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Q&A With Dr. Hodges: Teenage Bedwetting, Soiled Underwear, and X-rays for Constipation

By Steve Hodges, M.D.

Here's a round-up of recent questions about enuresis and encopresis that I've received via email and our private Facebook support group.

Q: My 13-year-old wets the bed every night, and instead of using toilet paper, he uses his clothing to wipe and then hides his dirty underwear. What do you suggest I do?


A: Poop smears, aka “skid marks,” aren’t caused by a failure to use toilet paper; rather, they signal the child’s rectum is harboring stool and the child is struggling to hold it in — in other words, chronic constipation. Bedwetting (enuresis), too, is a classic sign of constipation.

It is quite common for children to hide soiled underwear because they are embarrassed about their condition and don’t want to disappoint their parents.


It's important for your son to understand that his accidents and smears are not within his control. His rectum, enlarged by accumulated stool, is pressing against his bladder nerves, triggering forceful bladder contractions overnight. His stretched-out rectum also has lost tone and sensation, so he’s not fully sensing the urge to poop and can’t fully evacuate.


Cleaning out his rectum with an enema-based regimen such as the Modified O’Regan Protocol (M.O.P.) will resolve both the enuresis and the poop smears. M.O.P. for Teens and Tweens explains the regimen in terms middle school and high school students can relate to.


Q: What are your thoughts around “dream weeing” — waking children to use the toilet so they don’t wet the bed? We have two children on M.O.P. with nighttime enuresis, and most nights we take them for a wee before we go to sleep. Sometimes this allows them to wake up dry (less laundry for us). Can this cause negative long-term effects?


A: Waking a child to pee won’t harm the bladder, but we don’t recommend this practice because it disrupts the child’s sleep and does not help resolve enuresis.


Also, if you’re waking your children to pee, you can’t evaluate their treatment progress. You won’t know whether, or how often, your children are dry at night on their own. As the rectum shrinks and heals with M.O.P. treatment, nighttime wetting gradually diminishes. Your children’s pull-ups should be increasingly less saturated and remain dry overnight more often.


An important rule of thumb with M.O.P. is to adjust the regimen after any 30-day period without progress. For example, your child may need a different type and/or dose of enema solution and/or laxative. If you head off accidents by waking the child to pee, you will lose out on valuable information and may delay the permanent resolution of enuresis.


Q: Our 5-year-old has been on Multi-M.O.P. for 7 weeks. Encopresis has resolved. Daytime wetting has reduced but persists, and nightly wetting is unchanged. In the last week she has started pooping on her own some evenings before her enema. We still give the enema, obviously, and she often poops a bit more. My question: Is the new spontaneous pooping a sign of bowel recovery? I’m looking for some hope, I guess, since wetting has persisted.


A: Yes, spontaneous pooping is an excellent sign, suggesting her rectum has started to shrink and regain sensation. With continued treatment, her rectum will retract to normal size and stop bothering her bladder nerves altogether, and her wetting will stop. But this is a lengthy process, especially in children who start treatment with the trifecta of encopresis, daytime wetting, and nighttime wetting.


There’s often a lag between the resolution of encopresis and enuresis and an additional (and longer) lag between the end of daytime wetting and nighttime wetting. During that period, adding bladder medication can sometimes help. The emptier the rectum, the more effective medication is likely to be.


The fact that your daughter’s wetting persists is not a reason to lose hope! Try to focus on your daughter’s progress rather than the fact that her enuresis has not resolved.


Q: My daughter, now 9, successfully completed M.O.P. at age 8. For over a year, she had no pee or poop accidents and has not needed enemas, but she recently began wetting in the daytime again. She now reports urgency to pee and can’t make it to the toilet on time. In the year since her accidents stopped, she has taken Ex-Lax occasionally, when she hasn’t pooped for a few days. Should we start doing Ex-Lax every weekend?


A: I would implement a daily bowel-clearing regimen, rather than just on weekends, to see if you can nip this in the bud. It sounds like she's gotten backed up again. Urgency to pee is a sign of constipation, and so, of course, are pee accidents.


Daily Ex-Lax may be enough to shut down the accidents and urgency, assuming she takes a high enough dose to poop within 5 to 8 hours. However, you might also consider restarting M.O.P. If she wasn't pooping every day prior to the recurrence of accidents, her rectum probably filled back up gradually, to the point where it triggered the urgency and enuresis. I'm sure you can reverse the situation if you jump on treatment.


Once her accidents resolve again, you might keep her on a daily osmotic laxative for at least a year. Also, given her recurrence, I’d have her use Ex-Lax or an enema on any day she doesn’t poop, rather than waiting a few days.


Q: My son is 5. Nine months ago, he would frequently complain of stomach pain and point to his abdomen. An x-ray found “moderate retained stool in ascending colon and rectum,” and the doctor recommended Miralax, which we did not give. I’ve posted the x-ray here. Since then, my son has not mentioned stomach pain and has had soft poops every day. He has no daytime accidents but fully saturates his diaper every night. What is your feedback?


A: The term “moderate retained stool” in x-ray reports of children with enuresis often lulls parents into thinking treatment isn’t warranted. In reality, while there’s always some stool in the colon, and that’s no big deal, the rectum (the end of the colon) should remain empty. This organ is not designed to store poop. When stool accumulates in there, even if it’s a “moderate” rather than enormous mass, the rectum will eventually stretch and, in children with sensitive bladders, will start aggravating the bladder nerves.

Once chronic constipation develops to the point of causing enuresis, a mild treatment such as Miralax is unlikely to suffice. Even high-dose Miralax "clean-outs" often just shift poop downstream, clogging the rectum further. Often, soft poop just oozes around the hard mass, obscuring the problem. The child appears “regular” but is actually chronically constipated.


Countless children who poop every day, experience no stomach pain, and have soft stools are nonetheless severely constipated. That's why so many cases of enuresis go untreated and why I x-ray my enuresis patients and measure rectal diameter. For an accurate diagnosis, you can't simply rely on the traditional signs of constipation.


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