By Steve Hodges, M.D.
As a pediatric urologist, I treat dozens of medical conditions, but only two seem to generate family tension: encopresis (poop accidents) and enuresis (wetting).
When a child has blocked kidneys or refluxing ureters, there’s no talk in my exam room of emotional exhaustion or power struggles or a child’s “stubbornness.” Clinic visits feel matter-of-fact: Stuff happens, let’s get it fixed.
But when a clinic visit pertains to bedwetting or daytime accidents, the friction between parent and child is often palpable.
Some parents express exasperation openly. They’ll report their child’s “refusal” to use the toilet (“and then she has an accident 3 minutes later!”) or to acknowledge an accident has happened (“The smell is so obvious. How can he not notice?”).
I hear similar frustration in our private Facebook support groups, where parents have posted:
Why does a 9-year-old insist he doesn’t need to pee when he shows obvious signs?
Why do kids lie about having accidents?
I know bedwetting distresses my teenage son, but when I ask why he doesn’t follow through on his treatment, he just shrugs.
I understand the frustration! Enuresis and encopresis are misunderstood conditions that prompt kids to behave in ways that seem to defy logic. What’s more, these conditions carry great stigma in our culture, burdening the whole family.
When a child has accidents, it’s often parents who are judged and blamed — by other parents, relatives, school directors — for “failing” to properly toilet train. In some cases, a school has suspended, or threatened to suspend, my patient until accidents cease. Often, parents feel distressed because their child can’t participate in birthday sleepovers or school trips. Sometimes, parents internalize society’s judgment and blame themselves.
No wonder the parents feel so much pressure for the accidents to resolve.
Kids feel loads of pressure, too. Many have been blamed or shamed, suspected — even by physicians — of “acting out” or being “lazy.” As one mom in our private Facebook support group posted, “Our pediatrician said the problem is a control issue, and my son will stop having accidents when he is ready.” I hear this all the time, even though it’s untrue.
Our culture has a long history of attributing enuresis and encopresis to psychological or behavioral issues. In countless movies, TV shows, and books, bedwetting serves as short-hand for anxiety. The kid who wets the bed is always the one neglected by a parent! (See "Borgen" and Fleishman is in Trouble, to name two examples that my co-author, Suzanne Schlosberg, pointed out.)
In popular culture, I have yet to see bedwetting portrayed for what it is: a medical condition, straight up.
By the time parents land in my clinic, many have exhausted a long list of strategies and remedies — promises of screen time and M&Ms, midnight wake-ups, dietary restrictions, fiber and probiotics, oral laxatives. And still: wet sheets, soiled underwear, a child who seems unwilling to take responsibility for the most basic bodily functions.
These folks are at the end of their rope, and their kids know it.
In the best-case scenario, I’m able to ease the family’s anxiety by presenting a simple fact: enuresis and encopresis are caused by chronic constipation.
More specifically, a pile-up of stool has stretched the rectum, which, in turn, has aggravated the bladder nerves. The child’s bladder has gone haywire, emptying without warning even when it’s not full. In the case of encopresis, the enlarged rectum has lost the sensation and tone necessary to fully evacuate, so poop just drops out of the child’s bottom.
In other words, accidents are no more “psychological” than an ear infection.
For many families, a visit to my clinic is the first time they’ve heard enuresis and encopresis are medical conditions, and this is welcome news.
An abdominal x-ray demonstrates, in black and white, that the child’s rectum is clogged with stool. The rectal diameter measurement, usually at least twice the normal 3 cm, confirms the diagnosis of chronic constipation.
For some families, this knowledge changes the family dynamic entirely. A child who has been shamed and blamed for years suddenly gets a reprieve.
As one mom in our support group posted, “Seeing the x-ray really decreased our frustration with our 5-year-old son. We thought his accidents were a behavior or anxiety issue.” She stopped rewarding her son for dry nights, and the boy stopped trying to hide his wet underwear from her.
“Now he doesn’t have to feel disappointment for not earning a reward when he has no control over it," she continued. "We all have better attitudes, as we view the wetting as a medical issue.”
But often, parental frustration does not end with the confirmation of an enlarged rectum. The parents in our private support group are well aware that accidents are beyond their kids' control. They know all about impacted stool and overactive bladders. Many are better informed than their doctors.
Yet these folks, too, are not immune from frustration, as their children sometimes behave in ways that seem baffling and counterproductive.
Often, tensions revolve around the child’s “refusal” to use the toilet.
After all, the key to resolving a stool pile-up is for the child to fully evacuate the rectum every day and to poop when the urge strikes, not 2 hours or 2 days later. What’s more, the treatment I recommend — the Modified O’Regan Protocol, aka M.O.P. — involves enemas and laxatives to stimulate the urge to poop and keep stool soft so pooping doesn’t hurt. Kids on M.O.P. know why they’re using these tools! They know the goal is to poop following the enema and, to poop spontaneously, and to pee often.
So why on earth would they “refuse” to use the toilet, only to have an accident just minutes later?
Here’s why: The child isn’t actually refusing to cooperate. In reality, and despite outward signs to the contrary, the child does not feel the urge to pee or poop.
Kids with an overactive bladder simply don’t experience the normal sensation to pee. Those of us with a healthy bladder sense the urge gradually, as the bladder fills up. We may override the urge at first, because we’re in the supermarket or driving on the highway, but eventually the signal becomes strong enough that we’re forced to find a toilet.
But kids with enuresis may feel nothing at all. Then suddenly their bladder has a forceful contraction, like a big hiccup. But it’s too late. The child can’t get to the toilet, and the bladder empties.
Similarly, children with encopresis can’t feel the urge to poop, nor do they feel the poop coming out of their bottom. Often, kids become sensitized to the odor and don’t smell what is horrifying everyone else in the room.
This is hard for parents to process, so they may ask why their child is “lying” about having accidents. One mom posted:
My son had a poop accident in class and kids made fun of him. Later, when I asked him if he felt the urge, he said yes, but he just didn’t go to the bathroom. In the past, he has said, “going to the bathroom is boring.” I suspect he either didn’t feel the accident coming or it came on too fast for him to stop it. Still, why wouldn’t he just tell me that?
Good question! My guess is the boy was embarrassed to admit he couldn’t control his bowels, and it’s less mortifying to insist that using the toilet is “boring.” Countless parents have reported the “boring” explanation to me.
But I’m a urologist, not a psychologist, so to get a more complete and nuanced answer to this question, I consulted Amanda Arthur-Stanley, Ph.D., a Colorado school psychologist who is knowledgeable about M.O.P.
Dr. Arthur-Stanley urges parents not to perceive their child as “lying,” a term with negative connotations. There are several benign reasons a child might not acknowledge an accident, she says: “Maybe the child feels their parents will be disappointed by the accident and wants to minimize the disappointment.”
Or, maybe the child doesn’t fully understand that they’re not registering the cue to poop. “Maybe their brain is trying to make sense of what happened and find another plausible explanation.”
As a parent, Dr. Arthur-Stanley suggests, acknowledge your child’s explanation, even if it doesn’t make sense to you.
“You could say, ‘Yes, when you’re doing something fun, it’s hard to use the bathroom,’ and then offer an alternative explanation about how the urge comes on too fast to make it to the toilet. ‘Because it’s boring’ might just be the child’s reflexive response.”
If you and your child have been locked in power struggles, Dr. Arthur-Stanley advises, back down on reminders to use the toilet or to follow other aspects of treatment, even if it means accepting more accidents for a while.
Your reminders, even if offered gently, may be perceived by your child as nagging and may ratchet up their anxiety over the accidents.
“Let your kid breathe,” she says. “Everyone is doing the best they can — kids and parents.”
Among parents of older children, frustration often arises when the child doesn’t comply with enema treatment. One mom wrote:
“How (in the ever-loving heck) do we motivate our teens to follow their treatment plan? In order to get dry overnight, my teen needs to step up. Constantly reminding him to do his enemas and take his Ex-Lax is annoying to both of us. I know the bedwetting distresses him, but when I ask why he doesn’t follow through, he just shrugs.
I understand! It defies logic that a 10th-grader would blow off the very treatment that will resolve the condition that’s ruining his life.
But then, enuresis sucks. What teenager wants to give himself enemas? I understand why a kid might prefer to avoid treatment, maybe in hopes the accidents will spontaneously stop.
Most of my teen patients have been told by doctors for years and years, “Don’t worry, you’ll outgrow it.” They’ve been waiting forever for that magic day. Even though I’ve explained why that day is unlikely to come, they may still be hoping I’m wrong. Maybe they’re thinking: My friends don’t have to deal with enemas and Ex-Lax. Enough with this b.s. I just want to feel normal for a week.
Parents may need to let their teens learn for themselves what happens when they stop treatment. In M.O.P. for Teens and Tweens, I quote a 15-year-old who stopped her enemas after several months. “I started wetting again and was angry at myself and discouraged. I asked my mom, ‘Have I ruined all my progress?’ What motivated me to start again was remembering how good it feels to wake up dry, with no sheets to wash, just relaxing in bed.”
Progress on M.O.P. can be excruciatingly slow, especially for teens. A rectum that’s been stretched for a decade won’t spring back in 6 weeks. I can see why a kid would get demoralized and throw in the towel.
Remember, too, that the adolescent brain is still maturing.
“The last area of our brain to develop is the prefrontal cortex, the part that controls our ability to plan, to inhibit our impulses, to think about consequences of our behavior,” says Dr. Arthur-Stanley. “That’s part of why it can be hard for teens to stick with the treatment plan,”
Try to empathize with your teen, knowing they probably feel shame and embarrassment about their condition, no matter how much you emphasize that it’s not their fault.
“Let your teen know you’re there to support and problem-solve,” says Dr. Arthur-Stanley.
If your teen doesn’t want to discuss treatment face to face, find a different avenue of communication, like texting or chatting. “Your teen could send you a poop emoji when they’ve used the toilet,” Dr. Arthur-Stanley suggests.
M.O.P. for Teens and Tweens includes a simplified monthly tracking chart designed for older kids. Some teens fill it out on their own and hand it to a parent once a month, with little or no discussion.
Ask your child what approach might work best for them. “It’s important for kids to have a voice in how the process goes,” Dr. Arthur-Stanley says. “Engage in conversations that are not punitive or rushed, and help your child generate ideas.”
Families dealing with enuresis and encopresis have a lot to contend with. Between the accidents and the treatment, these conditions can be all-consuming. Parents are sometimes so desperate for the accidents to resolve — for their child to attend a slumber party or feel confident at school — that managing the child’s treatment becomes the focus of daily life.
If this has happened to you, try to cut yourself and your child some slack.
“As a parent, you want to track all the details, but keep it in perspective. Yes, pooping is super important, but it’s just one small part of your child’s life. Your child is a whole person with thoughts, feelings, and ideas — things that have nothing to do with stool withholding or bedwetting.”
Give your child the benefit of the doubt, no matter what you suspect. I promise: No child wets their pants because they don’t feel like getting out of bed. No child avoids the toilet for the purpose of making you mad. No child skips an enema because they don’t care about resolving their bedwetting.
Often, all this becomes clear only after all the hard work is done and accidents have ceased. A mom who recently “graduated” from our private M.O.P. support group wrote a farewell post reflecting on her family’s year of treatment for encopresis and enuresis.
When her 7-year-old daughter started M.O.P. — after years of useless Miralax treatment and a failed hospital clean-out — she was having daily poop and pee accidents, and family tension was through the roof. Today, the girl has been accident free for months, has weaned off Ex-Lax, and has a liquid glycerin suppository every few days.
“We went from daily outbursts and heightened anxiety to cooperation and logical discussions,” the mom reported. “Today my daughter is happy, cooperative, and grateful for the peace and freedom M.O.P. has afforded us. She’s a different kid than she was a year ago.”
This mom described the “cycle of shame and frustration” that stopped when she and her husband realized their daughter wasn’t purposefully ignoring the urge to go.
“It’s physical, not behavioral,” she wrote. “Knowing that has made all the difference.”
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and coauthor of Bedwetting and Accidents Aren't Your Fault, Jane and the Giant Poop, and The M.O.P. Book: The Proven Way to Stop Bedwetting and Accidents in Toddlers Through Teens.