"My 12-year-old's bedwetting won't stop. What now?"
By Steve Hodges, M.D.
Can a child who poops every day and does not complain of stomachaches be severely constipated?
What’s the next step when your 12-year-old can't get past 14 dry nights a month, despite months of aggressive bedwetting treatment?
Why would daytime pee accidents worsen after switching constipation regimens?
These questions, recently posed by parents via email or in our private support group, touch on common challenges and misconceptions surrounding childhood constipation.
If your child struggles with enuresis or encopresis, you may find the answers helpful.
Q: My 6-year-old has struggled with encopresis and enuresis for 18 months, and things took a nosedive when school started. An enema helped a lot, but now his accidents and behavior are getting worse. Our GI insists he can't be constipated because he poops once or twice a day and doesn’t have stomachaches. We can't get in to see a urologist for another eight months. Can you review his x-ray and recommend where to start?
A: Your son's x-ray shows a rectum packed with stool—not surprising, given his symptoms. I'd start with a twice-daily glycerin enema regimen, such as Multi-M.O.P. or J-M.O.P., following the instructions in the M.O.P. Anthology.
There's no reason to wait eight months to start treatment. With consistent rectal emptying, his daytime accidents should improve quickly, though nighttime wetting will likely take much longer.
Your son's x-ray also illustrates a point I can't emphasize enough: Children can be severely constipated even when they poop every single day and have no discomfort.
Traditional methods of diagnosing constipation — like feeling a child’s belly or asking parents about the child’s pooping habits and history — routinely miss these cases, as I explain in Even Severe Constipation Goes Undiagnosed in Bedwetting Children. Here's Why.
The fact that one enema temporarily improved your son’s symptoms is encouraging. A more intensive daily enema regimen, followed for several months, should produce much better results.
I also expect his behavior to improve. Children who can't control their bladder and bowels often feel embarrassed, frustrated, and demoralized, and those feelings can affect their behavior.
Many parents report dramatic behavior changes once constipation resolves and accidents diminish or disappear. You can find several examples in When Constipation Treatment Improves a Child's Behavior or Mood.
Q: My 12-year-old can't get past 14 dry nights a month, despite six months on Multi-M.O.P. His latest x-ray shows an empty rectum with a diameter of 4 cm. We've added oxybutynin, but what else can we try? Before M.O.P., desmopressin didn't help.
A: I'd continue Multi-M.O.P. and give desmopressin another try. With your son's rectum in much better shape, the medication is far more likely to work now than it did when he was clogged up.
Desmopressin works differently from oxybutynin, and the combination can be more effective than either medication alone. I explain the differences in Bedwetting Medication: When It Works, When It Doesn't.
Medication won't heal the rectum, but it can provide dry nights—and a welcome confidence boost—while the rectum continues to shrink and the bladder nerves recover.
He's made substantial progress. I'd stay the course!
Q: My 7-year-old started M.O.P. a year ago for encopresis, daytime wetting, and bedwetting. A few months ago, we switched to Multi-M.O.P. and then J-M.O.P. Her poop accidents have stopped, daytime pee accidents are less frequent, and she's occasionally dry overnight. A recent Miralax clean-out gave her a completely dry day. We're continuing J-M.O.P., but should we add anything else?
A: You're on the right track. For children with the trifecta — the challenging combination of poop accidents plus daytime and nighttime enuresis — I recommend starting with a twice-daily enema regimen such as Multi-M.O.P. or J-M.O.P. (which includes overnight oil enemas). Since you've only recently stepped up to that level of treatment, you're still in the early stages of tackling the trifecta.
This is exactly the kind of progress I'd expect at this point. An occasional dry night is a bonus. Most children with the trifecta don't achieve consistent nighttime dryness until daytime pee and poop accidents have stopped completely.
Periodic oral clean-outs can help, as you've seen. However, the benefits are often short-lived, so be sure to resume the enema regimen afterward.
You could also try bladder medication. If it doesn't help, that's a clue her rectum is still pretty full.
I'm in favor of throwing the kitchen sink at these cases, but there's a limit to how quickly you can empty and heal an enlarged rectum. Consistency and patience matter as much as finding the right regimen.
Q: My 6-year-old has always wet the bed and began having daytime pee accidents a year ago. We started with 10 days of J-M.O.P., using two glycerin-water enemas (GWE) per day plus an overnight oil enema, then switched to Multi-M.O.P. with two liquid glycerin suppositories (LGS) daily. The LGS produce much less stool output than the GWE, but I was wary of continuing with GWE because I know larger enemas can aggravate the bladder. Now, her daytime wetting has actually worsened. What should we do now?
A: I favor sticking with what works. I'd return to J-M.O.P. for a full month, then reassess. My rule of thumb is to give a new regimen 30 days before judging its effectiveness.
I wouldn't assume the larger glycerin-water enemas were aggravating her bladder. You only used them for 10 days, which isn't long enough to judge their effect.
However, if you're still concerned about bladder irritation, you could reduce the volume of glycerin and water, aiming for a happy medium: enough to produce substantial stool output without aggravating the bladder.
That flexibility is a key advantage of GWE over LGS. Liquid glycerin suppositories, whether store-bought or DIY, come in fixed doses, whereas GWE can be prepared in a wide range of volumes.
The M.O.P. Anthology explains how to adjust GWE volumes.