By Steve Hodges, M.D.
In my clinic and my private Facebook support group, parents often ask: When will my child start pooping on their own? I’m worried that she’s only pooping with an enema or Ex-Lax.
In fact, some parents worry more about their child’s lack of spontaneous pooping than they worry about the child’s pee or poop accidents!
Let me assure you: Pooping with the help of enemas and/or laxatives is far healthier than not pooping (or pooping incompletely). With appropriate treatment, such as the Modified O'Regan Protocol, children with enuresis and/or encopresis will regain the ability to poop on their own, as I explain in this week’s blog post.
I also cover questions about bedwetting medication and Multi-M.O.P., a regimen detailed in the M.O.P. Anthology 5th Edition. Multi-M.O.P. can be implemented with two daily liquid glycerin suppositories (LGS), homemade or store-bought, or docusate sodium mini-enemas (such as Enemeez). For stubborn cases of enuresis and/or encopresis, Multi-M.O.P. may well be the most effective treatment regimen I've seen in my two decades of medical practice. As more parents implement this protocol, I naturally receive more questions.
Q: When doing a version of M.O.P. without any oral laxatives, is there a risk of impaction higher up in the digestive system? We’re considering Multi-M.O.P., but I worry about leaving out any top-down approach.
A: There’s no reason for concern. The colon is all one pipe, and the only cause of blockage is incomplete evacuation of the rectum, the end of the colon.
When a child habitually delays pooing and the rectum becomes clogged, over time poop can accumulate earlier (higher up) in the colon. Imagine an assembly line with the slowest worker at the end: The products will pile up at the end and then start backing up earlier in the line. However, if the worker in the final position starts working super fast and gets back on track, the assembly line will flow as well as before.
Multi-M.O.P. is an especially effective way to empty the rectum and get things flowing again.
When I review x-rays of chronically constipated children, I often see stool accumulation higher up in the colon. However, that accumulation has no bearing on the child's accidents. It is only stool in the rectum that causes problems. It is the rectum that sits in close proximity to the bladder, so an enlarged rectum can press against and aggravate the bladder nerves. In kids with encopresis, the rectum is so stretched and floppy (and void of sensation) that poop just drops out, without the child noticing.
Back in the 1980s when Dr. Sean O’Regan developed the daily enema regimen that M.O.P. is based on, Miralax (PEG 3350) didn’t exist. Dr. O’Regan treated his enuresis and encopresis patients with enemas only — and with tremendous success. I have many patients, especially encopresis patients, who do better with enemas only, no laxatives.
If your child’s stool is firm even on Multi-M.O.P., an uncommon scenario, then it’s find to add an osmotic laxative, such as Miralax or lactulose. But there’s certainly no need to worry about impaction without it.
Q: My 5.5 year old has encopresis, no wetting. Before M.O.P., he took Ex-Lax and Miralax, but had frequent poop accidents and smears. Two GI doctors suggested more and more laxatives. We’re now on day 35 of Standard M.O.P., and his accidents have drastically decreased. However, he has only had three spontaneous poops since starting M.O.P. Should we try something new? I just don’t understand why he can’t poop when he’s on the toilet trying and the poop is obviously right there.
A: Stay the course! I recommend adjusting a child's regimen only if the child goes 30 days without progress, but your son has made great progress.
In a child with chronic constipation — that is, a clogged and stretched rectum — the rectum’s sensation and tone are compromised. So, your son’s ability to sense and respond to the urge to poop are compromised, too. The scenario you describe is totally unsurprising.
In my experience, there’s no benefit in trying to “make sense” of a child’s pooping behavior. I focus on treating the constipation. Once your son’s rectum is fully emptied and has had time to heal, your son will poop on his own and fully evacuate daily. It takes about three months for a stretched rectum, once emptied, to shrink back to size.
Once your son’s encopresis is fully resolved with enemas, he may be a good candidate for adding a stimulant laxative such as Ex-Lax during the tapering period (on the enema-free days). This will ensure daily evacuation and help get him in the habit of responding to his newly restored urge to poop. Then, he can wean off the Ex-Lax.
Q: My son is on Multi-M.O.P. for very persistent enuresis, and we added desmopressin three weeks ago. He still wakes up to a pull-up full of urine. Our last x-ray, about five months ago, showed his rectum was empty but dilated. What now?
A: I would continue with Multi-M.O.P. and add an anticholinergic medication to the desmopressin. I also suggest a new x-ray, to see if his rectum is still empty.
Desmopressin (DDAVP) is a drug that essentially tricks the kidneys into producing less urine at night, whereas anticholinergic drugs, such as Vesicare, calm bladder overactivity. In some children, the combination halts bedwetting better than either medication alone.
However, medication of any kind is far more likely to be effective if the rectum is empty — these drugs generally aren’t worth taking otherwise. That’s why I suggest a more recent x-ray and continuing with Multi-M.O.P. Some children, unfortunately, manage to fill back up despite strict adherence to a daily enema regimen. Other children succeed in emptying but need extra time for the rectum to retract and for the aggravated bladder nerves to stop triggering random bladder contractions. An x-ray can provide insight into where your child stands right now.
In general, desmopressin (DDAVP) has a poor track record, halting accidents in only about 30% of kids who take it. Even then, the drug only works as long as you take it, so some folks refer to good results as a “fake dry.” Still, desmopressin can offer a psychological boost, which can be hugely helpful for some kids and provide motivation to continue with their enema regimen.
Keep in mind that desmopressin, like all enuresis drugs, does not address the root cause of enuresis: chronic constipation. In fact, some enuresis medication, including older anticholinergics such as oxybutinin, actually cause constipation. However, newer anticholinergics are less constipating. I would discuss the various options with your doctor.
Q: My 5 y.o. is doing Multi-M.O.P., with two LGS per day. Should we be looking for a spontaneous poop? Or is pooping after the two enemas sufficient?
A: With Multi-M.O.P., we wouldn’t expect a spontaneous poop. The idea with this regimen is to focus aggressively on emptying the rectum — nothing more. With two daily bowel movements stimulated by the enemas, it’s unlikely the child would be pooping more.
Once your child has is 100% accident-free, day and night, and you tapering, he should start pooping on his own. If that doesn’t happen right away, laxatives can help.
Q: I'm treating my son for encopresis. Does a small poop accident on Day 19 of Phase 1 of Standard M.O.P. necessarily mean my son is still majorly backed up and we need to start again? Or could it just be that his rectum is still stretched, and he couldn’t feel that he needed to go? Everything was going really smoothly, so I’m feeling a bit discouraged!
A: It’s possible he was trying to hold in some poop that was looser than he’s used to, but if he didn’t feel the accident, that would “count” as encopresis. But I wouldn’t be discouraged! You’re only 19 days in, and all versions of M.O.P. call for at least 30 consecutive days of enemas before tapering, even if the child has zero accidents during the month. So, you would be continuing with your current regimen whether or not he had that accident.
Only time will tell whether you need to extend Phase 1 beyond 30 days. Keep in mind that resolving encopresis (and enuresis) requires two steps: 1.) cleaning out the rectum, and 2.) keeping the rectum clear so it can shrink back to size and regain tone and sensation. The second part takes a good three months even after the rectum is cleared. You can only hurry the process so much.
In children with encopresis, the rectum is particularly prone to filling back up, so I recommend a cautious approach to tapering. You may want to extend Phase 1 and then implement one of the Slow Taper regimens described on pages 68-69 of the Anthology.