By Steve Hodges, M.D.
Whether the issue is a child’s bedwetting, poop accidents, potty “refusal,” or another toileting difficulty, I often hear from frustrated parents, “I have nothing left to try.”
But inevitably, you have many more options!
In this post, I answer questions sent via email or posted in our private Facebook support groups about what to do when a potty problem seems impossible to fix.
Q: My 10-year-old son has bedwetting and poo leakage daily. We’ve had to take him out of school due to the poo accidents. We live in Australia, and our doctors keep telling me he just needs to sit on the toilet three time a day. Medication and a bedwetting alarm didn't work. I have nothing left to try. What do you advise?
A: You have plenty of options! The most effective will likely be a daily enema regimen such as the Modified O'Regan Protocol (M.O.P.). Your son’s poop accidents should stop within a few weeks, if not sooner. The bedwetting will take quite a bit longer to resolve, but your son should not have to miss any more school. All the products you need are available in Australia.
Medication and the bedwetting alarm failed because these treatments don’t address the root of the bedwetting and encopresis (poop accidents): chronic constipation. In some kids, drugs and alarms can help with dryness, but an aggressive regimen to clean out rectum is usually needed before the other remedies will make a dent. In your son’s case, use of these remedies is premature.
Sitting on the toilet three times a day won’t fix this, either. Due to your son’s stretched rectum, he is not feeling the urge to poop and can’t muster the oomph to do it, anyway. When he has accidents, overflow poop is just dropping out of his bottom. Chances are, he’s not feeling the accidents at all.
Enemas will give your son the help he needs to poop fully and unclog his rectum. Be sure to avoid osmotic laxatives, such as PEG 3350, magnesium citrate, or magnesium hydroxide, for at least the first two weeks of M.O.P., as explained in the M.O.P. Anthology. Your son may fare better without osmotic laxatives altogether, instead adding a senna-based stimulant laxative such as Ex-Lax. The options are spelled out in the book.
It's critical that your son understand he is not responsible for his accidents, as many children feel shame and blame.
If your son is feeling down about his situation, he may benefit from reading Emma and the E Club, our novel for kids ages 8 to 12. Just like your son, the main character has both enuresis and encopresis and experienced accidents at school. Bedwetting and Accidents Aren’t Your Fault offers the same message in a nonfiction format. If your son is on the more mature side, M.O.P. for Teens and Tweens may reassure him.
FOR MORE INFORMATION:
•"Bedwetting Drugs: When They Help, When They Don’t," The M.O.P. Book: Anthology Edition, pages 31-32
•"Are Bedwetting Alarms Worthwhile?," M.O.P. Anthology, page 33
Q: We are 3 weeks into M.O.P. for my 3 y.o. with daytime pee accidents and encopresis. Poop accidents stopped and pee accidents are almost gone. My concern: She will NOT self-initiate going potty. If I don’t have her go on the schedule, she’ll sit there and wiggle and look at me like she knows it’s driving me crazy inside. When she has an accident, she smiles and says, “I’m wet!” This seems very much behavioral to me. Any advice on self-initiation with a defiant 3-year-old?
A: You’re expecting too much too soon! For encopresis to resolve and daytime pee accidents to dramatically improve in three weeks is unusually fast progress, probably due to her young age. Her rectum hasn’t been stretched for very long, compared to, say, that of a 7-year-old or a teenager.
Nonetheless, her body’s signals to pee and poop are still out of whack. I wouldn’t call her “defiant.” She’s not actually trying to drive you crazy (even if she’s succeeding!). This isn't behavioral. It’s exactly what happens when a rectum gets enlarged by a pile-up of poop: it loses sensation, along the with the tone necessary to fully evacuate. The bladder nerves become aggravated, so the bladder contracts forcefully and empties without warning.
Just because accidents stop doesn't mean a stretched rectum has healed. That usually takes a good three months (and much longer if the rectum is stubbornly clogged). Honestly, it would be highly unusual if your daughter began self-initiating in three weeks. Stick with the program, and give it time!
FOR MORE INFORMATION:
Q: We were advised that our 4 y.o. should stop drinking water by 4:30 p.m. and eliminate dairy. We worked really hard on the dairy for about 4 months, but not much changed, so we added dairy back in. The water is next to impossible to stop. She just screams she's thirsty and sneaks water, which I don't want her to feel she has to sneak. Our regimen is a nightly large-volume enema, 1 square of Ex-Lax and ½ cap of PEG 3350. Daytime wetting has improved but not nighttime.
A: Limiting fluids is not only unnecessary and miserable for the child but also counterproductive, contributing to constipation and aggravating the bladder. I don’t recommend this approach!
Enuresis isn’t caused by drinking too much water, so restricting water won’t solve the problem. A child with a healthy bladder — a bladder that’s not overactive due to chronic constipation — can drink water right before bed and not need to pee overnight. Your daughter will get there eventually and right now should drink plenty of fluids. Two of our children’s books Bedwetting and Accidents Aren’t Your Fault and Jane and the Giant Poop encourage kids to drink plenty of water.
As for restricting dairy, this strategy can help kids whose constipation is caused by an actual dairy intolerance (which is not most kids). But any benefit should be obvious within a few weeks. A four-month trial isn’t necessary.
Even when dairy does cause or contribute to a child’s enuresis or encopresis, dietary changes rarely suffice to reverse the underlying constipation and stop accidents. A regimen such as M.O.P. is usually needed, although in these kids, dairy restriction can help prevent a recurrence.
As for your current regimen, I suggest shifting to a small-volume enema, such as a liquid glycerin suppository or Docusol Kids, to allow for more rectal shrinkage. I would also drop the PEG 3350 and increase Ex-Lax to ensure she’s pooping once a day on her own, in addition to pooping after the enema.
FOR MORE INFORMATION:
•"Is Dairy a Culprit?," M.O.P. Anthology, page 50
•"5 Strategies That Do More Harm Than Good," M.O.P. Anthology, page 33
Q: I'm 18 and wet the bed nights, but not every night. Is it constipation? I've had trouble all my life at night, and nothing has ever worked. Also, I’m not able to hold my pee very long during the day, which his scary at school. Where should I start?
A: It’s highly likely that you’re constipated. Bedwetting and urinary urgency (the feeling you need to pee RIGHT NOW) are two big red flags, and alternate explanations are rare.
However, given your age and sense of urgency to stop the accidents, I’d start by asking your doctor to order an abdominal x-ray, known as a KUB (short for Kidneys, Ureters and Bladder), ideally with a measurement of rectal diameter. An x-ray can confirm constipation, and a rectal diameter measurement indicates how much a rectum has stretched. A normal rectum measures no more than 3 cm in diameter, but in kids with enuresis, the rectum is often stretched beyond 6 cm. An x-ray can help guide your specific treatment regimen, as explained in the M.O.P. Anthology.
FOR MORE INFORMATION:
"Tips for Getting a Useful X-ray," M.O.P. Anthology, pages 43-44
Q: My son, almost 6, has been doing phase 1 of M.O.P. for almost 3 months (nightly enemas plus a magnesium powder drink). Poop accidents stopped right away, but he’s still wet at night. If I never potty trained him for nighttime, how would I go about moving to the next phase? He is an extremely deep sleeper. Should I wake him to start working on this?
A: It’s not possible to "train" a child to be dry overnight, and I don’t recommend overnight wake-ups. In children who aren’t constipated, overnight dryness happens naturally, and in children with a clogged, stretched rectum, dryness occurs once the rectum has been fully cleaned out, has shrunk back to size, and has stopped aggravating the bladder nerves. In kids with both encopresis and enuresis, this process often takes several months.
However, I do recommend adjusting your child’s regimen after any 30-day period without progress. When daytime accidents have resolved but overnight accidents persist, I often recommend M.O.P.x: daily small-volume enemas (such as liquid glycerin suppositories) pus daily Ex-Lax (instead of an osmotic laxative).
An x-ray can assess whether your son’s rectum is empty but still stretched — and therefore still aggravating the bladder nerves. However, given that he started with both encopresis and enuresis, my instinct is that the healing process may just take longer. I don’t recommend shifting to phase 2 (enemas every other day) until a child is completely accident-free, day and night, for at least 7 days, but ideally longer.
Deep sleep plays no role in bedwetting. The problem isn’t that your son is failing to wake up to pee overnight; it’s that his bladder is overactive, contracting when it shouldn’t. Kids with healthy bladders, no matter how deeply they sleep, don’t need to pee overnight. Deep sleep can’t cause a bladder to be overactive.
Waking a child overnight may solve a laundry problem but doesn’t tackle the root cause of enuresis and usually just leaves the whole family exhausted.
FOR MORE INFORMATION:
•"M.O.P.x: When Daytime Accidents Resolve but Bedwetting Persists," M.O.P. Anthology page 92