By Steve Hodges, M.D.
A 3-year-old who wets her underwear at preschool every day. A 4-year-old who pees constantly. A kindergartener with sudden, desperate urges to pee. A 2nd-grader with daily poop smears in his underwear. A 5th-grader with daily poop accidents. An 8-year-old who has a urinary tract infection every other month. A 13-year-old and a 16-year-old who wet the bed nightly
That’s a random sampling of my patients. What do these kids have in common?
They are all chronically constipated, and their constipation is the root cause of their toileting difficulties. But also: Their constipation went unrecognized, and their symptoms were misinterpreted, explained every which way from Sunday.
Here’s the typical storyline that accompanies these symptoms and age groups:
•Preschoolers who wet their pants are often considered “not fully potty trained.” Preschools often ask the child’s parents to “work on it” at home, with sticker charts and such.
•Children who suddenly sprint to the toilet are assumed to have “waited too long” and ignored the body’s urge to pee.
•Kids who pee incessantly — several times an hour — are often labeled “disruptive” by their teachers. Sometimes, parents worry the child might have diabetes.
•Children with poop smears are assumed to need help with “wiping hygiene.”
•Kids who have poop accidents are often assumed to be “seeking attention” or “acting out.” Many are referred for behavioral therapy.
•Girls with chronic UTIs are sometimes considered poor wipers. I’ve heard parents say, “She doesn’t always wipe front to back.”
•Elementary-age kids who wet the bed are often told their enuresis is normal, nothing to worry about — a sign their “bladder hasn’t caught up to their brain” and a situation they’ll inevitably outgrow.
•Tweens and teens with enuresis are often told their bedwetting is genetic, caused by deep sleep, or an overproduction of urine, or is triggered by anxiety.
The healthcare professions tend to compartmentalize these symptoms, failing to connect the dots. Pee and poop accidents are treated as entirely different conditions. So are daytime and nighttime wetting. Incessant peeing, UTIs, poop smears — all are considered as different as apples, oranges, and watermelons.
Just as explanations for these symptoms are all over the map, so are recommended treatments. More potty training, more sleep, more patience, behavioral counseling, stress reduction, bladder medication — all to no avail.
These approaches fail because they do not address the root cause. If you x-ray virtually every child with bedwetting, daytime enuresis, encopresis, chronic UTIs, urinary frequency, urinary urgency, or chronic poop smearing, you’ll see the same picture: a rectum enlarged by a pile-up of poop.
A stretched rectum, in turn, causes the bladder and bowels to go haywire in a variety of ways. Let us count them!
In one common scenario, the enlarged rectum encroaches upon the neighboring bladder, aggravating the bladder nerves. If you look at an illustration of pelvic anatomy, you’ll see the rectum and bladder are literally touching. So, in children with a particularly sensitive bladder, the slightest bulge in the rectum can wreak havoc.
For example, the child may feel a sudden and extreme urge to pee, a condition known as urinary urgency. Or, the urge to pee may strike preposterously often, well before the bladder is full. That symptom, one that drives teachers and parents bananas, is known as urinary frequency.
Pee accidents are simply a more extreme version of the same story. Either the rectal bulge is larger (in some kids, the rectum measures 3 times a normal diamter) or the child’s bladder is more susceptible to the rectum’s territorial invasion, or both.
The upshot: Highly irritated bladder nerves trigger contractions so forceful and abrupt that the bladder empties right then and there. Boom! No warning, no chance for the child to sprint to the toilet.
This can happen day or night, at age 4 or age 14, in preschool story circle or at an 8th-grade slumber party. It doesn’t matter where or how old the child is — it’s the same scenario and entirely beyond the child’s control.
Now let’s look at the poop side of things.
Some children with an enlarged rectum don’t experience urinary frequency, urgency, bedwetting, or daytime accidents. Instead, the very same rectal enlargement leads to very different symptoms: poop smears and/or full-on poop accidents.
Over time, the pile-up of stool stretches the rectum to the point where it loses the tone necessary for complete evacuation. The rectum just doesn’t have the oomph to shovel out the entire load of stool awaiting expulsion. The rectum becomes floppy, like an old, stretched sock that has lost elasticity.
The floppy rectum also loses sensation, so the child does not feel the urge to poop. Normally, this urge strikes when a critical mass of stool arrives in the rectum; receptors in the rectum then signal the brain to issue an alert: Find a toilet soon!
But in kids who regularly delay pooping, the rectum is already stretched out. So, it takes a truckload more poop to trigger those receptors. Sometimes, kids can’t feel a thing, and a vicious cycle ensues: More poop piles up, so the rectum becomes floppier, so even more poop piles up, and so on.
At this point, poop just drops out of the child’s bottom. The child cannot feel it and, eventually, becomes sensitized to the smell, a situation parents find hard to believe.
Poop smears are a less extreme version of this scenario. These “skid marks” signal the child is, unconsciously, overriding the urge to poop or not fully sensing the urge and a small amount escapes, anyway.
Some chronically constipated kids only have urinary symptoms; others only have poop accidents. Some have both.
In addition, some have recurrent urinary tract infections. Parents are often surprised that antibiotics don’t prevent UTIs from coming back, but that’s easily explained. Medication doesn’t attack the root of the problem: constipation.
As I’ve explained, chronically constipated children harbor a hefty load of poop in the rectum. Know what’s in this load? A gazillion bacteria. And by now you know what sits right near the rectum: the bladder. The offending bacteria crawl over the perineal skin and into the vagina and the area around the urethra, where they set up shop and multiply, causing pain and irritation.
Girls are far more prone to infection because they have shorter urethras than boys, so the bacteria have a shorter trip from the anus to the bladder, as I explain here.
So, there you have it: a rundown of the numerous symptoms triggered by a single medical condition, chronic constipation.
Unfortunately, the connection between these symptoms and a clogged rectum is not well known among the folks who regularly encounter children with toileting troubles, including teachers, school administrators, behavioral therapists, and even some medical professionals.
In many cases, the symptoms are misread as having psychological or behavioral origins.
A mom in our private Facebook support group posted a text message sent by her child’s therapist in which the therapist posits the boy’s accidents signal an attempt to “get his wants and needs met.” The therapist even scolded the mom for “reinforcing” the boy’s behavior by allowing him to wear a diaper.
“Constipation doesn’t have anything to do with urinating, I promise you that,” the therapist texted.
Actually, constipation has everything to do with the boy’s accidents. I promise you that!
Another mom recounted that when her daughter was 3, the girl’s preschool teacher punished her for having accidents — “no recess, no art class, no library time.” Unsurprisingly, the girl became even more constipated, holding pee and poop all day, for 12 hours, and then “exploding” when she came home.
The girl, now 6, was recently referred to a psychologist to help her overcome her “fear” of pooping on the toilet. But this scenario isn’t about fear of the toilet; it’s about a chronically clogged and stretched rectum. Everything follows from that.
When a child’s rectum is fully evacuated on a daily basis, it has the chance to shrink back to size, regain full tone and sensation, and stop irritating the bladder nerves. A saggy, stretched-out sock won’t bounce back, but fortunately, a stretched rectum will!
The healing process takes roughly 3 months but can begin only after impacted stool is cleared out and can continue only if the rectum remains clear, two challenges that can be far greater than parents realize.
I explain all of the above in the M.O.P. Anthology. If you’d like free resources to learn more, try these:
•For a more scientific explanation of the link between constipation and urinary troubles, read “Relevance of Constipation to Enuresis, Urinary Tract Infection, and Reflux,” a 1987 review paper by Sean O’Regan, M.D., and colleagues at the Hôpital Ste-Justine in Montreal. Dr. O’Regan, a pediatric kidney specialist, was the genius who first connected the puzzle pieces, revealing a picture clear as day.
•To better understand urinary frequency, read The Real Reason Some Kids Pee All the Time (No, Not to Get Attention!).
•Nope, "Deep Sleep" Doesn't Cause Bedwetting (It's Impossible) explains, well, exactly what the title says.
•To learn more about the link between constipation and urinary tract infections in young girls, read Why 1 Million Girls a Year Get UTIs.
•About That "Bedwetting Gene explains why nobody should wait around for their child to “outgrow” bedwetting, even if the condition runs in your family and you yourself outgrew it. I recommend treating bedwetting at age 4, as explained Don’t Assume Your Child Will Outgrow Bedwetting.
•To understand why psychological and behavioral therapy won’t fix bedwetting and accidents, read Enuresis and Encopresis Are Not ‘Mental Disorders.’ Let’s Remove Them From the DSM-5.
•Why is impacted stool so hard to dislodge, and what are the most effective methods? Read Children with Encopresis and Enuresis Deserve the Best Treatment, But Most Aren't Getting It and Olive Oil Enemas for Childhood Constipation: An Old-School Treatment Gets Scientific Validation.
•If you worry that enemas and suppositories are unsafe, too traumatic for children, or likely to cause dependence or electrolyte imbalance, read Daily Enemas Are Really, Truly Safe for Constipated Children.
•If you’re frustrated at the slow pace of your child’s treatment for chronic constipation, enuresis, or encopresis, download the M.O.P. Kickstart Guide.
•If you’re tired of waiting for your teenager to outgrow bedwetting, read Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable.
•If you have a constipated baby or toddler and would like to avoid spending the next decade dealing with toileting troubles, read A Better Way to Fix Constipation in Kids 3 and Under.