By Steve Hodges, M.D.
If there’s one critical lesson I’ve learned in my 20+ years of medical practice, it’s this: Encopresis and enuresis must be taken seriously and treated aggressively.
Doctors routinely underestimate the distress that poop accidents and wetting accidents cause families, and they continue to push useless treatments, such as endless doses of PEG 3350 (aka the Miralax merry-go-round). Medical providers assume most kids will eventually “outgrow” accidents and (I’m guessing) don’t feel an urgency to step up treatment because, well, accidents aren’t life-threatening.
Except that sometimes they are.
This week a mom in our private enuresis/encopresis support group posted about her almost-7-year-old’s four-year ordeal with encopresis. The family lives in Canada, but their experience could have taken place anywhere. The mom posted:
My daughter literally leaked stool all day long. Had severe abdominal pain and was no longer able to attend school. Her paediatrician kept pushing Restoralax [PEG 3350] and telling us to increase the dose. We saw two paediatricians, a paediatric NP, and had one ER visit. They just continued to recommend PEG 3350, no matter how many times we went back.
Finally, paediatrician agreed to Ex-Lax but wasn’t able to give it more than once per week due to “dependence issues.” No other solution was ever presented to us. Just to keep giving the PEG 3350 and she will outgrow it eventually. Also said accidents were due to her “strong willed” personality and "lack of emotional connection" to her mother.
They also recommended psychotherapy, as it was a “behavioural disorder”. We did that for a good 3 years too. Every type of therapy — equine, dog, art, play. And saw a child behavioural therapist “specializing” in toileting. It only continued to get worse and worse. The accidents caused her severe emotional distress to the point of self-harm and suicidal ideation. We were started on anti-depressants. Our next step was anti-psychotics.
More than three years into their journey, a pelvic floor therapist recommended the Modified O’Regan Protocol (M.O.P.), the enema-based regimen I advocate for encopresis and enuresis. Right away, the girl’s accidents dramatically reduced, and she had a 50-day stretch with no accidents at all, along with the typical (and fixable) setbacks. The regimen wasn’t even difficult for the girl, who self-administered the enemas with her mom’s supervision. The mom continued:
Once we started M.O.P. all these behaviours improved, and she was able to wean off all antidepressants. . . M.O.P. literally saved my daughter’s life. She is back at school and thriving!
In the midst of implementing M.O.P., the family got a long-awaited appointment with a pediatric GI doctor at a children’s hospital. The mom kept the appointment, hoping for reassurance from the specialist that she was on the right track. Reassurance is not what she got:
Doctor told me that enemas are not recommended as kiddos become obsessed/preoccupied with having things up their bums. Refused to give us an x-ray, saying the colon will always have stool in it. Felt her tummy and said she’s not constipated, as it’s soft. Referred us to the dietitian and told us to stop the enemas and use Ex-Lax instead, as I was insistent that Restoralax was of no help.
By this time, the mom felt confident enough to continue with M.O.P. on her own and to recognize the doctor's recommendations as unfounded. However, countless parents, understandably, don’t have the knowledge or confidence to defy their doctor's recommendations so they persist with laxative-only treatment, no matter how useless or detrimental.
This family’s story encapsulates nearly all the medical community’s misconceptions about encopresis, enemas, and laxatives. In this post, I will address these misunderstandings and provide links for further reading to help families educate themselves.
•Myth: Encopresis is caused by a “strong-willed” personality and family discord and is a “behavioral disorder.”
Reality: Encopresis has but one cause: chronic constipation. When stool accumulates, the rectum stretches and loses the sensation and tone needed for daily evacuation. Poop just drops out of the child’s bottom, without the child feeling it. No amount of behavioral counseling, art therapy, or equine therapy will resolve the stool mass that is causing accidents.
Enuresis, too, is caused by chronic constipation. The enlarged rectum encroaches upon and aggravates the bladder nerves, causing sudden, forceful bladder contractions, day or night. Contrary to popular opinion, stress, anxiety, or “willful behavior” play no role in wetting accidents.
Sadly, these myths are perpetuated by the psychiatry literature. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA), includes entries for both enuresis and encopresis. The “research” on which these entries are based is shamefully flawed.
Encopresis and enuresis do not qualify as “mental disorders” any more than chronic urinary tract infections do. If you clean out the rectum and give it enough time to heal, accidents will stop.
Helpful reading: Enuresis and Encopresis Are Not “Mental Disorders.” Let’s Remove Them from the DSM-5 (blog post) and The Mental Health Professional’s Guide to Enuresis and Encopresis (free guide).
•Myth: Ex-Lax and enemas cause dependence.
Reality: Research shows long-term, daily use of senna-based laxatives such as Ex-Lax is safe for children and does not cause dependence. Enemas don’t cause dependence, either.
Ex-Lax is a useful tool for children with a deeply ingrained habit of overriding the urge to poop. I commonly recommend stimulant laxatives in conjunction with daily enemas (the M.O.P.x regimen, described in the M.O.P. Anthology) and during the period when a child is tapering off enemas.
If a child poops only after enemas or Ex-Lax, this simply means the rectum hasn’t fully recovered from being stretched. Dependence is something different. A patient with type 1 diabetes, for example, will always be dependent on insulin to live. A child will not always rely on enemas or suppositories to poop, though it may take many months to taper off them. In the meantime, if enemas are what it takes for a child to fully evacuate every day — well , that’s much healthier than not pooping.
Helpful reading: Constipation Treatment for Children and the Myth of Enema “Dependence” (blog post) and Stimulant Laxatives: Options, Timing, and Dosing (section of M.O.P. Anthology 5th Edition pp. 104-105).
•Myth: Children will “outgrow” accidents eventually, so there’s no point in aggressive treatment.
Reality: You absolutely cannot assume a child will spontaneously stop wetting the bed or having daytime pee or poop accidents. I have a large caseload of teenagers who can attest to that. Almost all these children developed enuresis and/or encopresis by age 4, but their symptoms were dismissed or undertreated. All these kids were assured by doctors, “Don’t worry, you’ll outgrow it.” But they didn’t.
The children least likely to outgrow bedwetting are those who have accidents nightly and those who also have daytime pee or poop accidents.
It is my firm belief that children do not benefit from waiting around for that magic day when they will wake up dry or stop having daytime pee or poop accidents. That day may or may not come, and in the meantime, many children miss out on sleepovers and camps, suffer embarrassment and teasing, and experience a blow to their self-esteem.
Helpful reading: Don’t Assume Your Child Will Outgrow Bedwetting (blog post), Why Some Kids Outgrow Bedwetting and Others Don’t (blog post), and Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable (blog post).
•Myth: Children become “obsessed/preoccupied with having things up their bums.”
Reality: That’s flat-out ridiculous. I’ve prescribed enemas for thousands of patients and have never heard such a thing. I don’t know what else to say on that subject.
Most children, even those initially apprehensive, tolerate enemas just fine. In fact, the Canadian mom posted, “The first week took some coaching. But after day 4, it was smooth sailing. My daughter became braver each time and has pretty much done her own enemas since the second or third week.”
Helpful reading: The Enema Rescue Guide: 12 Strategies to Help Your Child Get Comfortable with M.O.P., included in the M.O.P. Anthology 5th Edition.
•Myth: X-rays are of no use for detecting constipation, because “the colon will always have stool in it.”
Reality: X-rays are extremely useful for detecting constipation, whereas feeling a child’s belly is highly unreliable.
X-rays are one of only two diagnostic methods I consider reliable (the other is anorectal manometry). While it’s true the colon will always have some stool in it, the rectum, the end of the colon, should be empty and have a diameter of under 3 cm. Stool in the rest of the colon is irrelevant.
X-rays aren’t usually needed for encopresis, since constipation is literally the only cause of poop accidents. In most cases, an x-ray won’t tell you anything you don’t already know. However, I do x-ray all my enuresis patients, to rule out the rare alternative causes of wetting and to show skeptical parents the rectal clog that is pressing against their child’s bladder. I will x-ray encopresis-only patients if their progress on M.O.P. plateaus, and I want to see how much stool is sitting in the rectum.
As for feeling a child’s abdomen, even tiny, wiry children can harbor hard masses of stool that you simply cannot feel but that are visible on an x-ray.
Helpful reading: Even Severe Constipation Goes Undiagnosed in Bedwetting Children ( blog post) and Yes, Your Child Can Poop Every Day and Still Be Constipated (blog post).
•Myth: Dietary changes will resolve encopresis.
Reality: Obviously, the highly processed foods common in the developed world play a role in our society's high rates of chronic constipation, and all of us would be better off eating “real” food. However, by time a child is chronically constipated to the point of having pee or poop accidents, the rectum can’t be healed with dietary measures alone. No amount of broccoli or kale or “clean eating” will evacaute the harden mass stretching the rectum and pressing against the bladder nerves.
Plenty of children who avoid processed food, even dairy and gluten, end up in my clinic, anyway. Genetics plays a huge role in chronic constipation, and there are many other cultural reasons why children become constipated.
Helpful reading: Why Is Your Child Constipated? Because We Live in the 21st Century (blog post) and Is Dairy a Culprit (page 50 of the M.O.P. Anthology 5th Edition).
The same week the Canadian mom posted in our support group, a member from the United Kingdom posted a similar story about her son, now age 10, who struggled with encopresis for years. She posted:
We were just told to aim for one good poo per day, and he’d outgrow it. So, I consistently undertreated him for a long time, as he pooed most days.
We were finally referred to a consultant who prescribed more osmotics, which lead to even bigger accidents. By then I had talked to my son about enemas, and we read Emma and the E Club. Two days after his 10th birthday, my son requested to carry on with enemas. There is no way this child could handle these accidents any longer. He was showing signs of actual depression. For 4 years my son suffered, and on M.O.P., his life quality massively improved after 4 days. We still have a very long way to go, but for now he is slowly regaining his old happiness as accidents have slowed massively.