Insights on Teenage Bedwetting, Encopresis and ADHD, Oil Enemas for Constipation
- schlos1
- 2 hours ago
- 6 min read
By Steve Hodges, M.D.,
Here are a few questions recently posted by members of our private enuresis/encopresis support group or emailed to me.
Q: My son is 15 and wets the bed 4-5 times per week. We are desperate. His bedwetting affects many areas of his life, as well as ours. Where should we start?
A: I have many teenage enuresis patients and understand your family’s stress and sense of urgency. I assure you: Your son’s bedwetting can be resolved! However, it’s important to understand the treatment process can take many months, if not longer, especially with teens.
I suggest your son read my blog post for teens — Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable — so he knows he’s not alone in this struggle and that we have many tools to get him dry.
Next, I’d ask your pediatrician to order an abdominal x-ray, called a KUB, to evaluate your son for chronic constipation.
Bedwetting is almost always caused by constipation that has gone untreated or under-treated. The rectum, enlarged by a poop pile-up, presses on the bladder nerves, causing the bladder to “hiccup” forcefully and empty without warning.
I use x-rays to minimize wasted treatment time. The more clogged the rectum, the more aggressive a bowel-emptying regimen I recommend.
Request that the radiologist comment on the extent of stool in the rectum, rather than higher up in the colon, and, ideally, measure rectal diameter. A measurement over 3 cm indicates enlargement due to constipation. Most of my enuresis patients have a rectum at least 6 cm in diameter.
Radiologists are trained to look for serious intestinal injuries and often note “a moderate amount of stool in the colon” while overlooking the giant mass of poop in the rectum. I’d ask your pediatrician to review the x-ray personally rather than rely on the radiology report.
I tend to start my teen patients with an enema-based treatment regimen that stimulates not one but two bowel movements per day — that is, the M.O.P.x or Multi-M.O.P. protocols, spelled out in the M.O.P. Anthology 5th Edition. (M.O.P.x involves a daily enema plus properly dosed Ex-Lax; Multi-M.O.P. involves multiple glycerin or docusate sodium enemas and no laxatives.)
In my experience, pooping twice a day is the most effective way to make a dent in the poop pile-up and resolve the accidents.
If a teen’s wetting persists after several months, and a follow-up x-ray shows the rectum is empty but still stretched, bladder medication can help. If that fails, bladder Botox will shut down the accidents.
It is essential for teens with enuresis to receive treatment, as they are highly unlikely to “outgrow” accidents at this age.
Q: Our son is 10 and has ADHD, and we've been dealing with encopresis for years. How can I get him to care about taking care of his body? He would rather do enemas than sit down on the toilet and try to have a spontaneous bowel movement.
A: It’s important for parents to understand that children with encopresis, whether or not they have ADHD, cannot feel the urge to poop. It’s not that your son “doesn’t care” about his body; he’s simply can’t poop spontaneously, at least not on a consistent basis.
Daily enema treatment is exactly what he needs to fully evacuate the rectum and allow it to heal. It's great that he's receptive!
In children with encopresis, the rectum has become stretched and floppy, losing both sensation and tone. These kids are stuck in a vicious cycle: They can’t feel the urge to poop, so even more poop piles up, further stretching the rectum and compromising its tone and sensation.
Children with a diagnosis of ADHD and/or autism have higher rates of chronic constipation and encopresis than neurotypical kids, but in my experience, these kids respond very well to enema-based regimens such as M.O.P. Adding a stimulant laxative such as senna (Ex-Lax) to the regimen, especially when your son tapers off enemas, can be hugely helpful.
Keep in mind that children with encopresis are at high risk for a recurrence if they stop treatment too soon or taper off enemas too quickly. I suggest following one of the Slow Taper regimens described in the Anthology (see page 68).
Give his rectum a chance to fully heal, with a judicious use of enemas and Ex-Lax, and I bet your son will resume pooping on his own!
Q: How much of constipation is genetic versus diet and exercise?
A: Having treated enuresis and encopresis for 20+ years, I’ve come to believe genetics matter more than diet and exercise. Other factors — a child’s temperament, maturity at the age of toilet training, and school restroom policies — play a role, too.
Certainly, a lifestyle of videogames and fast food won’t keep the digestive process humming. However, I have plenty of severely constipated patients who avoid highly processed foods and are high-level athletes.
At the same time, many sedentary kids with unhealthy eating habits are able to avoid constipation. Even if kids do carry around a belly load of poop, their genes enable them to steer clear of enuresis or encopresis.
In some children, constipation develops in infancy, when they switch from breastmilk to solid foods. Their stool becomes firmer, pooping becomes painful, and they instinctively start to override the urge.
More commonly, kids delay pooping when they toilet train. Here, maturity and temperament play a role. Some young kids have no problem using public toilets or asking their preschool or kindergarten teacher if they can use the restroom. Other kids won’t poop anywhere but home and are more prone to become constipated.
My research suggests children who toilet train before age 2 have triple the risk of developing chronic constipation and daytime enuresis. Many kids this young don’t grasp the importance of heeding your body’s signals when the urge strikes rather than 5 hours later. Whether these kids develop daytime wetting or bedwetting depends on how sensitive their bladder is to the enlarged rectum.
In general, constipation is a product of life in the 21st century: the modern diet, low activity levels, our concept of decency (you can’t just poop anywhere!), the modern toilet (we’ve abandoned the natural squat position), preschool, the glorification of early potty training.
It would not occur to our prehistoric ancestors to delay pooping when the urge strikes. But today’s humans, particularly human children, constantly postpone pooping.
I urge parents not to dwell on the origins of a child’s constipation – you may never figure it out. What matters is treating the condition — to resolve the child’s accidents and prevent a lifetime of pooping problems.
Q: My 7-year-old started with encopresis plus daytime and nighttime wetting. We’ve tried several treaments: enemas every other day, daily enemas, and now Multi-M.O.P. My son’s encopresis resolved quickly, and then his daytime wetting improved a lot — 18 dry days one month, 19 the next. But then he dropped to 5 dry days. He still wets the bed every night. What do you see in our x-ray? Our GI recommended a nightly mineral oil enema for a week. Do you agree?
A: Your x-ray shows rectal stool and dilation (stretching) but not impaction (a big mass of densely packed stool). I would give Multi-M.O.P. more time rather than try overnight oil enemas. I generally recommend oil only when I see impaction on an x-ray.
READ: Olive Oil Enemas for Childhood Constipation: An Old-School Treatment Gets Scientific Validation
You’ve seen great progress! You’ll get there. Improvement is rarely linear and setbacks are common. Resolving the “trifecta” — encopresis, daytime wetting, and night wetting —takes much longer than most doctors and parents expect, often over a year.
I typically start my trifecta patients with Multi-M.O.P. Partial treatment, such as enemas every other day, falls far short. Our free guide, Treating the Trifecta with M.O.P., explains this condition in more detail.