Enuresis and Encopresis Q&A: Bladder Meds, Ex-Lax, and Weaning Off Enemas

By Steve Hodges, M.D.

How can you help a teenager counteract a bedwetting setback? Is it a good idea to start tapering off enemas if a child's x-ray shows his rectum is still enlarged? What should you do if travel messes with your child's constipation treatment?

These are among recent questions posted in our private Facebook support group. I'm answering them here, as the issues raised are quite common

Q: My 18 y.o. son has always struggled with nighttime wetting. We jumped right into Multi-M.O.P., with two homemade LGS [liquid glycerin suppositories] per day. We saw immediate progress — he was consistently hitting 5-6 days dry with a wet night or two in the middle. But now he's hit a rough two-week period with more wet nights than dry. He hasn’t changed the regimen. Previously, he took desmopressin for 6 weeks but didn’t feel it helped. Is there something else we can do? He wants so badly to move forward.

A: Definitely keep up Multi-M.O.P. His early and quick progress is encouraging, despite the recent setback. As we emphasize in the M.O.P. Anthology, progress is usually not linear, and setbacks are common — it’s often two steps forward, one step back. With older kids especially, I recommend adding medication once the rectum has been pretty well emptied. If he doesn’t want to try desmopressin again, mirabegron (described on page 115 of the Anthology) is worth a try. Though enuresis meds usually don't work when the rectum is full, medication is often useful further into treatment.

Also, a new x-ray would show us whether his rectum is empty but still dilated, in which case medication will likely help, or whether he’s still somewhat clogged up, in which case he may just need more time on Multi-M.O.P. or might benefit from overnight olive oil enemas to help dislodge the stubborn stool.

READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable

Q: After 9 weeks on daily enemas (no laxatives), my 4 y.o. with encopresis has been accident-free for 30 days, but he’s still not pooping on his own. Our x-ray shows his rectal diameter is 4.8 cm. I’m worried about tapering if he still can’t feel when he needs to poop. Can you review our current and previous x-rays and advise?

A: The x-ray shows his rectum is still a bit dilated, but it has shrunk enough that he should now feel the urge to poop. The question is whether he will respond to the urge, and the only way to find out is to start tapering and see what happens. To ensure a daily bowel movement while tapering, either use a daily osmotic laxative or a stimulant laxative such as Ex-Lax on non-enema days. If all goes well, he can then gradually taper off the laxative.

Children with encopresis are particularly vulnerable to a recurrence in accidents, and it takes a good three months for the rectum, once emptied, to shrink back to normal size and completely regain tone and sensation. I suggest following one of the Slow Taper regimens described on pages 68-69 of the Anthology — for example, 3 days of enemas/1 day off or 2 days of enemas/1 day off. If accidents recur, you can resume daily enemas to give his rectum a chance to further shrink back.

READ: Why an X-ray for Childhood Constipation Can Seem Like a Rorsach Test

Q: We live in Amsterdam, and my question is about following M.O.P. on holidays. My 4.5 y.o. reached a phase of doing great with daily enemas — no accidents — and was pooping on his own. But since traveling to New York, his spontaneous poops are gone, and his poop consistency is harder. We’ve had to change our schedule to morning instead of evening enemas, and we’ve had a change in time zone and diet (the American way — not super healthy). Can travel cause such drastic changes? Shall we just wait out things until we get back to our routine?

A: Absolutely, travel can worsen constipation, even when kids are able to stick to their enema and laxative regimen (no easy task!). In addition to time-zone and dietary changes, children are also contending with erratic schedules, unfamiliar toilets and numerous other obstacles to pooping promptly and evacuating completely. I discuss these challenges, along with solutions, here.

You may want to increase your child’s osmotic laxative dose while you're traveling. My general advice for vacations is: Do the best you can, and know that any setbacks can be reversed when you get home.

READ: Treating Your Child's Constipation on Vacation

Q: My 7 y.o. began with encopresis and both day and night enuresis. After a few months of enemas and two daily Ex-Lax, daytime accidents stopped, and bedwetting significantly improved. We continued the regimen until he was dry every night for 30 nights and then started a very slow taper — 6 enemas per week for a month, then 5 enemas per week. At 4 enemas per week, he had one wet bed after a vacation, but now he’s been accident-free for two months and poops daily. What do you advise next?

A: Great job with the slow tapering! Weaning off enemas at this very slow pace will likely keep accidents away for good. From this point, you could continue with your pattern, shifting to three enemas per week for a month, then two enemas, then one. Or, given his long dry streak, he might do fine following the standard M.O.P. tapering pattern — that is, enemas every other day for a month, then twice a week and then no enemas.

Either way, I suggest continuing with daily Ex-Lax until your son is entirely weaned off enemas, and then slowly taper Ex-Lax while adding an osmotic laxative. Assuming he remains accident-free and poops daily, you could taper off the osmotic after 6 months, dropping to half a dose daily, then half a dose every other day, and so on.