“Potty Refusal” or “Lying” About Accidents? It’s Physical, Not Behavioral

Children who appear to "refuse" to use the toilet simply aren't getting the signal.

Editor's note: This post was updated in 2026 to reflect Dr. Hodges' current treatment recommendations.

By Steve Hodges, M.D.

As a pediatric urologist, I treat dozens of medical conditions, but only two generate family tension: encopresis (chronic poop accidents) and enuresis (daytime or nighttime wetting).

When a child has blocked kidneys or refluxing ureters, there’s no talk of power struggles or emotional exhaustion. But when a clinic visit pertains to accidents, family friction is often palpable.

Parents will tell me their child “refuses" to use the toilet (“and then she has an accident 3 minutes later!”) or denies having an accident (“How can he not notice?”). Or that the child "won't listen" to their body. Children sit quietly, clearly feeling distress and embarrassment.

These parents are at the end of their rope — often they've tried tried sticker charts, patience, consequences, counseling — and their kids know it.

I understand the frustration. From the outside, these kids' behavior looks willful. But in reality, the behavior isn’t behavioral at all. The child's signals to pee and poop have simply gone haywire, thanks to a stool pile-up in the rectum. In other words, chronic constipation that has gone overlooked or under-treated.

Once families understand what actually triggers toileting accidents, the whole picture changes. Treatment stops being about correcting behavior and starts being about restoring sensation and control. When you fix the physical problem, the “behavior” resolves on its own. Kids stop feeling blamed for something they can’t feel, and family tension melts away.

It’s not surprising that this physical problem is so often missed, even by doctors. Chronic constipation doesn’t look the way most people expect.

Many severely backed-up children poop every day, even multiple times a day. Many have soft stools and no belly pain. From the outside, everything appears “normal,” so parents (and doctors) are none the wiser.

READ: Even Severe Constipation Goes Undiagnosed in Bedwetting Children. Here’s Why.

But an x-ray tells a very different story.

I x-ray all of my patients with enuresis, and the images I show families are often a turning point. Folks can clearly see the rectum packed with stool and enlarged, often to twice the normal diameter.

I point out that newer, softer stool simply slides around this hard mass. So, a child can appear “regular” while significant constipation has quietly taken hold. Over time, the stretched rectum becomes floppy and loses sensation. The child can't feel the urge to poop, and in children with encopresis, stool drops out, without the child noticing. These kids aren't being defiant or careless. Their body isn’t sending clear signals anymore.

In children with enuresis, the enlarged rectum presses on and irritates the bladder nerves, prompting the bladder to empty without warning, day or night. Because control comes and goes, parents may assume the accidents are intentional or due to laziness. In reality, the signals are simply unreliable.

Learning all this changes will change the family dynamic entirely, even before the child begins treatment to resolve the constipation.

"Seeing the x-ray really decreased our frustration with our 5-year-old son," one mom in our support group posted. "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.”

Once families understand that accidents are driven by a physical problem, not behavior or lack of motivation, I shift to explaining the goal of treatment: We have to empty the rectum completely and consistently, so it will shrink enough to regain sensation and stop bothering the bladder.

That’s the idea behind the Modified O’Regan Protocol (M.O.P.), the enema-based treatment approach I use with my patients and explain in detail the M.O.P. Anthology. M.O.P. is not about “making kids try harder.” It’s about healing the rectum, so the bladder and bowel can work the way they’re supposed to.

Once children start M.O.P., parents quickly grasp why sticker charts, bribery, behavioral counseling, and even dietary changes were never going to work. A clogged rectum simply will not respond to the promise of M&Ms or more screen time. Even oral laxatives, on their own, typically aren't up to the job.

READ: Children with Encopresis and Enuresis Deserve the Best Treatment, But Most Aren't Getting It

The healing process is slow, and progress is rarely linear. Setbacks are common — a child may have a stretch of dry days, followed by more accidents — and can cause frustration.

Even when parents understand why their children have accidents, they may wonder why their child won't acknowledge they they couldn't feel the accident coming (or even acknowledge having had an accident). One mom in our support group 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?

I suspect 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.

Amanda Arthur-Stanley, Ph.D., a Colorado school psychologist who is knowledgeable about enuresis and encopresis, urges parents not to perceive their child as “lying,” a term with negative connotations. She says there are several reasons a child might not acknowledge an accident. “Maybe the child feels their parents will be disappointed by the accident and wants to minimize the disappointment.” That's an explanation we hear frequently from pelvic floor physical therapists.

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," Dr. Arthur-Stanley says.

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 just to be difficult or to make you mad.

I believe it's helpful for share that message directly with their kids. Our children’s books — Bedwetting and Accidents Aren’t Your Fault and Emma and the E Club — help children understand that accidents are a purely medical medical.

Often, all this becomes clear only after the hard work is done and accidents have stopped. A mom in our support group reflected on her 7-year-old's of treatment for encopresis and enuresis.

When the girl started M.O.P., at age 7, after years on the Miralax merry-go-round and a failed hospital clean-out, family tension was through the roof. Now she has been accident-free for months.

“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.”