By Steve Hodges, M.D.
Could a sleep disorder, rather than constipation, be the root cause of bedwetting in some kids?
What’s the right age to treat bedwetting?
What if you want to try M.O.P. but your doctor opposes enemas?
These are among the questions I address in today’s blog post. They were posted by members of our private Facebook support groups, and they’re questions I often hear in my clinic. In addition to my own guidance, I’ve included input from other parents who know what they’re talking about!
Q: We are struggling to help our 13-year-old son. We find senna pills around the house that our son has pocketed and not taken. Enemas don’t happen nightly, and my husband worries they will cause “psychological damage.” Originally, we waited with faith that our son would outgrow bedwetting. Now we are trying to have faith that M.O.P. will work. Is it possible that some kids wet at night because of constipation and others because of sleep problems? Maybe we should do a sleep study?
A: Bedwetting is not caused by sleep disorders or deep sleep. I’ve had many patients, mostly teenage boys, who landed in my clinic after various sleep-related diagnoses. When I x-ray these kids, they prove to have a clogged and enlarged rectum, just like my other enuresis patients.
One family spent thousands of dollars on a bedwetting treatment center that advises parents to spray their children with cold water “to wake them out of their deep sleep.” Another teen was first diagnosed with narcolepsy, then anxiety, and then sleep apnea, and he spent three months sleeping with a sleep-apnea mask, to no avail. An x-ray at my clinic showed severe constipation. Several months of daily enemas, in conjunction with overactive-bladder medication, got him dry.
Rather than search far and wide for alternative and unfounded explanations like a sleep disorder, I urge you to get an x-ray for your son, ideally with a measurement of rectal diameter. I don’t need such a measurement to tell me whether a child is constipated — I’ve seen enough x-rays to recognize a dilated rectum. However, a precise measurement might help persuade your son that the root cause of his wetting is indeed constipation. A normal rectum measures less than 3 cm in diameter. In most of my enuresis patients, the rectum is stretched beyond 6 cm.
If your son isn’t following through on M.O.P., you can’t fairly judge whether the treatment is effective. Unfortunately, half-measures don’t suffice — not when a kid’s rectum has been dilated for over a decade. Achieving dryness overnight isn’t a matter of faith. It's a matter of a.) finding an enema/laxative combination and dose that empties the child’s rectum and b.) sticking with the program long enough for the rectum and aggravated bladder nerves to heal.
It’s not enemas that cause psychological damage in kids or feelings of despair; it’s under-treated bedwetting. When accidents finally cease, and kids get their lives back, they regain lost self-esteem.
You have the empathy of other parents who’ve been in the same boat!
One mom posted: “There has to be total consistency. Our son was 11 when we started M.O.P., and it took 2.5 years for him to get totally dry. Adding Ex-Lax on top of enemas got him to 50% dry and then increasing the dose got us all the way there. Now my son only does Ex-Lax. Kids have to stay empty for quite a while so the bladder nerves can calm down. There is no way any other program would have helped. X-rays are the proof. When your son gets dry, his self-confidence will improve so much.”
Another chimed in: “I have two boys. One followed M.O.P., and it worked for him. With my older son, we are almost 6 years into protocol because he refuses to follow it consistently. If we hadn’t had success with my younger son, I might be doubting M.O.P., too. Noncompliance is a problem, and I think different personalities handle it differently.”
Q: My 4.5-year-old daughter frequently wets her pants, holds her wees, and has a full nappy overnight, tummy aches, and itchy bottom. The GPs brush it off and say not to do anything until she’s 5. She poops once, if not twice, a day. Will M.O.P. still help?
A: Absolutely. All the symptoms you describe are among the “12 Signs Your Child is Constipated.” Plenty of kids who are “regular” nonetheless have a clogged rectum; soft poop just oozes around the hardened mass, fooling adults into thinking the child isn’t constipated. In fact, pooping two or more times a day is itself a sign of constipation, indicating the child isn’t fully evacuating with each bowel movement. Constipation is about incomplete emptying, not how often a child poops.
Accidents in a 4-year-old should never be brushed off. Left untreated, chronic constipation tends to worsen, not vanish, especially in children with both daytime and nighttime enuresis.
Kids who outgrow bedwetting are typically those who had a mild case of enuresis — in other words, infrequent accidents and only at night. By contrast, children with daytime and nightly wetting have a “significantly greater chance of persistent [bedwetting] in adult life,” one study of 15,000 children in Hong Kong found.
The Hong Kong researchers concluded that kids with enuresis should be treated “at a much earlier age” than is commonly practiced. I agree. I believe any toilet-trained child with daytime accidents should be treated, regardless of age. Accidents are not part of any maturation process and shouldn’t persist longer than a few weeks after toilet training.
I treat bedwetting at age 4 with M.O.P. In my experience, accidents signal trouble to come, and nobody wins when treatment is delayed.
Q: My 15-year-old grandson had great success with Fleet phosphate enemas, but he switched to large-volume enemas because he found phosphate irritating and because he was not having consistent SPs [spontaneous poops]. With large volume, he has now been wet three nights in a row, despite having good output. What now? He also takes Miralax at night and Ex-Lax in the morning.
A: I’d switch to a small-volume enema such as a liquid glycerin suppository (LGS) or docusate sodium mini-enema (Enemeez). In some kids, the extra volume over-stretches the rectum, so accidents persist even when the rectum empties. For kids with a long history of enuresis, especially teens, I prefer smaller-volume enemas.
One option is M.O.P.x: a daily small-volume enema — such as a store-bought or homemade LGS or docusate sodium mini-enema — plus enough daily Ex-Lax (or other senna-based stimulant laxative) to trigger an SP. Glycerin is more gentle than phosphate and is just as effective for many kids. Increasing your grandson’s Ex-Lax dose may help with his SPs. (M.O.P.x is discussed on p. 92 of the M.O.P. Anthology.)
Another option is for him to skip the Ex-Lax and self-administer two or three 283-mg Enemeez per day. Like LGS, docusate sodium mini-enemas are gentle and small, but unlike liquid glycerin, docusate sodium can be used rectally up to three times a day for kids age 12+, according to the U.S. Food and Drug Administration. (See the Enemeez label.)
It’s not easy for teens to fit in two or three enemas per day, but among my patients, this regimen is proving highly effective for motivated teens who can manage it.
Q: After 3 years taking Miralax, our daughter still has a lot of soiled pants, but our pediatrician opposes enemas. I don't feel confident enough to go against the doctor’s advice. What do you advise?
A: I know it’s tough to disagree with your physician. Research finds that even confident, assertive people feel too anxious or intimidated to challenge their doctor’s opinion. In one survey, only 14% of patients said they would openly disagree with their doctor. Most folks fear being labeled a “difficult patient.”
But if your doctor’s treatment plan hasn’t succeeded after three years, why continue? Who benefits?
In The Physician’s Guide to M.O.P., written for my fellow physicians, I make the case for enema-based treatment based on decades of research and my own experience. There’s zero evidence to suggest a daily enema regimen is unsafe, and plenty of evidence demonstrating enemas are both safe and far more effective than Miralax. M.O.P. involves over-the-counter products and does not require a doctor’s supervision.
Over the years, many parents in our private support groups have found themselves in your quandary, only to conclude their physician had no scientific basis for opposing M.O.P. and had nothing better to offer. Some searched out a new physician; mostly implemented M.O.P. on their own.
As one mom posted: “My son started withholding at age 2. Doctors only prescribed Miralax. We could have saved 12 YEARS of bedwetting, laundry, sleepless nights, shame, no sleepovers, and money spent on pull-ups — if only we had done enemas. My son is finally dry at age 14. We didn't need any local support for M.O.P. It's not easy to go against doctors, but if they are continuing to prescribe ineffective treatment why do it? Please don't wait too long."
Q: My 6-year-old daughter weaned off enemas four months ago by adding 3 Ex-Lax squares daily. I’ve now added back one enema per week because she’s having tummy aches and less daily output, which I interpret as back-up. To prevent accidents from returning, should I increase Ex-Lax or keep the enema?
A: You’re wise to stay vigilant and be proactive. For now, I’d continue with the weekly enema plus enough daily Ex-Lax to stimulate a productive bowel movement. Kids with a history of enuresis and/or encopresis are quite prone to filling back up, so I’d err on the aggressive side to keep accidents at bay.
Once she’s pooping more and her stomachaches cease, drop the enema and maintain daily Ex-Lax for at least a few months before tapering. You may want to add an osmotic laxative at that time.
Remember, your goal isn’t just to keep your daughter’s rectum clear but also to help her poop on her own every day. While enemas are more reliable than Ex-Lax for triggering a bowel movement — kids usually poop within 10 minutes — once accidents stop, Ex-Lax (which kicks in 5 to 8 hours later) is more useful for instilling the pooping habit because kids must take the initiative to respond to their body’s urge to poop.