By Steve Hodges, M.D.
Could Prozac be an effective treatment for bedwetting?
That’s the question posed by a new study published in the Journal of Urology. The short answer is no. Prozac (fluoxetine) fared poorly in the 12-week trial, halting overnight accidents in just 10.7% of cases and providing partial relief in 21%.
Yet the authors, from Mansoura University in Egypt, arrived at a rosier conclusion, asserting Prozac "could be considered as a reasonable treatment" for difficult cases.
A medical communications outlet further spun the results in article titled “SSRI Helps Hard-to-Treat Bedwetting." A physician commenting in the Journal of Urology even called the results "impressive."
This study and commentary demonstrate so much of what the medical profession gets wrong about nocturnal enuresis, aka bedwetting.
First, the researchers set a ridiculously low bar for success. We owe our patients more. When three months of treatment leads to zero improvement in 68% of subjects and only resolves enuresis in 10%, that's not impressive. That's a flop.
Second, treating enuresis with antidepressants amounts to barking up the wrong tree. Enuresis is not caused by a brain-chemistry imbalance. It’s caused by chronic constipation. Antidepressants, not matter how “well tolerated,” have no role here.
Third, the study authors did not use a reliable method for assessing constipation, assuring most cases would be missed. From my perspective, those “hard-to-treat” enuresis were never treated properly in the first place, so they only appeared resistant to treatment.
Rather than scour the universe for enuresis therapies that might randomly cure a few kids, we should focus on refining treatments that tackle the condition’s root cause: a clogged, dilated rectum that is aggravating the bladder nerves.
Let’s start with what the study’s authors get right: Kids with enuresis suffer. As the researchers wrote, “nocturnal enuresis is associated with negative psychological, emotional, and social implications for children and their families.” What’s more, successful treatment improves a child’s “self-esteem and mental health.”
Agreed! When accidents stop, parents tell me, “This has given us our lives back and saved my son’s dignity.” Or, “My son was finally able to go to an overnight party with friends.”
The authors also correctly note that the first-line treatment options — bedwetting alarms and drugs that suppress bladder contractions or overnight urine production — have a high failure rate. Even when drugs “work,” accidents recur when patients stop the medication. With demospressin, a urine-suppressing drug, fewer than 20% kids achieve sustained dryness.
For these reasons, the authors argue, we must search “for novel and more efficient therapies.”
I disagree. In virtually all cases, novel treatments aren’t needed. Efficient treatment for enuresis already exists and has existed for nearly 40 years, thanks to the diligent research of Sean O'Regan, M.D.
Dr. O'Regan's approach involves using daily enemas to clean out the child’s clogged rectum and keep it clear until the rectum has healed. Once the rectum has retracted to normal size and stops aggravating the nearby bladder nerves, accidents cease — no drugs needed.
I adopted (and modified) Dr. O'Regan's approach a decade ago, calling the regimen the Modified O'Regan Protocol (M.O.P.) and saw my success with enuresis increase dramatically. Today, I treat patients with five different variations of M.O.P., described in detail in the M.O.P. Anthology.
Resolving constipation is a process, not an event. For the challenging cases, it’s best accomplished, in my experience, by combining Dr. O'Regan's step-down enema regimen with osmotic or stimulant laxatives. The recipe will differ for each child. Tinkering with this recipe — adjusting the type, timing, and dosage of existing products — is where doctors should focus their efforts, not trialing drugs that alter brain chemistry.
That said, for the most persistent enuresis cases — for example, when the rectum has emptied but remains dilated and the bladder nerves remain aggravated — there actually are two "novel" surgical procedures that will resolve bedwetting and daytime wetting: bladder Botox and the InterStim device. But I do not turn to these procedures until the child has implemented an aggressive bowel-emptying regimen.
Standard enuresis treatments fail not for mysterious reasons but because they don’t address the underlying constipation.
A bedwetting alarm can solve the laundry problem by conditioning the child to wake before wetting. But children with a healthy rectum and stable bladder don’t need to pee overnight. They enjoy dry nights and a full night’s sleep.
Desmopressin is likewise a Band-Aid. I’ll prescribe it as a stop-gap measure for sleepaway camp or overnight class trips or to older patients who are treating constipation aggressively but aren’t yet reliably dry. (Sometimes, an emptied rectum remains stretched, so accidents persist for a while.)
Desmopressin can give kids a psychological boost, but my patients understand the drug’s limits. One mom reported her teenage son chose to stop desmopressin because he wasn’t satisfied with the “fake dry.” He felt he could only gauge progress on his enema/laxative program without drug-aided dryness. Suppressing urine production will never be a solution to nocturnal enuresis because the condition is not caused by an overproduction of urine.
Likewise, antidepressants will never be a solution. Scientists who trial antidepressants for enuresis seem convinced there’s a significant group of bedwetting children who are not constipated — the “hard-to-treat” cases. The Journal of Urology authors indicate they excluded constipated children from their study, including only unexplained cases.
But on what basis did they exclude those kids? How how did they assess constipation?
They asked the children’s parents to maintain a bowel diary, presumably excluding children with infrequent bowel movements. This method is highly unreliable, to say the least. Children can be “regular” yet monumentally clogged, as I explain here. Newer stool just wends its way around the hard stool mass, fooling parents and doctors who don’t look further.
Many severely constipated children have multiple bowel movements a day; they just don’t fully evacuate. Incomplete evacuation, not pooping frequency, defines constipation.
Feeling a child’s belly is likewise inadequate. Even a small, wiry child can harbor a large stool mass not palpable to the physician.
Only two methods reliably detect constipation: x-ray and anorectal manometry, a test that involves inflating a small balloon in the child’s bottom to detect rectal tone.
I x-ray all my enuresis patients and measure their rectal diameter. A normal rectum measures less than 3 cm. In my enuresis patients, even those who are “regular,” the rectum is typically stretched beyond 6 cm. The bulge is what aggravates the bladder nerves, triggering accidents.
Anorectal manometry was the favored diagnostic tool of Dr. O’Regan back when he demonstrated the constipation-enuresis link. In his research, Dr. O’Regan noted that constipation in enuresis patients was “extremely common though often unrecognized.”
In fact, Dr. O’Regan did not recognize constipation in his own son, a 5-year-old with nocturnal enuresis. When the boy underwent anorectal manometry, the practitioner told Dr. O’Regan, “The kid has no rectal tone.” Resolving the constipation halted the boy’s bedwetting, as it does in virtually all my patients, even the "hard to treat" kids.
Once in a blue moon, I have a wetting patient with a clear x-ray, and I evaluate the child for other medical conditions. For example, two patients turned out to have tethered cord syndrome, a neurological condition that requires surgery. But in nearly all cases, a clogged and stretched rectum explains the wetting. In the majority my patients, the child's constipation was overlooked by the referring physician. Many of these kids have been on desmospressin for ages and tried alarms to no avail.
The Egyptian researchers argue that we must keep searching for new treatments because "approximately 50% of children are "refractory to treatment."
That's flat-out wrong, a ridiculous exaggeration. My profession's standard treatments don't work because they don't address the cause of the problem. In my experience, almost no child is "refractory" to treatment, and those who who don't achieve complete dryness with M.O.P. can get there with bladder Botox. By the way, in children who remain constipated, accidents return when Botox wears off, additional evidence that it is a clogged, enlarged rectum that causes enuresis. That's why Botox is a last resort.
With some kids, it's difficult to chip away at the constipation, because their rectum has been stretched for years and their habit of delaying bowel movements is deeply ingrained. That doesn't mean you give up. It means you adjust the procotol — you add Ex-Lax, implement overnight olive oil enemas, shift from phosphate enemas to liquid glycerin or even three docusate sodium enemas per day (yes, that's a thing, and it's safe). The list goes on. In a handful of cases, a child needs bladder Botox to get over the hump.
When a child is declared "refractory to treatment," this signals to me that the child has not been treated appropriately.
If doctors x-rayed their enuresis patients and prescribed more aggressive and creative constipation treatments, they’d find more success — and recognize the folly in testing antidepressants.
I fear that headlines such as “SSRI Helps Hard-to-treat Bed Wetting” will drive researchers and parents further in the wrong direction.