By Steve Hodges, M.D.
Back in 1985, when I was in middle school and Foreigner was huge, a team of Maryland physicians published a study of 58 kids with encopresis, a really crummy condition characterized by chronic poop accidents.
These kids, like many of my own patients today, were in dire straits, averaging 13 poop accidents a week. The researchers, affiliated with Johns Hopkins University, noted that children with encopresis suffer profound distress — they are “taunted by their peers and excluded from peer activities” — and their condition generates family conflict, all as true today as it was back then.
At the start of the Hopkins study, each child received an enema. Then, for 21 weeks, the children followed a straightforward daily regimen: They’d attempt to poop after a designated meal, usually breakfast, and if they went 2 days without pooping, they’d receive an enema after breakfast on the second day. Enema were presented to the families matter-of-factly, “never as a punishment,” authors noted.
The treatment was a striking success: Among the 43 kids who stuck with the regimen, the average reduction in poop accidents was 96% — a drop from 13 poop accidents per week to .5. Sixty percent were having no accidents at all, and another 23% had only occasional underwear poop stains. The 17 kids whose accidents did not completely resolve, who'd started with more severe cases, were averaging 16 fewer accidents per week than when the program began.
Three years later, most of the children had sustained excellent results with minimal, if any, maintenance.
Their parents viewed the protocol in a positive light, the researchers observed: “The use of enemas to relieve impaction normally resulted in a reduction in soiling, which seemed to gratify parents and to encourage them to cooperate with the treatment regimen.”
The Hopkins team described its regimen as “highly effective,” “rapid and easy to perform” and “involv[ing] minimal risk," concluding it “appears to be the treatment of choice for encopresis."
From where I sit, that is a big understatement. Enemas are, hands-down, the treatment of choice, not just for encopresis but also for enuresis (bedwetting and daytime pee accidents), both of which are caused chronic constipation.
Several studies — mostly from the era of Miami Vice and Wham!, but also from my clinic — confirm this, as does my experience treating thousands of children. A dozen years ago, when I began treating encopresis and enuresis with enemas rather than PEG 3350 (Miralax), my success rate skyrocketed. The difference was obvious and dramatic.
Yet physicians today routinely push Miralax, even though the laxative powder is clearly inferior to enemas and even when Miralax fails to help their patients for years on end. As a result, children are left to experience mortifying accidents at school, miss out on sleepovers, battle with their parents, and live in a state of distress and/or discomfort.
All because of an unwarranted, unsupported bias against enemas.
Doctors, on the whole, don’t just disapprove of enemas; many tell parents that the insertion of solution in the rectum is “unsafe,” “traumatic,” “overly aggressive,” even “tantamount to child abuse.”
We physicians like to think medicine inexorably advances, that today we offer patients more effective treatments than existed before. Mostly, we do. But on occasion, we drive medicine in reverse, promoting therapies that are considerably less valuable, often entirely useless, and sometimes detrimental.
Worse, in contradiction to the evidence, we disparage the earlier, better remedies. Nothing illustrates this better than the case of enema treatment for encopresis and enuresis.
In 1985, the Hopkins team emphasized that enemas were well received by the participating families. Yet in a 2017 book chapter on encopresis, a psychologist describing that very study stated that the children “were made to use enemas.”
The italics are mine, and I use them to illustrate today’s common characterization of enemas as coercive.
Other examples: In a 2021 article on urinary frequency, another condition caused by chronic constipation, Chinese authors describe enemas as “not well-accepted by children” — yet provide no evidence for this assumption. In a 2009 study comparing high-dose Miralax to enemas in severely constipated children, Dutch physicians noted, “It is often assumed that children strongly dislike enema administration.”
The authors made that same assumption, hypothesizing that enemas “would be less well tolerated.” Their study not only proved this hypothesis wrong but also demonstrated that Miralax caused more poop leakage than enemas. And still, the authors concluded that enemas and Miralax should be “considered equally as first-line therapy” for fecal impaction. Talk about ignoring the obvious! (More on this study shortly.)
In scientific papers, the language used to describe enemas tends to be moderately disparaging while overlooking the fact that enemas are highly effective. But in person, many physicians don’t hold back.
I’ve heard numerous colleagues criticize enemas, assuming they’re unsafe for children or traumatic. Most parents in my private enuresis/encopresis support groups follow an enema-based regimen, the Modified O'Regan Protocol, without the support of their physicians, and many have been scolded for this practice.
“Our pediatric urologist said he was ‘horrified’ by our use of enemas and that he ‘should’ call both child protective services and the police,” a mom from the United Kingdom posted. “The counselor at my daughter's school advised me to get a letter from a doctor stating enemas are not abusive, so I could present it to child protective services should the need arise.”
She asked me to write such a letter, defending a treatment that she said brought “immediate and significant improvement” in her 5-year-old’s daytime enuresis.
Another mom group posted, “When my child told the doctor she liked enemas because she felt better, her statement was immediately dismissed with ‘No, you don’t. No one likes them.’”
Yet another mom wrote: “When I told our doctor we were getting good results with enemas, she told us to ‘stop that right away.’ The most upsetting thing was her language around the ‘trauma,’ which has not been our experience at all. Enemas are just part of our evening routine, like brushing teeth.”
The mom of a 16-year-old told me enemas literally saved her son’s life, after he’d been hospitalized for suicidal ideation triggered by encopresis and enuresis. “We were both on board to try enemas because nothing else had worked. It’s still shocking to me how much resistance we got from everyone — the GI doctor, the pediatrician, the mental health care providers. But we did it, anyway, and it worked. He is 16 ½, and I just recently bought him underwear.”
Just last week I had a video consultation with another 16-year-old and his mom, after the boy, who’d never had a dry night, became so severely constipated that he landed in urgent care. “The urgent care doctor told my son enemas at his age are dangerous,” the mom reported, “and said he just needs a stool softener.”
The idea that a stool softener could resolve this child’s enuresis is preposterous. The freshly softened stool would just ooze around the hard, dry, crusty mass in his rectum, likely creating a diarrhea-like mess and accomplishing nothing.
LISTEN TO JANET LANSBURY INTERVIEW DR. HODGES: "Problems with Potty Training, Constipation, Bedwetting, and Preschool Policies"
In reality, to resolve encopresis and enuresis permanently, a lot must be accomplished, and oral laxatives, whether used daily and/or in high-dose clean-outs, are usually not up to the task.
When a child is chronically constipated, the rectum is not only clogged, like a drain pipe harboring a hairball, but also stretched out, like a sock that has lost its elasticity.
In the case of encopresis, the stretched rectum loses tone and sensation, so poop just drops out of the child’s bottom, without the child noticing. With enuresis, the enlarged rectum aggravates the bladder nerves, prompting the bladder to “hiccup” and empty without warning.
For accidents to stop for good, three things must happen: 1.) impacted stool must be dislodged from the rectum, 2.) the rectum must be fully evacuated daily thereafter, and 3.) the rectum must shrink back to size, so it can regain tone and sensation and stop bothering the bladder.
That’s when kids get their lives back.
The Dutch study I mentioned is the only published research to have compared enemas and PEG 3350 for the dis-impaction part of this process. The study tracked 90 children, ages 4 to 16, who had stool lodged in their rectums and were having multiple poop accidents each week. For 6 consecutive days, half the kids received daily enemas at home, and the other half received high doses of Miralax.
The upshot: Among the enema group, 80% of the children had a successful dis-impaction, compared to 68% of the PEG 3350 group. One additional day of enemas led to success in another three kids in the enema group. During the study, the enema group averaged 3.4 accidents, compared to 13.8 accidents for the PEG 3350 group. Watery stools were nearly three times more frequent among the PEG 3350 group than the enema group.
To me, the results favor enemas. Since both treatments were equally well-tolerated by the children and Miralax caused far more poop leakage, why declare the two treatments equally useful? Who wants poop leaking into their underwear, a known side-effect of Miralax?
The Dutch authors seemingly gave thumbs-up to both treatments because both were more or less successful in reducing impaction and in increasing pooping frequency (a worthless measure of constipation if the child is not completely evacuating).
Interestingly, the study “did not find more fearful behavior in the enema group” compared to the Miralax group. Therefore, the authors concluded “enemas should not necessarily be withheld to prevent anxiety.”
That’s a backhanded endorsement if I’ve ever heard one!
In both groups, the authors reported, anxiety ran high: Among the enema group, 95%, “exhibited fearful behavior,” compared to 81% of the PEG group. First off: What kid wouldn’t be anxious about treatment to evacuate a mass of poop from their butt? Second: How you present enemas matters a lot. The Dutch authors stated up front that they expected kids to fear the treatment. Is it any wonder that the kids actually did? In 1985, the Hopkins team made a point of presenting enemas as a benign, helpful treatment.
I do the same. I guarantee you that nowhere near 95% of my patients fear enemas. I have loads of tricks up my sleeve to reduce anxiety about this approach, and I've published an Enema Rescue Guide packed with ideas from parents who know the ropes.
But back to the issue of effectiveness. I agree that high-dose Miralax clean-outs can be successful in breaking up hardened stool, and there’s no harm in trying if that’s what a family prefers to do. However, more often, oral clean-outs fail to dis-impact the rectum, and even when Miralax succeeds, the results don’t last without a follow-up program involving enemas. The kid fills right back up.
Two weeks after the Dutch study was completed, the Miralax kids were averaging 5.9 accidents per week, compared to 5.4 accidents for the enema kids — not much of a difference. But I’d like to know: How were the kids doing after 6 months?
In my experience, what matters most is the follow-up, not the method of dis-impaction. Most of my patients can’t get anywhere near accident-free without ongoing enema treatment. A study I conducted at my clinic offers insight into why.
We tracked 60 kids with daytime enuresis: 40 used Miralax, and the other 20 followed an enema-based regimen: one month of daily enemas, then a month of enemas every other day, and then a month of enemas twice a week. (This is a rudimentary version of the Modified O'Regan Protocol, aka M.O.P.)
After three months, daytime accidents had ceased in 30% of the Miralax group, compared to 85% of the enema group. The children's rectal diameter explains the huge difference.
X-rays conducted prior to treatment showed these kids were seriously constipated, with a rectal diameter averaging greater than 6 cm — twice the normal maximum of 3 cm. After three months of treatment, the average diameter among the Miralax group was 5 cm, not much of an improvement. But the rectums of the enema group had shrunk dramatically — to 2.15 cm, on average.
Three kids in the enema group were still wetting; unsurprisingly, all three of them still had enlarged rectums, which just means they needed more effective enemas. As I’ve learned, a kid can have an enema every day forever and still not get dry if the enema solution doesn’t work for that particular child. (I discuss the various options in The M.O.P. Anthology 4th Edition, my guide to enuresis and encopresis for toddlers through teens.)
The medical establishment seems to approve of enemas only in very limited circumstances. For example, the American Academy of Pediatrics, on its web page about encopresis, states: “For the first week or two the child may need enemas, strong laxatives or suppositories to empty the intestinal tract so it can shrink to a more normal size.”
But here’s the thing: A chronically stretched rectum will not shrink back to normal in 1 or 2 weeks.
Certainly, a week or two of enemas can make poop accidents stop. That happens all the time, and families are thrilled. But it takes a good three months for the rectum to heal, and that will happen only if it’s fully emptied daily. The AAP’s recommended maintenance phase — oral laxatives and scheduled toilet sits — will not reliably produce lasting results.
There are two reasons for this: 1.) the habit of delaying pooping is deeply ingrained in chronically constipated kids, and 2.) children with a stretched rectum cannot reliably sense the urge to poop. Until the rectum shrinks back and regains sensation, these kids need significant daily help emptying.
(This applies, too, for children with enuresis, who typically need longer enema treatment to resolve their accidents. Interestingly, in on its misinformed webpage, the AAP does not even recommend enemas for treating enuresis.)
An extended enema regimen has a much better chance of leading to complete rectal healing. That’s why so many of the children in the Hopkins study had durable results whereas the Miralax-cleanout regimens promoted by today’s physicians do not.
I have patients who were instructed by doctors to do a high-dose Miralax clean-out every month for months on end — and still these kids landed in my clinic, continuing to have daily accidents.
One mom in our private support group reported that at age 4, her daughter was having up to 20 accidents a day, which caused "ulceration of the skin around her anus." And yet, for 3 years, she posted, "our pediatrician and pediatric GI specialists did nothing other than recommend more Miralax and clean-outs, which would help for a couple of days, then she would regress again. I was at the end of my rope, it was so stressful and emotionally draining." When, at age 7, her daughter started on daily enemas, "the encopresis resolved immediately."
Another mom posted that her son was on oral laxatives for 3 years "and was a big, poopy mess. On enemas, the accidents pretty much stopped immediately.”
Both of these moms kept their children on enemas long after the accidents stopped, a wise move because their children were still not reliably pooping on their own.
I often remind parents that the goal is not to get your child off enemas asap; it’s to heal the rectum and help your child develop the habit of fully evacuating every day. If that takes an extra 6 months, fine! Enemas do not cause “dependence” or “damage,” as I explain in The M.O.P. Anthology 4th Edition. Once the rectum is healed, an otherwise healthy child simply will not need them.
And by the way, many folks with congenital conditions such as spina bifida require enemas every day for their entire lives, and their sphincters are just fine.
In recent years — heck, in recent decades — you’d be hard pressed to find a published study (other than my own) on the extended use of enemas in children with encopresis and/or enuresis. Enemas have fallen deeply out of favor.
Why? Well, one mom in our support group posted a theory that sounds right to me:
"I wonder if the shift toward viewing enemas as 'abusive' and last-resort over the last 30+ years is connected to the greater awareness of child sexual abuse and a subconscious connection between that and enemas. Obviously, greater awareness of child sexual abuse is a good thing, but I do wonder if enemas have been tainted by association."
I'm sure the advent of Miralax — less invasive than enemas and seemingly easier on both parent and child — also has contributed to the medical community's repudiation of this treatment.
But let's rewind to the eighties again. In 1985 alone, not one but two such investigations made it into print. The same year the Hopkins team had its work published in the Journal of Pediatric Gastroenterology and Nutrition, researchers at Canada’s Université de Montréal scored publication in Clinical Nephrology (always a fun read!).
The studies bore striking similarities.
The Montreal study was led by Sean O’Regan, M.D., the pediatric kidney specialist whose research changed the course of my career. Dr. O’Regan tracked 47 girls, average age 8, all with recurrent urinary tract infections, yet another condition caused by chronic constipation. Most of these girls also had encopresis, enuresis, or both, as is often the case.
The girls followed the same regimen Dr. O’Regan had used to resolve is own son’s bedwetting: daily enemas for a month, followed by a month of enemas every other day, followed by a month of enemas twice a week.
After three months, 44 of the 47 girls no longer were having UTIs. Among the 21 patients with encopresis, 20 stopped having poop accidents, and 22 of the 32 girls with enuresis stopped wetting.
I discuss this study, and Dr. O’Regan’s other published research at length in my books. Dr. O’Regan’s regimen is the reason my success rate shot up.
Over the years, I have adjusted, refined, and added variations to his regimen, all the while seeing my success improve. Back in 2015, I dubbed this regimen the Modified O’Regan Protocol (M.O.P.), and the name stuck.
When I first dug up Dr. O’Regan’s studies, I was curious to know how his protocol was received by patients’ families and other physicians. I tracked him down in Arizona, where he was enjoying retirement, and he told me, “Everyone bought into it.” Physicians did not suggest oral laxatives would be safer or “less traumatic.” (Though Miralax wasn’t available back then, senna, magnesium, and castor oil were among common oral remedies.) Parents didn’t balk.
To Dr. O’Regan, enemas were a no-brainer.
“We knew the root cause of bedwetting was incomplete rectal emptying,” Dr. O’Regan said, “and enemas were the only way to solve the problem.”
When I asked Dr. O’Regan if any of his patients ever suffered complications on his regimen, he told me, “Our only complication was a 7-year-old girl who clogged the toilet at our hospital after an enema. She was legendary.”
In other words, the damage was to the plumbing, not the patient.
And yet today, physicians routinely warn parents against the one remedy that has been proven to offer reliable, lasting results. I have yet to find a study, from any era, supporting today’s anti-enema bias.
Enemas are as old as medicine. The procedure was referenced in the Ancient Egyptian Ebers Papyrus and was touted by Hippocrates himself 400 circa B.C.E. (If you’re seriously bored one weekend, check out “The History of the Enema.”)
In a 1955 article published in the Journal of the American Medical Association, three Virginia physicians observed that the popularity of enemas has varied from era to era. The 18th century, they wrote, marked "a particularly low point in their extent of use" whereas in "today, the value of a satisfactory enema solution properly used is well nigh universally recognized as a desirable procedure.”
Seventy years later, we seem to have reached a new low point! I believe children with encopresis and enuresis deserve nothing less than the best treatment available. Right now, most of them aren't getting it.
Still, I remain hopeful that history will circle back around.
Lately, more parents in our private support groups are reporting their healthcare providers support their use of enemas, and I’ve encountered a number of physicians who prescribe enema-based regimens to their patients.
Perhaps the enema will once again be recognized for what it is and has always been: the single best way to stop bedwetting and daytime accidents.