By Steve Hodges, M.D.
Would you know if your child had chronic constipation?
Would your child’s doctor?
Would a researcher tracking your child in a bedwetting study?
Most parents and medical professionals assume they’d have no problem identifying a chronically constipated child. In reality, even cases of severe, chronic constipation are routinely overlooked, especially in children with enuresis — that is, bedwetting or daytime wetting.
As a result, children miss out on effective treatment. Either their parents, unaware of the red flags, don’t schedule a doctor visit, or the doctor uses unreliable diagnostic methods (or doesn’t look for constipation in the first place).
Not only is all this problematic for individual families, but the use of insufficient diagnostic techniques also skews research results.
The ripple effect is huge: When study results are off base, healthcare providers get the wrong message. Instead of prescribing constipation treatment, they attribute enuresis to behavioral or emotional problems, hormonal disorders, “deep sleep,” and other non-causes. Children with enuresis are advised to “wait it out” or are referred for psychological counseling, art therapy, and other inappropriate treatments.
In this blog, I’ll consider the Rome IV criteria, a list of symptoms commonly relied upon by healthcare providers and researchers to diagnose constipation. Among the criteria: pooping less than three times a week, experiencing at least one weekly poop accident, and a history of painful or toilet-clogging bowel movements.
The Rome IV criteria are helpful but inadequate, as many severely constipated children check none of these boxes.
For example, one mom in our private Facebook support group posted that her son, who has nighttime enuresis, was not diagnosed with constipation until age 13, when she insisted on an abdominal x-ray. “He pooped regularly, didn’t have large stools, didn’t clog toilet, and didn’t have encopresis or complain of stomach aches,” she wrote.
For years, the boy’s bedwetting went untreated, as the family was assured, “He'll grow out of it eventually.”
Yet the Rome IV criteria are considered an accurate yardstick by many clinicians and researchers.
For example, in the Journal of Pediatric Urology, a Swedish team described the criteria as the “gold standard definition for diagnosing constipation in children.” Relying heavily on these criteria, the team characterized just 35% of their subjects — 23 of 66 children with enuresis — as constipated.
I consider this percentage preposterously low, and I believe studies like this obscure the strong connection between bedwetting and chronic constipation.
For some of the subjects, the Swedish researchers used a second diagnostic method I consider unreliable: ultrasound. More on that shortly.
If the Rome IV criteria and ultrasound aren’t dependable, which methods are? In my experience, just two: anorectal manometry and x-ray, particularly with rectal diameter. (Without rectal diameter, x-rays are subject to misinterpretation, as some physicians focus on the wrong part of the colon.)
Let’s start with the Rome IV criteria. The rubric is published by the Rome Foundation, an international nonprofit formed in the late 1980s to advance the scientific understanding of GI disorders. The group’s first meeting was held in Rome — hence the name.
Below I’ve listed the most recent Rome criteria (version IV, published in 2017) for pediatric “functional constipation,” which just means constipation unrelated to an anatomic abnormality or disease.
According to the Rome Foundation, diagnosis requires that at least two of the following symptoms have presented at least once a week for at least one month. (The emphasis is mine.) The diagnosis assumes that irritable bowel syndrome (IBS) has been ruled out and that the symptoms cannot be explained by another medical condition.
Two or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years
At least one episode of fecal incontinence per week
History of retentive posturing or excessive volitional stool retention
History of painful or hard bowel movements
History of large diameter stools which can obstruct the toilet
Presence of a large fecal mass in the rectum
Certainly, all these are telltale signs of chronic constipation! No argument there. Problem is, this list falls way short.
Rome IV is like a net with big holes: You’ll catch the biggest fish — the most extreme cases of constipation — but the slightly smaller fish will get away.
Actually, because the list relies largely on reports from parents or children, even some of the most extreme cases will be overlooked.
Many kids don’t know, or can’t remember, how often they poop, nor do they scrutinize the size and consistency of their bowel movements. Most parents, especially of school-age kids, don’t have their children’s pooping habits under surveillance and may just be guessing.
You just can’t rely on questionnaires designed to detect constipation based on the Rome IV criteria.
In fact, a Dutch study found that 45% of children ages 11 to 18 couldn’t follow the instructions on a Rome Foundation questionnaire. What’s more, many children answered the same questions differently two days apart. So, some kids who qualified as “constipated” one day did not meet the standard 48 hours later.
In the real world, a child's constipation status doesn’t change from day to day, especially if that child is constipated enough to have developed enuresis.
The Dutch authors noted that having parents complete Rome IV questionnaires does not make the diagnoses more reliable: “We recommend not relying on this questionnaire exclusively to select, recruit, or evaluate children for research purposes," the authors concluded.
Let’s take a closer look at the Rome criteria.
Symptom #1: Two or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years
There's no doubt a child who poops twice a week is chronically constipated. The digestive system never grinds to a halt, so any day a child doesn’t poop is a day that poop accumulates (assuming that child eats every day). If a child is only pooping twice a week, the rectum (the end of the colon) will harbor a significant pile-up of stool.
But two bowel movements per week is an arbitrary cut-off. Kids who poop three times a week accumulate stool, too. In fact, a child who poops every single day, even multiple times a day, can have a seriously clogged rectum.
That’s because chronic constipation is characterized by incomplete evacuation. It doesn’t matter how often a child poops if the child is not fully evacuating. The stool left behind — the hard mass stretching the rectum — is what causes enuresis, by encroaching upon the bladder nerves.
One member of our support group posted that her daughter, who has struggled with bedwetting, daytime wetting, and encopresis, had “VERY regular BMs (daily if not more)” prior to her constipation diagnosis at age 5.
“I was told her accidents were behavioral,” this mom continued. Worried her daughter would have accidents in kindergarten, she advocated for an x-ray. “I was shocked to see how backed-up she was. It was mind blowing how she could be so regular and still be so backed up!”
In my clinic, this scenario plays out often.
Symptom #2: At least one episode of fecal incontinence per week
Every child who has poop accidents (encopresis) has chronic constipation. Full stop. A clogged rectum is the only cause of encopresis, so this symptom alone is sufficient to diagnose constipation — no questionnaire or x-ray needed.
However, not every child with enuresis also has encopresis. Among my enuresis patients, about 20% to 30% also have poop accidents. But that means the majority don’t.
Children with both encopresis and enuresis tend to be the big fish, the most severely backed up. But this hardly means bedwetting-only children are not constipated.
What’s more, some kids have particularly sensitive bladders, so even a moderately enlarged rectum will aggravate the bladder nerves enough to cause accidents.
While Rome symptom #2 is telling, the absence of poop accidents is not.
Symptom #3: History of retentive posturing or excessive volitional stool retention
“Excessive volitional stool retention” is another way of saying “champion poop withholding.” But this symptom, too, doesn’t reveal much.
Sometimes, “retentive posturing” is evident to parents — kids are obviously contorting their bodies to prevent poop from exiting, or you can see the effort in their facial expression. But many children have a deeply ingrained, finely honed tendency to withhold stool. You’d never know they’re clenching their pelvic floor muscles to override the urge to poop.
I don’t even like the word “withhold” because it assumes the child has full knowledge that they’re avoiding a bowel movement and are doing so willfully. In most kids, retaining stool isn’t “volitional.” It’s habit.
READ: “Potty Regression,” “Potty Refusal,” “Not Fully Potty Trained": Why These Terms Should be Canceled
As pelvic floor therapist guru Dawn Sandalcidi, PT, explains in the M.O.P. Anthology, “Many children keep their pelvic floor muscles tightened all day. . . Eventually, all the holding inhibits the natural reflex to pee or poop, and kids may not even feel the urge.” On top of that, a stretched rectum compromises a child’s ability to sense the urge to poop.
Most cases of stool retention are more subtle than the term “retentive posturing” would suggest.
Even pelvic floor therapists, who are very attuned to these things, use biofeedback — with sensors placed on the child’s anus — to evaluate whether a child’s pelvic floor muscles are working appropriately.
Rome symptom #3 relies on parents to notice something that often is not even visible.
Looking back, I suffered from chronic constipation my entire childhood. I had no idea I was “withholding” poop, and certainly my parents had no clue.
Symptom #4: History of painful or hard bowel movements
This is another symptom that depends on parents having intimate knowledge of their child’s pooping habits.
Yes, some children will report pain to their parents. Some suffer so much that they’ll burst into tears on the toilet. But most kids are not inclined to say, “Mom, it really hurts when I poop.” I never said such a thing to my mom. I figured pooping was inherently painful, just a part of life.
As for hard bowel movements, most kids don’t scrutinize the contents of the toilet bowl, and once children start wiping on their own, parents typically aren’t standing by to observe.
Furthermore, many constipated children don’t even have painful bowel movements or expel hard stool. New, soft poop oozes around the hard mass, so what lands in the toilet bowl is mushy.
That's why "super loose poop" is included in my list of 12 Signs Your Child is Constipated. It's also why high-dose PEG 3350 (Miralax) clean-outs so often fail to resolve constipation.
Symptom #5: History of large diameter stools which can obstruct the toilet
Toilet-cloggers are an excellent way to assess constipation! I co-wrote an entire children’s book, Jane and the Giant Poop, about a girl whose XXL stool clogs the toilet.
However, the Rome IV list requires symptoms to have occurred “at least once a week for at least one month.” Even the most constipated kids may not be clogging the toilet on a weekly basis or evacuating stools that parents consider “large diameter,” a decidedly subjective measure.
Some kids never have giant stools. Instead, they poop multiple times a day, squeezing out a bit at a time.
Symptom #6: Presence of a large fecal mass in the rectum
Forget about the rest of the symptoms — a poop pile-up in the rectum is the defining feature of chronic constipation, the direct culprit in enuresis. But too often, these “large fecal masses” go undetected.
Often, a doctor who suspects constipation will feel the child’s abdomen in search of a mass. I do this myself. But I do so knowing that even in small, lean children, you often cannot feel a mondo mass of poop. I often read reports from referring physicians stating “no mass palpable,” as if such a description were definitive or even instructive.
Some physicians perform digital rectal exams — meaning, they stick their finger up the child’s bottom in search of rectal poop. I don’t do this (unless the child is under anesthesia for some type of surgery) because it’s 1.) uncomfortable for the child, 2.) alarming to the parents, and 3.) of limited clinical value.
The rectum curves behind and then over the bladder, in somewhat of a “C” shape, so you can only stick your finger up so far. Sometimes, the end of the rectum is empty but a hard mass sits up higher, beyond the reach of the doctor’s finger.
Relying on a physical exam to evaluate constipation status often steers families in the wrong treatment direction.
One mom in our support group said her daughter’s doctor “did an abdominal and rectal exam and told us we didn’t need to increase Miralax or do anything else constipation-related.” She knew her daughter, who struggled with both enuresis and encopresis, was constipated but had no idea how severely.
“The doctor suggested we see a psychologist,” she posted. “We were told the accidents were behavioral, developmental, and/or sensory.”
In my experience, the best way to confirm the “presence of a large fecal mass in the rectum” is to literally see it, on an x-ray.
To remove the guesswork, I x-ray all my enuresis patients. Now, I am absolutely opposed to the overuse of x-rays in children, but the amount of good a plain x-ray can do for a child with
enuresis far outweighs any risk, as I explain in the M.O.P. Anthology.
I’ve treated countless teenagers with enuresis whose constipation was never diagnosed. These kids suffer for years on end, missing out on sleepovers and summer camps, struggling with low self-esteem, anxiety, depression, even suicidal ideation.
All because the fecal mass in their rectum was never detected.
READ; Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
I should note that an x-ray is only valuable if the healthcare provider evaluating the picture knows what they’re looking for. Many don’t, for reasons I detail in the Anthology.
Often, doctors report a “moderate stool burden” and tell parents, “Oh, there’s always going to be some stool in the colon. Nothing to be concerned about.”
True, there’s always some stool in the child colon, but a child should not stockpile stool in the rectum. Because of its proximity to the bladder, the rectum is the only part of the colon that’s relevant to enuresis.
The colon is so large and stretchy that it can collect days, even weeks, of poop. When it comes to enuresis, you need to ask: Is the rectum functioning normally? The rectum is a sensing organ; its job is to signal to your brain that it's time to poop. The rectum is not a storage organ. If the rectum is storing poop, you have a problem.
In my experience, the most objective way to evaluate an x-ray for constipation is to measure the diameter of the widest part of the rectum. A normal, empty rectum will measure less than 3 cm in diameter. Most of my enuresis patients measure 6 cm or more.
I am often asked whether ultrasound can substitute for x-rays. In my opinion, no.
Ultrasound tends to provide a more focused view of the rectum, providing less than a full picture. I’ve reviewed the x-rays of numerous patients who, for various reasons, previously underwent ultrasound. In other words, I have two images to compare: one x-ray and one ultrasound. Often, the fecal mass is visible in the x-ray but not in the ultrasound.
Recently, a mom in our private support group, who lives in Australia, where x-rays are frowned-upon, posted that her daughter’s bedwetting persisted despite several months of enema treatment. This mom found it hard to believe her daughter could possibly still be constipated, and an ultrasound showed the girl’s rectum was clear.
I suggested she push harder for an x-ray. Eventually, she persuaded her doctor to order an x-ray, which indeed showed the culprit: a persistent fecal mass. (For these cases, I often recommend adding overnight olive oil enemas to the regimen.)
READ: Olive Oil Enemas for Childhood Constipation: An Old-School Treatment Gets Scientific Validation
Do I have data to prove x-ray is more reliable than ultrasound? Nope. I am only speaking from experience. That would be a good topic for a future study.
However, if one of my patients with enuresis has been declared “not constipated” based on an ultrasound, I will not believe it without an x-ray. The only reliable alternative would be an anorectal manometry exam.
Anorectal manometry is the real “gold standard” method of diagnosing chronic constipation. This method was used by Sean O’Regan, M.D. in his groundbreaking studies linking bedwetting with chronic constipation.
You insert a balloon into the rectum and inflate it until the child detects pressure. When you can inflate the balloon to its maximum capacity and the child feels nothing, it means the child's rectal tone is severely compromised.
Though you can’t literally see the “presence of a large fecal mass in the rectum” with anorectal manometry, the way you can with an x-ray, this method allows you to assess whether the rectum is functioning normally. Again, that’s the heart of the matter. If the test demonstrates seriously compromised rectal tone, you know a large fecal mass has been stretching the rectum. That's chronic constipation.
Incidentally, Dr. O’Regan noted in his studies that his patients’ anorectal manometry results correlated to a rectum stretched, on average, to 6.5 cm in diameter, consistent with my patients’ x-ray results.
Now, anorectal manometry, while highly dependable, is also cumbersome and no fun for the child. That’s why my clinic uses x-ray instead.
Bottom line: Each symptom listed in the Rome IV criteria does indeed point to constipation. However, relying on these criteria guarantees that countless cases of chronic constipation will be overlooked, to the detriment of children.
Often, families are sent on wild goose chases.
“At first, we were told our son’s enuresis was a behavioral regression related to the anticipated arrival of a new baby,” one member of our support group posted. “We wasted a bunch of time and money putting him in play therapy, since everyone was suggesting it was behavioral.”
Only after insisting on an x-ray, when their son was 4, did they get a constipation diagnosis from their doctor. “It’s particularly frustrating that everyone seems to jump to conclusions about behavioral issues when there are obvious physiological explanations.”
It’s bad enough when this happens to a 4-year-old. It’s far worse for a 14-year-old. Yet teens go undiagnosed all the time. One mom in our support group posted that no doctor had diagnosed chronic constipation in her son, despite his lifelong bedwetting.
“We were told he was a heavy sleeper,” she wrote.
Over the years, they tried bedwetting alarms, waking him up to pee, and fluid restriction, all remedies that do not address the underlying constipation.
Her son pooped daily, never complained of painful pooping, and did not have encopresis or toilet-clogging stools. She posted, “According to Rome IV, he only had one symptom — presence of a large fecal mass.”
But even that symptom went unnoticed until for years. The boy had his first x-ray at age 12, but the report stated “moderate stool.” Given the boy’s lack of evident pooping problems, the family remained in the dark about the cause of his enuresis.
He was x-rayed again at age 15, and I saw the film myself. The x-ray showed an extremely full rectum.
“We were totally surprised he was so clogged,” his mom told me.
Given the boy’s persistent bedwetting, and the thousands of cases I’ve reviewed, I wasn’t surprised at all.