Two Reasons Poop Accidents Return — And What to Do
By Steve Hodges, M.D.,
Several recent posts in our enuresis/encopresis support group have highlighted a frustrating problem:
A child with encopresis starts the Modified O’Regan Protocol (M.O.P.), and the poop accidents stop almost immediately. After a month accident-free, the family begins tapering off enemas, as outlined in the M.O.P. Anthology.
But then something goes wrong. The child won't poop on their own. Poop smears appear in their underwear. Or full-blown accidents return.
Parents ask: What's going on? How can we get out of this cycle?
In my experience, there are two common explanations, and each calls for a different solution, though some kids experience a degree of both scenarios.
#1: The treatment stopped the accidents but didn't empty the rectum enough to restore normal function.
#2: The rectum has healed, but the child continues overriding the urge to poop. (In this scenario, poop smears are more typical than full-blown accidents.)
Let's start with reason #1: The accidents stopped, but the rectum hasn't healed. This is the more common scenario.
Now, it's important to understand that a typical child with encopresis is, by definition, extremely backed up. The poop-clogged rectum has become so stretched that it's lost sensation.
That's why these kids may not even realize they've had an accident. They genuinely can't feel the poop coming out.
With a daily enema regimen such as M.O.P., poop accidents often stop within days. Even a modest reduction in the stool pile-up, maintained day after day, may be enough to prevent poop from falling out.
Parents think: Awesome! We're done! Let's get off enemas!
Not so fast.
Stopping the accidents, life-changing as it is for child and parent alike, is just the first step in resolving encopresis. If the rectum is still partially filled with stool, it can't shrink back to size and regain its lost sensation and tone.
The child may have clean underwear, but the rectum is still harboring poop. (Keep in mind the rectum is a sensing organ, not a storage organ. It's supposed to be empty except just before a bowel movement.)
Essentially, the child is treading water rather than moving forward.
In my experience, once the floppy rectum is fully emptied, it takes a good three months to spring back and provide a strong, reliable urge to poop.
Yet the accidents might stop in just three days.
That's a huge difference — and a major reason encopresis recurs.
In the M.O.P. Anthology, I advise parents not to start tapering enemas until their child has been 100% accident-free, day and night, for at least 30 days.
But even 30 days may not be enough, particularly for children following Standard M.O.P., which involves one daily enema.
That's why, for children with a history of daily encopresis, I recommend starting with a regimen that triggers two bowel movements a day, such as Multi-M.O.P. or M.O.P.x.
The goal isn't just to stop accidents. It's to empty the rectum thoroughly enough for healing to begin. In my experience, a more intensive regimen accomplishes this faster and may prevent months of setbacks later.
What if your child has already started tapering and the accidents have returned?
My advice: Return to your chosen M.O.P. variation and, this time around, wait to taper until your child has been accident-free for 60 days. Then follow one of the Slow Taper regimens described in the Anthology.
Yes, this may add a few months to treatment. But it can dramatically reduce the odds of another recurrence.
Remember, the goal is to stop accidents for good, not to stop enemas ASAP. In the span of an entire childhood, a few extra months of treatment is nothing.
Now let's consider the second scenario: A child starts having poop smears during or after tapering off enemas.
This suggests the rectum has regained sensation but the child hasn't broken the habit of withholding poop.
After years of ignoring or not feeling the urge, responding to the signal may not come naturally, even when sensation returns.
These children don't necessarily need more intensive emptying; they need help relearning to act on the urge.
In this situation, I recommend senna (Ex-Lax) on enema-free days during the taper period.
When dosed properly, senna is an excellent tool for retraining children to heed the urge to poop.
The key words are dosed properly.
The goal is to stimulate a strong urge to poop within 5 to 8 hours. If the urge is strong enough, even a child's withholding superpowers won't suffice — the child will need to stop what they're doing and head to the toilet.
As I explain to parents, under-dosing senna can backfire: The child continues overriding the urge, and the withholding cycle continues.
Once the child has relearned to heed the signal, I recommend gradually transitioning from daily senna to a daily osmotic laxative. Our Senna Taper Plan explains how to make the transition.
One caveat: Poop smears don't automatically mean the rectum has healed. The child may still be backed up, in which case reason #1 applies.
Here's something I've noticed over the years: Children with encopresis alone — no daytime or nighttime wetting — seem to have higher rates of recurrence than children with enuresis.
I think I know why.
Poop accidents often stop within days of starting M.O.P. So, parents may begin tapering well before the rectum has fully recovered. Bedwetting and daytime pee accidents, on the other hand, generally take longer to resolve.
By the time a child with enuresis has been completely dry, day and night, for 30 consecutive days, they've typically been on M.O.P. far longer, so their rectum has had more time to heal.
This doesn't mean enuresis can't recur. It certainly can, particularly when treatment is reduced too soon or too quickly.
But in my experience, children who follow a sufficiently intensive M.O.P. regimen and taper gradually have a much better chance of staying dry.
The irony is that the faster accidents stop, the easier it is to mistake early success for full recovery.