back in the eighties, Dr. O’Regan proved the connection masterfully, solving the case beyond a reasonable doubt.
The psychiatry manuals are more concerned with linking certain “subtypes” of enuresis and encopresis to certain behavioral symptoms, such as classroom disruption, and psychiatric disorders, such as ODD. A common theme is that children with both daytime and nighttime wetting have “more behavioral symptoms” than a child with just one symptom.
Well, of course! Having accidents at school and wetting your sheets makes your life more miserable than just wetting your bedsheets. And having poop accidents on top of wetting makes your life that much more distressing.
Among the most discouraging themes in the psychiatry literature is that for many children, the prognosis is grim — that only 30% to 50% for children with encopresis, for example, may recover after a year. The Handbook cites particularly poor treatment outcomes in children with parents of “low education level, low socioeconomic status” or with families “characterized as divorced, disorganized, or chaotic.”
That’s insulting and ridiculous. There’s only one factor that leads to a poor prognosis: a lousy treatment protocol.
By lousy I mean treatment that is either completely off base (play therapy and sticker charts) or half-baked (treating impacted stool with Miralax for years while avoiding rectal treatments).
I have plenty of patients whose parents are divorced or have little education. I have plenty of autistic patients, patients with ADHD and anxiety, and patients who’ve experienced trauma. All these kids do great on M.O.P.
So do teenagers. Absolutely, enuresis and encopresis become more challenging to treat as kids get older; a rectum stretched for a decade won’t bounce back overnight. But with aggressive and persistent treatment, it will bounce back. In the most challenging cases, bladder Botox can get the kid dry for good.
When you treat a child’s dilated rectum, rather than a child’s behavior or family background, the prognosis is excellent.
Yet the manuals continue to miss this point.
The Handbook suggests teens with encopresis may require a “different treatment approach” due to their age and particularly difficult family dynamics. In support of this nonsense, the manual cites a case report of four teens admitted to the medical-psychiatric unit of an Israeli children’s hospital.
The authors, two psychiatrists, describe the teens’ family background and dynamics like this: The mother “was pedantic and obsessive,” the father “came from a low-social class,” “the father was an alcoholic,” “the mother lived a Bohemian life, reluctant to set any limits for her children” — you get the idea.
After a 2-week stay in the medical-psychiatric unit, the authors reported, the teens, who had been unsuccessfully treated for 6 years, experienced “complete remission.”
To what did the authors attribute this success? Several factors, including: “admission to our inpatient unit,” “separation of the parent and child,” and “peer pressure” (other patients in the unit knew about the teens’ embarrassing condition).
To what do I attribute the success? Enemas!
The teens’ 12-point treatment protocol included this: “If the patient had no bowel movement during the day, an enema was administered after the last meal. The patient was made aware that the enema was not a punishment, but a means to help the bowel regain normal activity.”
That’s right: Four kids who had suffered for years stopped having accidents in two weeks because their rectums were emptied, a scenario that happens every day in my clinic. One of the teens was so clogged that he required a manual evacuation of the impacted stool under general anesthesia.
No child needs admission to a hospital psychiatric unit for the treatment of encopresis or enuresis. And yet, on occasion, teenagers end up there because their condition was grossly misinterpreted and improperly treated. A mom I have never met emailed me this:
M.O.P. was literally life saving for my son, who was repeatedly hospitalized for suicidal ideation due to encopresis and enuresis. 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 health care 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 their case report, the Israeli psychiatrists asserted that admitting teens to a psychiatric-medical unit for encopresis treatment “is considerably cheaper than the accumulated costs of outpatient treatments.” After all, the doctors noted, those four teenagers suffered 6 years of outpatient treatment to no avail. In reality, you can stop poop accidents almost immediately with a $30 reusable enema kit, a $5 bottle of liquid glycerin, and saline solution made with tap water and table salt – no psychiatric evaluation needed. (However, resolving accidents for good requires extending the regimen until the rectum heals, typically three months.)
I could dismantle all the resources I’ve mentioned sentence by sentence, footnote by footnote. But that would put us all to sleep and miss the forest for the trees. The problem is the mere inclusion of enuresis and encopresis in manuals for diagnosing psychiatric disorders.
Not only should these entries be removed, but our vocabulary must change.
For starters, let’s retire “the behavior” in reference to pee and poop accidents, a term the DSM-5 repeatedly uses. Wetting your bed is not a “behavior” any more than sneezing is a behavior. Soiling underwear is not a “behavior” any more than hiccuping is. These are symptoms.
Also, let’s stop using “inappropriate” to describe accidents. The very first sentence of the DSM-5 “elimination disorders” entry defines these conditions as “the inappropriate elimination of urine or feces.”
The use of “inappropriate” is itself inappropriate.
Grab your thesaurus. What are the synonyms? Incorrect. Improper. Unseemly. Tactless. Unacceptable.
None of these words apply to my patients. But our literature — our culture, really — continues to suggest otherwise.