The Constipation Crisis No One Is Explaining Correctly
- 54 minutes ago
- 6 min read
By Steve Hodges, M.D.
Constipation in children has gotten so severe in the UK that hospital admissions have jumped 60% in the past decade.
That statistic was flagged by the UK’s Royal College of Nursing—and I was glad to see it. The constipation crisis is real, and it’s hardly confined to the UK.
And the nurses are spot on about what happens when constipation is missed: Kids fall through the cracks, symptoms escalate, and some end up in the hospital with acute abdominal pain, having gone days, or longer, without pooping. I see those kids all the time.
But the nurses are only telling part of the story, and they’re repeating some unhelpful myths about what’s driving the problem.
Here’s what they’re missing: Constipation doesn’t just lead to encopresis (soiling). A rectal stool pile-up also can aggravate the bladder and is behind virtually all cases of enuresis (bedwetting and daytime wetting).
That connection gets overlooked. So, families wait for kids to “outgrow” wetting accidents or try behavioral fixes that don’t address the root cause, while the constipation stealthily worsens.
What’s more, constipation often doesn’t present the way most folks expect. The signs are more subtle—and the list of signs more expansive—than those noted by the nurses and in most medical guidelines. As a result, cases that could be caught early go unheeded.
Healthcare providers are trained to diagnose constipation using checklists such as the Rome IV criteria: infrequent bowel movements, hard or painful stools, abdominal pain, soiling. Those signs are real. The problem is, they don’t capture a large percentage of constipated kids.
Many of my patients poop every day. They don’t complain of pain. They don’t soil their underwear or pass unusually large or firm stools. And yet their rectum is enlarged and interfering with both bowel and bladder function.
I explain the diagnosis problem in detail here: Even Severe Constipation Goes Undiagnosed in Bedwetting Children. Here’s Why.
What’s happening isn’t complicated. The rectum sits right next to the bladder, and when it fills with retained poop, the bulge irritates the nearby bladder nerves. At first, the child may feel extreme urgency to pee or pee too often. Eventually, the bladder starts “hiccupping” at random and empties before it’s even full, day or night.
The child appears to have a bladder problem. In reality, it’s a rectum problem affecting the bladder.
But the underlying cause—the constipation—goes unrecognized. Families are told the accidents are due to an underdeveloped bladder or an immature “bladder brain connection.” Or, stress, behavior, “deep sleep,” or genetics. Kids are reassured: “Don’t worry, you’ll outgrow it.”
But they don’t outgrow it, and they do worry.
So, parents do their best to manage the symptoms. They wake their child overnight. They limit fluids. They try reward systems or behavioral therapy. Some kids are put on desmopressin to reduce urine production at night. I prescribe the drug myself, as a stop-gap measure, but it doesn’t fix the root cause. It just covers it up.
In some kids, these approaches seem to help, especially when the accidents come and go.
But the rectum keeps stretching. By the time kids reach my clinic, often after years of accidents, the rectum often measures two or three times its normal diameter. You can see this clearly on an x-ray.
Many families had no idea their child was constipated. Others knew but didn’t connect the constipation to the wetting. In many cases, the treatments they were given—such as a Miralax clean-out followed by daily Miralax—led to only temporary improvement, or none at all.
So, what’s behind the childhood constipation crisis?
The UK nurses point, in part, to a “cultural shift in how we approach potty training,” urging parents not to wait for “readiness” and to introduce the potty as early as six months. They also suggest that prolonged diaper use causes children to withhold stool or saps their motivation to use the toilet.
These arguments don’t hold up.
There’s no evidence—and no physiological explanation—for why wearing a diaper would cause a child to stop responding to the urge to poop.
In reality, the opposite is true. Children nudged to toilet train early are more likely to start holding stool. They lack the maturity to interrupt what they’re doing and get to the toilet, so they clamp down and forge ahead. The praise they get for “staying dry” gives them even more incentive to hold pee and poop.
If you delay pooping (and peeing) often enough, you have the beginnings of chronic constipation and an aggravated bladder—and, eventually, enuresis.
Research from my clinic at Wake Forest found that children who trained before age 2 had triple the risk of developing chronic constipation and daytime wetting compared to those trained between 2 and 3.
Preschool deadlines don’t help. Neither does the popular “window of opportunity” theory I’ve written about here: I Read 14 Potty Training Books and Found Some Really Bad Advice.
The Royal Nurses mention diet and “lifestyle”— and sure, highly processed food and inactivity contribute, on a population level, to chronic constipation. But a poor diet is rarely the main driver in children. Among my patients with severe constipation are plenty of athletes with stellar eating habits.
In my experience, it comes down more to temperament and a genetic predisposition to constipation.
Some kids are cool with using the bathroom anywhere; others won’t poop unless they’re at home. Some will excuse themselves from the classroom. Others will stifle the urge all day, a habit promoted by misguided school restroom policies.
In other words, there isn’t a single cause, as I explain here: Why Is Your Child Constipated? Because We Live in the 21st Century.
Modern life prompts us to delay bowel movements. And repeated delay is what leads to stool buildup, rectal stretching, and the accidents that follow.
But for parents, the more useful question isn’t why their child became constipated. It’s whether the treatment is actually working.
Once the rectum has stretched to the point of aggravating the bladder nerves, the situation is unlikely to resolve by eating more broccoli or taking a “wait and hope” approach. Nor is softening stool enough. Miralax often makes pooping less painful, but even in high doses doesn’t usually clear the hardened mass already stuck in there.
What needs to happen is straightforward. First, the rectum must be fully evacuated, a harder task than most folks realize. Then, it must be kept empty long enough to shrink back to normal size, regain tone and sensation, and stop irritating the bladder. When that happens, the wetting stops.
That’s the basis of the approach I use in my clinic, known as the Modified O’Regan Protocol, or M.O.P.
Sometimes, though, the rectum doesn’t bounce back right away. An empty rectum can remain stretched for a while, continuing to bother the bladder nerves. In those cases, the wetting can persist despite aggressive constipation treatment.
That’s when I step in with additional support. I may prescribe bladder medication, to boost the child’s confidence while they continue M.O.P. and wait for the bladder to retract. In tougher cases, I inject Botox into the bladder to quiet the spasms while the rectum heals.
Resolving chronic constipation—and related enuresis—isn’t a quick fix. When a rectum has been stretched for years, it can take many months to shrink back and function normally again. The bladder nerves don’t reset overnight, either.
Wetting takes a bigger toll than many parents realize. Kids start avoiding sleepovers, fearing trips, feeling different from their peers. That’s why it’s so important to recognize the underlying cause and treat it early.
READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
Which brings us back to the “constipation crisis.”
The Royal College of Nursing is right to sound the alarm. Constipation is routinely overlooked and undertreated.
But this isn’t just about keeping kids out of the hospital. It’s about ending the cycle of wet sheets, pull-ups, and years spent treating the wrong problem.