By Steve Hodges, M.D.
Anxiety, ADHD, depression: What do these conditions have in common?
Plenty: They’re prevalent among children, and parents talk freely about them, at least among friends. Little, if any, stigma is attached, as anxiety, ADHD, and depression are considered medical conditions, not personal failings. Generally, folks sympathize. Parents typically don’t feel judged or blamed if their child struggles with these conditions.
Now, how about bedwetting, daytime pee accidents, poop accidents: What do these conditions have in common?
Well, they’re also prevalent among children, and they’re also medical conditions; all three are caused by chronic constipation and are highly treatable. Yet most parents don’t dare reveal to friends that their children are wetting the bed or pooping in their parents.
Most fear the accidents will reflect poorly on them as parents, as if they “failed” at potty training or even at parenting. Or, they worry the accidents will reflect poorly on their children, who may be perceived as lazy, “difficult,” or otherwise responsible.
No one blames or shames parents when their child is diagnosed depression or ADHD, yet blame and shame abound when a child wets the bed.
I was reminded of this difference when a mom in our private enuresis/encopresis support group posted that she’d mentioned her child’s bedwetting at a Bible study. Among the six moms in the group, it turned out, four had children struggling with accidents and chronic constipation.
“It was eye opening,” this mom posted. “One mom said her child has been wetting the bed for years. The pediatrician said it was genetic and he would outgrow it. Another said her kids have been wetting the bed and taking Miralax for years. Bedwetting is prevalent, but the problem is, no one talks about it. It’s so hush hush.”
The problem with all this secrecy, aside from making parents and kids feel crappy and perpetuating a stigma, is that kids miss out on the treatments that will actually resolve the accidents.
None of the parents at the aforementioned Bible study had heard about enema-based treatment, such as M.O.P. (the Modified O’Regan Protocol), for enuresis (wetting) and encopresis (poop accidents).
That’s not surprising. When parents do muster the courage to talk about their child’s accidents, it’s usually to the child’s doctor, and since doctors typically tell parents, “Don’t worry, it’s normal, he’ll outgrow it,” the accidents persist. Families wait and wait and wait for that magic day when the child reliably wakes up dry — a day that, for many children, simply does not come.
When doctors do recommend treatment, the remedies usually include Miralax, inceased fiber, time toilet sits, bedwetting alarms, or medication These treatments are typically ineffective, for reasons I explain in detail in The M.O.P. Book: Anthology Edition.
In short, while Miralax softens poop, the laxative often does not break up the large, hard mass of stool that’s clogging and stretching rectum. The soft stuff just oozes around the mass, accomplishing nothing. In the case of encopresis, Miralax and other osmotic laxatives often make accidents worse.
Increasing a child’s fiber intake, whether through dietary measures or fiber supplements, also does nothing to break up the offending mass or help the child overcome the withholding habit. Timed toilet sits don’t help, either, if the child doesn’t feel the urge to poop — a common scenario, since a stretched rectum loses sensation — or if the child has a deeply ingrained habit of overcoming the urge to poop.
Bedwetting alarms can be useful in certain situations but don’t get to the root of the problem, chronic constipation, and can be exhausting for the whole family. I urge families to put their effort and energy into treating the constipation before trying an alarm.
Finally, medication to reduce urine overproduction, such as desmopressin (DDAVP), is typically unhelpful because the drug treats a problem that doesn’t exist. Overproduction of urine is not the reason kids wet the bed; chronic constipation is.
Medications that relax the bladder have their place, but I don’t prescribe them unless the child is also on an aggressive program to resolve chronic constipation. If an x-ray shows the child’s rectum is no longer clogged but is still stretched and is therefore still aggravating the bladder nerves, medication may help and possibly bladder Botox.
Bottom line: The most common treatments typically are not aggressive enough to resolve chronic constipation or break the withholding cycle that drives constipation.
Of course, these treatments are better than the really outrageous and harmful advice floating about, such as “start a sticker chart for dry nights” or “have your child help with the laundry” — advice that wrongly implies the child has control over the accidents.
It’s critical for families to understand that enuresis and encopresis are medical conditions, straight up.
When children delay pooping, as they often do, stool accumulates in and stretches the rectum. The enlarged rectum in turn presses against and aggravates the bladder nerves, triggering “hiccups.” These hiccups come on quickly and without warning, so the child has no chance of making it to the toilet, day or night.
The medical nature of enuresis becomes obvious when you look at an x-ray of a chronically constipated child. The rectum is stretched to two or three times the normal diameter and is encroaching upon the bladder. I x-ray my enuresis patients and measure their rectal diameter, and the films are eye-opening to parents.
One mom told me: “Seeing the x-ray really decreased our frustration with our 5-year-old son. We thought his accidents were a behavior or anxiety issue.”
She stopped rewarding her son for dry nights, and the boy stopped trying to hide his wet underwear from her. “Now he doesn’t have to feel disappointment for not earning a reward when he has no control over it. We all have better attitudes, as we view the wetting as a medical issue.”
Encopresis has the same cause: a stretched rectum. In this case, the rectum loses tone and sensation, so stool just falls out the child’s bottom, without the child even feeling it. The child can no longer sense the urge to poop, a scenario that adds to the pile-up, setting off a vicious cycle.
Some kids have encopresis only; while the rectum is quite stretched, the bladder just isn’t sensitive to the stretching, so the child doesn’t have pee accidents. Another child with the very same amount of rectal stretching may wet the bed and/or have daytime pee accidents but not have encopresis. Many of my patients have all three conditions.
Since these conditions have the same cause, they all can be resolved by the same treatment: daily enemas. In the case of encopresis, the accidents usually case within a month, at which point I recommend tapering to enemas every other day and then, after another 30 days, tapering to twice a week.
For kids who have poop accidents or underwear poop smears, I advise holding off on osmotic laxatives for at least two weeks during this process, as explained in the Anthology. For kids with enuresis, daily enemas typically are often needed for significantly longer than 30 days before tapering, and laxatives are helpful throughout the process. For children with either or both conditions, stimulant laxatives such as Ex-Lax also can play a helpful role.
Enuresis and encopresis have long been stigmatized. Sometimes it’s parents who shoulder the blame, as I’ve detailed in No, "Lazy Parenting" Does Not Cause Potty Accidents — Constipation Does. Often, it’s children who are shamed, which is why I wrote Bedwetting and Accidents Aren’t Your Fault.
Interestingly, encopresis and enuresis are exceptionally common among children with ADHD, as well as autism. Anxiety, too, can make a child more susceptible to withholding poop, a habit that often becomes deeply ingrained and difficult to break. These kids often receive treatment for the conditions that society recognizes as medical issues yet the same kids miss out on treatment for conditions that society stigmatizes and does not recognize as caused by constipation.
Members of our private support groups often post about the guilt they feel for having waited so long to start proper treatment for a child’s enuresis and/or encopresis. We have an entire support group just for parents of teens and tweens — kids who were told, year after year, “Don’t worry, you’ll outgrow it.” At some point, when the child was 12 or 15 or 18, the parents stopped accepting that answer and took matters into their own hands.
One mom of a child with enuresis posted, “The guilt I have felt initially was a HUGE weight in addition to the all-consuming nature of the condition. I’m trying to give myself a little more grace.”
Yes! Give yourself some grace! Enuresis and encopresis are stigmatized, misunderstood, and treated inappropriately. Many, if not most, physicians are unfamiliar with the most effective treatments for these conditions. Parents can hardly be expected to know more than their doctors.
I look forward to the day when, instead of keeping their children’s conditions secret, parents can share freely, without fear of judgment, so more kids can get the help they need.