By Steve Hodges, M.D.
When my patients’ parents learn their child’s bedwetting is caused by chronic constipation, many are both relieved and frustrated.
Relieved because they finally have a culprit and a treatment plan. Frustrated because they were never told constipation is the root cause of virtually all enuresis cases. As a result, their child went years without effective treatment or any treatment at all.
Parents ask, “How did my doctor not know this?”
Easy: Because it’s generally not taught in medical school.
Even pediatric urologists — the specialists children are often referred to when bedwetting persists — receive little to no training during their residencies on the link between a clogged rectum and wet sheets. What’s more, doctors in my field tend to have little incentive to treat enuresis and little interest in doing so.
Many pediatric urologists have been taught enuresis is caused by “deep sleep” or an overproduction of urine, so they default to bedwetting alarms or desmopressin, medication that suppresses urine production (and is, at best a Band-Aid for bedwetting). Or, they simply urge families to “wait it out,” assuring the child, “Don’t worry, you’ll outgrow it.”
Just the other day I read a media interview with a pediatric urologist at a prominent medical school. She said, “I like to tell my [bedwetting] patients, one of the first kind of treatments is actually reassurance — reassuring parents that this is, again, usually normal and will go away.”
That’s the problem in a nutshell. In reality, bedwetting is not normal, and you cannot assume the condition will go away.
These assumptions, and my profession’s default to alarms and desmopressin, treatments that do not address the underlying constipation, are why so many teenagers struggle with bedwetting.
To this doctor’s credit, she mentioned that managing constipation is a “huge factor” in treating bedwetting. So true. However, she attributes only 20% of bedwetting cases to constipation, an extreme understatement.
Other pediatric urologists overlook the constipation-bedwetting link entirely, as many parents in our private enuresis/encopresis support group have reported.
One mom posted:
The urologist we saw did not look at constipation or do much of an exam at all. He felt my son's abdomen and prescribed desmopressin. He stopped short of rolling his eyes at my questions, but in general, his attitude seemed to be that we were wasting his time.
Another, who lives abroad, posted:
We went to paed urologist who scoffed at the idea that bedwetting had anything to do with constipation but more to do with a small bladder and deep sleeper.
A third posted:
We waited 6 months for an appointment only to be told we should try bedwetting alarms again and restrict fluid intake at night and “He will grow out of it.” No one had ever checked my son for constipation.
How can this be? Aren’t pediatric urologists the bedwetting experts? After all, urology is the medical field that deals with the bladder!
The problem is, is a surgical field. Surgeons tend to be fascinated with reconstructive procedures, like fabricating new bladders out of intestinal tissue for kids with spina bifida. Mostly what we do is fix congenital anomalies of the kidneys, ureters, bladder, and genitals. It’s fun and satisfying work.
But for most pediatric urologists, bedwetting just doesn’t rate. Plus, there are the financial realities. Compared to kids who need surgery, those with wetting accidents don’t contribute much to the bottom line.
In addition, since bedwetting often resolves with age, and since it’s not a life-threatening condition, many doctors don’t feel an urgency to treat these kids aggressively. Many don’t understand the misery that children with enuresis, especially older kids, experience — the missed sleepovers and summer camps, the stress and embarrassment, the blow to their self-esteem, the panicky prospect of wetting the bed in a college dorm.
“It’s a crippling emotional toll,” one mom posted in our support group for parents of teens with enuresis.
At pediatric urology clinics, children with enuresis are typically assigned to physician assistants or nurse practitioners, who may be even less familiar than urologists are with the research linking urinary problems to large rectal poop masses.
One mom in our support group posted:
We lived in Alberta, Canada. Urology referral isn’t possible for enuresis. I was informed that paediatric specialists only see ‘serious’cases! Enuresis and encopresis are managed by the paediatrician, since it is considered behavioural.
Of course, enuresis and encopresis (chronic poop accidents) are not behavioral conditions; both are caused by an enlarged, stool-stuffed rectum.
Many pediatric urologists are no more informed, or may even be less informed, than the pediatricians, nurse practitioners, and other healthcare providers who are on the front lines. I find that pelvic floor physical and occupational therapists often know more about enuresis treatment than medical doctors do.
Numerous parents have told me their pediatric urologists insisted enuresis was a behavioral issue and that simply getting the child on the toilet more frequently would resolve the issue. A mom in Australia posted:
Our first paed urologist funneled us to a GP who prescribed behaviour change (a watch with reminders) to our 4 y.o. This was a disaster, setting up a power struggle and behavioural issues. Another paed urologist said it was our expectations as parents that was the problem, that we should consider having her in nappies — at almost age 5.
Another, who visited a general urologist, posted:
He said my daughter will outgrow it. He did an ultrasound of her bladder and felt her abdomen. He said everything is normal. He said we could try bladder meds if she’s desperate. He didn’t mention any link with constipation.
I find this unsurprising, because as a medical student and then a resident, I learned almost nothing about enuresis. I remember our chief resident saying, “We usually don’t treat bedwetting kids until they’re 6, and then you can give them medicine.”
Eventually, I picked up the idea that constipation was a culprit, but I would default to the cookbook treatment: a Miralax (PEG 3350) "clean-out" followed by daily Miralax. The mild cases improved, but the majority of my patients did not stop wetting, an unsatisfactory situation that was also, for a doctor, embarrassing.
Until I started x-raying my patients, I had no idea how clogged these kids really were or how inadequate the Miralax route is. (In the M.O.P. Anthology, I tell the story of the 6-year-old patient who changed my perspective on enuresis and the course of my career.)
It seems little has changed since my medical training.
Recently, I talked with a urology resident who is considering a career in pediatric urology. When I asked him what he learned about enuresis in med school, he said: “What’s covered is that enuresis is common and that it often resolves on its own. And if you were going to treat it, you’d use alarms and desmopressin. That’s pretty much all I heard about it.”
As for his pediatric urology training, he says, “The general impression is, enuresis it’s not life-threatening, and it’s brushed off. Every specialty has its thing that’s chronic and not super sexy or exciting to treat.”
Only recently did this resident learn of the strong link between constipation and enuresis, and he said he was “surprised.” He’s still deciding whether to specialize in children or adults.
“Even if I don’t end up being a pediatric urologist," he said, "this knowledge will be something I carry with me.”
I wish more pediatric urologists carried that knowledge, since we’re the ones pediatricians look to for guidance.
Several pediatricians have told me they won’t routinely recommend aggressive constipation treatment for enuresis, such as the Modified O’Regan protocol, until pediatric urologists as a whole get on board. These pediatricians may support enema-based treatment if the family initiates the conversation but otherwise don't mention it, typically recommending Miralax instead.
Unfortunately, many doctors, whether pediatricians or pediatric urologists, take away the wrong lesson from failed Miralax treatment. They assume that since PEG 3350 didn’t work, that particular patient's enuresis must have a cause other than constipation — perhaps “deep sleep” or urine overproduction or one of the other “causes” that aren’t really causes.
In almost all cases, constipation actually was the cause, but Miralax wasn’t up to the job.
Since this information generally isn’t taught in medical school or pediatric urology training, it’s important for parents to do their research and be proactive. This is no easy task.
One mom’s experience indicates just how confusing it can be to navigate the contradictory guidance offered by different medical providers. In our support group she posted:
For enuresis, our pediatric urology clinic will not let you make an appointment with an MD, only an NP. To their credit, the NPs did tell us about enemas and gave us a M.O.P. handout. However, they really emphasized timed sits, which overemphasized the behavioral component and led us into needless battles around control. Then they referred us to pediatric GI, who told us to stop enemas and set us back probably 6 months to a year.
She added: It’s like the Wild West out here.