Q&A with Dr. Hodges: Teenage Bedwetting, Enema Tapering, and Potty Training to Prevent Constipation

By Steve Hodges, M.D.,

Children who potty train before age 2 have triple the risk of developing chronic constipation than those who train later.

How can you potty train to prevent constipation? What if your 17-year-old is still bedwetting? How do you wean your child off enemas without having accidents return? How to convince a teacher your child's accidents aren't due to attention-seeking? How long does it take a stretched rectum to shrink back to normal size? Is it worth treating a child who has to pee constantly but doesn’t have accidents?

These are all good questions posted in our private Facebook support group. I address them below.

Q: My older child has struggled so much with enuresis and encopresis that I would do anything to avoid all that misery with my youngest. What advice do you have to potty training to prevent constipation?

A: You’ll find useful suggestions in our free download 7 CRAZY IMPORTANT Rules for Potty Training Success and more detailed guidance in The Pre-M.O.P. Plan. Among the key recommendations: 1.) Wait until your child is ready to toilet train (I define “ready” in the book). 2.) Let your child lead the way, 3.) watch closely for pee holding, and 4.) provide a tall footstool for pooping.

A mom in our private support group who followed the Pre-M.O.P. regimen with her youngest recently posted:

With my 3.5 y.o., we watched output like a hawk. He was on Pre-M.O.P, and toilet trained absolutely seamlessly 6 months ago. Never has even a hint of a daytime accident and is90%  dry overnight. It has been so nice to experience what it is like to toilet train with a normal, healthy bowel on board. The knowledge we have gained from M.O.P. is invaluable.

Q: What’s the best way to educate my daughter’s school about accidents and constipation treatment? Her teacher seems to think she’s “seeking attention” when she has an accident or asks to use the restroom “too many times.”

A: Hand our free K-12 Teacher’s Packet on Student Toileting Troubles to your child’s teacher, school nurse, and school counselor. Give it to the principal, too!

Also useful for school personnel: The Mental Health Professional’s Guide to Enuresis and Encopresis. Few teachers and counselors receive training on toileting issues, so they often default to believing the root cause is behavioral or psychological.

Q: I need help for my 17-year-old who is going to college next year but still bedwetting. Where should we start?

A: Start with abdominal x-ray (called a KUB) to assess the extent of your teen’s constipation (and to guide you in a different direction in the rare case her rectum is empty, as explained on page  40 of the M.O.P. Anthology). Make sure the doctor who evaluates the x-ray looks for stool in the rectum, rather than elsewhere in the colon.

I use x-rays to guide treatment. The more clogged and enlarged the rectum, the more aggressive a M.O.P. regimen is warranted. (In my practice, most teens start with Multi-M.O.P. or M.O.P.x, explained in the Anthology). We often add bladder medications and, if needed, a Botox injection.

It’s not easy to start treatment at age 17, but dryness can still be achieved! M.O.P. for Teens and Tweens, written specifically for kids, explains the process and ensures teens that plenty of other kids their age share their struggles.

Q: How to get an older teen (16) to buy into M.O.P. when they’ve already tried everything that was supposed to work but didn’t?

A: I feel for these kids! My teen patients have been through so much, and I don’t blame any teen for being skeptical of M.O.P.

Most bedwetting teens were assured for years, “Don’t worry, you’ll outgrow it.” Most were told they are “deep sleepers” or have a “small bladder” or that they’re just stressed or have poor eating habits or drink too much caffeine.

I explain to my fed-up teen patients why all those supposed “causes” of bedwetting are wrong, and why their previous treatments, such as medication or bedwetting alarms, didn’t work. X-rays make a big impression on teens. Kids can literally see how their enlarged rectum is crowding out their bladder.

I also assure my teen patients that if M.O.P. doesn’t get them 100% dry, bladder Botox can — but that we can’t start with Botox because it doesn’t work if the rectum is full.

I explain all this in my blog post Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable. Maybe you can get your teen to read it!

Q: How long will it take my child’s rectum to shrink back to normal size once she’s empty and stays that way?

A: In my experience, it takes about 3 months for a dilated rectum, if fully emptied and kept empty, to retract and regain its tone and sensation. But the timeline will differ from kid to kid.

It’s critical to understand that accidents often stop well before the rectum is healed. Completing the full M.O.P. regimen will dramatically lower the odds that accidents will recur. Many families, excited the child is finally accident-free, stop treatment as soon as accidents stop, but this is an express ticket to a recurrence.

Q: Once my child has success with M.O.P., how do we wean off the enemas so accidents don’t come back?

A: My rule of thumb: The longer it took your child to become accident-free on M.O.P., the longer you should wait to taper, and the more gradually you should proceed.

Early in my career, I advised my patients to taper off enemas after 7 accident-free days and nights (assuming they’d done 30 consecutive days of enemas). However, many kids relapsed. Now I err on the conservative side and often suggest waiting to taper until the child has gone 30 days and nights accident-free.

Also, I used to recommend a tapering regimen that went, month by month, from daily enemas to every other day to twice a week — the original regimen developed by Dr. Sean O’Regan. However, I’ve learned that to avoid a recurrence, many patients need one of the Slow Taper regimens described on page 68 of the Anthology.

For children who are accident-free but not reliably pooping every day on an osmotic laxative, I recommend taking Ex-Lax on the no-enema days during the tapering process.

Q: Is it worth treating a child who has to pee constantly and desperately but doesn’t have accidents? At what point is this concerning, and what treatments do you recommend?

A: Urinary frequency and urgency are signs of chronic constipation — see 12 Signs Your Child is Constipated — and left untreated, these symptoms can progress into daytime enuresis and/or bedwetting. A daily osmotic laxative may be enough to keep these kids pooping daily and reverse the symptoms. If a month of that approach doesn’t help, shift to daily senna (Ex-Lax) or the Pre-M.O.P. regimen.