By Steve Hodges, M.D.
This week a mom emailed: “Years ago I bought your book, but I put it aside, thinking and hoping that my son would outgrow the bedwetting. Well, he hasn't, and now he's almost 12, and we're both really determined to work on this now.”
The edition of The M.O.P. Book she bought ceased publication six years ago (and has since been updated four times!), so she has waited a long time for her son to wake up dry.
I understand why! Families are commonly told by doctors, “Don’t worry, he’ll outgrow it.” And since most kids do eventually stop bedwetting without treatment, waiting seems reasonable.
No one thinks their child will be among the small percentage whose bedwetting persists into middle school, high school, or beyond.
But I urge parents to shift their thinking.
If you have a child aged 4 or older who wets the bed, I’d operate on the assumption your child won’t outgrow the accidents any time soon. Rather than avoid treatment, I’d jump on it. Enuresis is highly treatable, especially with a regimen such as the Modified O'Regan Protocol (M.O.P.), and the sooner you get started, the better.
From my perspective, as a pediatric urologist with loads of teenage bedwetting patients, nobody benefits from a strategy of waiting and hoping. (Well, nobody but the diaper companies.)
Certainly, waiting does not benefit kids, who, with age, become self-conscious about wearing pull-ups, who miss out on birthday sleepovers and school overnights, and whose self-esteem suffers more than their folks may realize. As a 15-year-old boy recently told me, “My accidents make me feel trapped in my own body, like I don’t have control.”
Parents feel distress, too, as their kids pull back from social events and need ever larger (and more expensive) pull-ups.
If you’re contemplating treatment for your child but haven’t yet taken action, consider these facts:
•After age 9, most children with enuresis don’t spontaneously outgrow the accidents.
In other words, if you have a 5th-grader with enuresis, the odds are quite poor that your child will stop wetting without treatment.
Medical organizations such as the American Academy of Pediatrics emphasize that “only” 2% of teens wet the bed. This tiny percentage is construed as evidence that your child will not be among them.
But 2% represents a lot of adolescent kids — over 860,000 in the United States alone and 26 million children worldwide! These numbers make enuresis in ages 10 to 19 more common than autism. About 1 in 50 teens have enuresis. With autism, it’s 1 in 54.
What I’m saying is, just because most kids outgrow enuresis does not mean that your child will outgrow enuresis.
Many of my patients have been told, “No kid goes off to college in diapers.” But this is false!
Last week a 19-year-old student asked, via email, if I would work directly with her university’s health service on enuresis treatment. (“I can't even speak with my parents about this issue,” she wrote, explaining that her parents had shamed and beaten her.)
I’ve done numerous video consultations with college students and their parents. And I’ve treated countless high school students with enuresis who, after years of waiting and hoping, were absolutely panicked about the prospect of bringing pull-ups to college.
All these kids were wetting the bed at age 5. All expected the accidents to stop long before high school. But that did not happen.
•You can’t predict which kids will outgrow enuresis.
Certainly, there are red flags. Children who wet the bed nightly and/or have daytime accidents have a “significantly greater chance of persistent [bedwetting] in adult life,” a study of 16,000 children found.
I receive many emails that begin, “My 12-year-old has never had a dry night in her life.” Odds are, overwhelmingly, that this child will continue wetting without treatment.
With younger children, you can’t predict so easily. Enuresis is almost always caused by chronic constipation, as I explain in the M.O.P. Anthology, and some kids become less constipated simply with maturity. For example, they may become more comfortable pooping at school or in public restrooms, and that may be enough to halt the wetting.
On the other hand, it may not be enough. Some kids have highly sensitive bladders, and even a slightly enlarged rectum will aggravate their bladder nerves, triggering accidents. So, even if these kids poop daily and become somewhat less constipated on their own, or with mild constipation treatment, the wetting may persist.
Why wait around to find out? Why not proceed with full-on treatment and nip it in the bud?
If a 4- or 5-year-old is on a trajectory with fewer and fewer overnight accidents, then sure, maybe that child will soon be dry every night and holding off on treatment might be reasonable. But if a kindergartener is wetting nightly, I would not hesitate to implement a regimen such as M.O.P.
•Over time, chronic constipation becomes more difficult to treat.
Halting accidents requires 1.) cleaning out the clogged rectum and 2.) keeping the rectum clear on a daily basis for months, so it can shrink back to size, regain sensation and tone, and stop aggravating the bladder nerves.
The longer the rectum remains clogged, the more challenging both tasks become.
Over time, the mass of stool accumulates, dries out, and hardens. At some point, even a daily enema plus a daily osmotic laxative may not suffice to break up the mass and dislodge it.
As one mom in our private support group posted, “I feel like I am chipping away at a cement block with a garden hose.” When M.O.P. didn’t make a dent, her child shifted to Double M.O.P.: overnight oil enemas to soften impacted poop, followed by a morning stimulant enema to wash out the remnants.
Another mom wrote: “I thought if we can put a man on the moon, we can get impacted stool out of my child and move on. My biggest surprise has been that for my son, this is a long process.”
The healing process lasts even longer when the child’s habit of delaying poop becomes deeply ingrained. Enemas can clean out the rectum, but they are a short-term treatment; ultimately, kids need to be able to poop on their own.
Most kids who delay pooping don’t even realize they’re doing it. They keep their pelvic floor (pooping) muscles clenched all day. Some kids relax these muscles when they should be contracted, and vice versa.
“Eventually, all the holding inhibits the natural reflex to pee or poop,” explains Dawn Sandalcidi, PT, a Colorado physical therapist who lectures internationally on childhood incontinence and hosts our Zoom course for medical professionals.
Some children need pelvic floor therapy, in addition to daily enemas, in order to restore complete bowel function.
Treating chronic constipation early and aggressively not only saves kids from years of accidents, discomfort, and distress but also dramatically shortens the treatment period.
•Bedwetting disturbs children’s sleep.
Many kids with enuresis wake overnight because they’ve soaked through their pull-ups and need to change their PJs and sheets. That scenario obviously disrupts sleep, no small issue. Loads of research links insufficient sleep and sleep disruption, to compromised learning and school performance, behavior problems, stress, anxiety, and other mental health issues.
But even children who sleep through their wetting episodes get shortchanged in the sleep department. It’s just not obvious.
Many parents assume their bedwetting child sleeps more deeply than the average child, but research actually shows the opposite. Several studies have detected more overnight restlessness — that is, less REM sleep — in kids with enuresis compared to children who are dry at night. This is likely because their bladders are going haywire all night.
One study, presented a while back at a meeting of the International Children’s Continence Society (ICCS), directly connected bedwetting with compromised learning.
A pediatric urologist a university in Hong Kong, Dr. Chung Kwong Yeung, monitored 95 enuresis patients, comparing their cognitive function over time with that of 46 children who were dry at night.
Compared to their peers, the children with enuresis scored lower on standardized tests of attention, learning speed, and short-term and long-term memory. However, six months of bedwetting treatment significantly improved all these measures of cognitive function.
At the time, a pediatric urologist at Harvard Medical School, Dr. Stuart Bower, said: “The findings are important because treatment of bedwetting should help patients achieve more than getting over the stigma of being wet. We now know that treatment can improve cognition and can therefore be expected to improve their school performance, self-image, and their interactions with peers and family members.”
Bottom line: Treat bedwetting now, not later.
Many parents downplay the impact of bedwetting, insisting, “It doesn’t bother my child” or “In our family, we don’t make a big deal over it.”
In my experience, enuresis causes kids far greater distress than their parents recognize, and the blow to a child’s self-esteem is, itself, good reason to begin treatment.
But there are so many other good reasons to resolve this highly treatable condition.
And no good reasons to simply keep waiting and hoping.