I’m a Pediatric Urologist. Sarah Silverman’s “The Bedwetter” Is Emotionally True But Medically Wrong

By Steve Hodges, M.D.

Sarah Silverman's "The Bedwetter": a lost opportunity to educate about enuresis

I’m a pediatric urologist, not a theater critic (that’s for sure). However, I’ve been inundated with reviews of Sarah Silverman’s musical The Bedwetter, thanks to a Google alert I’ve set for “bedwetting.”

As a work of art, The Bedwetter may indeed be “comic gold.” I’m not qualified to opine, and, anyway, I haven’t seen the off-Broadway show.

But I’ve read excerpts from the book it’s based on, The Bedwetter: Stories of Courage, Redemption, and Pee, along with interviews with Silverman about the musical.

As a doctor with many teenage bedwetting patients, I have two observations: 1.) Silverman’s story of shame and isolation rings true, and 2.) The Bedwetter, like many movies and TV shows, reinforces damaging myths about bedwetting.

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

Unfortunately, folks who see or read about the musical will come away believing that bedwetting, aka nocturnal enuresis, is caused by a small bladder, emotional issues, or both.

Children who suffer from enuresis will continue to miss out on the treatment that will halt their accidents and end their despair.

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

In reality, bedwetting is caused by chronic constipation. The rectum, enlarged by a pile-up of stool, encroaches upon the bladder nerves, causing the bladder to randomly “hiccup” and empty. The way to resolve bedwetting is to clean out the rectum and keep it clear on a daily basis, so it will shrink back to normal size and stop aggravating the bladder.

I know that’s not comic gold, but it happens to be true.

Sadly, even severe constipation routinely goes undiagnosed in children. Kids with enuresis are referred for counseling, art therapy, even psychiatric treatment when what they actually need is a regimen of suppositories and Ex-Lax.

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

Silverman’s dad, who meant well, sent his daughter to a hypnotist and to a doctor who prescribed Xanax. By age 14, Silverman was taking 16 Xanax a day.

Sarah’s mom took a hands-off approach. In the musical, she begs Sarah’s father to stop trying to “fix” their daughter.

“She’s not broken,” Sarah’s mom sings. “She’s just having trouble coping. The ground underneath her has shifted a bit. The clouds overhead haven't lifted just yet.”

While I appreciate the sentiment — obviously, children with enuresis are not “broken” — doing nothing has its own catastrophic consequences, allowing accidents to persist for years. The older kids get, the harder they work to hide their secret, and the more they despair.

READ: Why Some Kids Outgrow Bedwetting and Others Don’t

Silverman spontaneously stopped wetting at age 16. In that respect, she was lucky — most kids who are still wetting at 16 and are not properly treated will continue to wet the bed into adulthood. In fact, research shows, a 10-year-old, left untreated, has better-than-even odds of wetting at age 18. “Don’t worry, you’ll outgrow it” is not something a doctor should tell a child with enuresis.

READ: Don’t Assume Your Child Will Outgrow Bedwetting

If Silverman’s enuresis had been treated a decade earlier, she would have avoided a massive amount of suffering. In her book, Silverman describes a school overnight at age 12:

My mother helped me hide three diapers in the bottom of my sleeping bag and sent me off to go lead my fellow students camping. We were loaded on to the bus and on our way. When we got there, we lifted our gigantic packs on to our backs and up the mountain we hiked, led by me. I don't even think it was an hour before I started sobbing.

As quickly and casually as someone catches the flu, I caught depression, and it would last for the next three years.

I stopped being social. The thought of seeing my friends felt like a burden. All I could focus on was that I was alone in my body. That no one would ever see through the same eyes as me, not ever. It filled me with a loneliness that only deepened when I was not alone.

In elementary school, Silverman recalls, “all the doctors could offer was a diagnosis of enuresis — meaning my bladder was too small. I was tiny for my age, there was no medical cure but to grow.”

But that definition of enuresis is erroneous. Bedwetting is not caused by an underdeveloped bladder, and an excellent medical cure exists. (In my experience, the most effective treatment is the Modified O’Regan Protocol, known as M.O.P., and in certain cases, bladder Botox is warranted to finish the job.)

Unfortunately, Silverman never learned about any of this. In her book, she writes:

I finally grew, bladder and all. Around the time that I got my driver's license, and the final traces of Xanax left my system, and the cloud of depression lifted, my enuresis went away. Just as the doctor had predicted, more than a decade before.

No child should have to wait a decade for bedwetting to stop. But I fear that Silverman’s musical will only reinforce the notion that, eh, there’s nothing to be done.  

In fact, Silverman’s musical has spawned plenty of uninformed commentary.

A Huffington Post interviewer began with, “Bedwetting, although sounding quite comical, is actually a serious issue for those with clinical depression.”

Say, what?

It’s bad enough that folks think bedwetting sounds “quite comical” — it’s become a jokey term in politics, shorthand for “excessive worry.” But to conflate clinical depression with bedwetting is nonsensical.

Fact: Depression does not cause bedwetting, but bedwetting can cause depression.

In another commentary, a psychiatrist notes that “enuresis is a common problem child psychiatrists see in our offices” — again, suggesting a connection that doesn’t exist.

In one of her interviews about The Bedwetter, Silverman says, “The biggest thing I learned was that facts . . . really don't change people's minds. Feelings do. And that's, you know, obviously why art is so important.”

I agree that all too often, facts don’t change minds. Many adults, including physicians, simply do not believe a clogged rectum causes bedwetting — despite the studies that prove it, despite x-rays that show an enlarged rectum encroaching upon the bladder.

The perception of bedwetting as a psychological condition remains stubbornly rooted in popular culture and in the psychiatric literature.

In her book, Silverman finds an upside to her years of enuresis: the absence of stage fright.

Maybe that daily shame had ground away at my psyche, like glaciers against the coastline, so that somewhere in my consciousness, I understood that bombing on stage could never be as humiliating. My early trauma was a gift, it turned out, in a vocation where your best headspace is feeling that you have nothing to lose.

Not everyone comes away from enuresis with confidence. One mom told me her son was repeatedly hospitalized for suicidal ideation — until, at age 16, he was finally treated for constipation that had gone undiagnosed all those years.

Another mom, grateful that constipation treatment had resolved her teenage son’s enuresis, told me he nonetheless remains wounded, emotionally, by his decade of bedwetting. She described her son as reluctant to develop close relationships — “as fragile as a ripe pear.”

I’m sorry Silverman was failed by her doctors, and I wish she knew the facts about enuresis.

She could have used her platform to save other kids from the condition that traumatized her for so long.