What You Can—and Can’t—Expect When Treating Bedwetting and Daytime Accidents

Treating bedwetting and accidents takes persistence—and sometimes a change in strategy.

By Steve Hodges, M.D.

My topic today is expectations — what’s reasonable to expect when treating your child’s enuresis and/or encopresis.

I find that many families expect accidents to diminish more quickly and more consistently than typically occurs. As a result, frustration mounts, and families stop treatment, assuming it’s “not working” or that constipation wasn’t the culprit to begin with.

But stopping treatment early only drags out recovery, and constipation is virtually always the cause, unless proven otherwise via x-ray.

Families who start out with realistic expectations are better equipped to weather setbacks, make adjustments, and hang in there long enough to shut down accidents for good.

In my clinic, I aim to head off frustration by reminding folks that chronic constipation is, well, chronic. Resolving this vexing condition takes both resolve and experimentation — or, as one dad in our support group put it, “persistence and pivoting.”

This dad recently updated our support group on his 7-year-old’s treatment for the “trifecta” — bedwetting, daytime wetting, and poop accidents.

The family began Multi-M.O.P. (a variation of the Modified O’Regan Protocol) a year ago. The boy’s encopresis resolved right away, but wetting persisted day and night for months.

At that point, many families, understandably tired of the routine, would have abandoned ship, perhaps assuming the child’s condition was intractable or had a different cause altogether.

But these folks carried on. Six months into treatment, an abdominal x-ray showed why the wetting persisted: the child’s rectum was still harboring stool. It was past time for a shake-up.

Two high-dose oral clean-outs, in conjunction with Multi-M.O.P., temporarily stopped daytime wetting, further confirming that constipation was the underlying cause. Further adjustments led to more progress.

Now, his dad reports, the boy’s progress has accelerated. He hasn’t had a daytime pee accident in a month and has been dry three out of four nights. What’s more, for the first time ever, he’s able to stop playing and use the toilet.

“It is nice to not have laundry full of underwear every day and travel with ease to see family,” his dad posted.

It has taken a full year of robust treatment—and plenty of persistence and pivoting—for the boy to get this far. This is a common timeline for children who begin with the trifecta.

Here’s a summary of what you can — and can’t — expect from the M.O.P. approach to treatment.

#1: You can expect quick and dramatic improvements in encopresis.

I’m not a person given to hype, but even children who’ve had daily poop accidents for years typically see a major decrease—if not a complete cessation—within a week of starting Multi-M.O.P.

Some kids, such as those with fecal impaction (visible on an x-ray), need to start with J-M.O.P., a regimen that involves overnight oil enemas in addition to daytime stimulant enemas. But it is rare for a child not to make huge leaps upon implementing Multi-M.O.P., a protocol involving two daily glycerin or docusate sodium enemas.

#2: You can’t expect a clogged rectum to empty on one enema per day.

This is a corollary to #1. Children with daily poop accidents or the trifecta will likely see improvement on a regimen such as Standard M.O.P. However, experience has taught me that to make a real dent in the rectal clog, these kids need to stimulate not one but two bowel movements per day.

In kids with chronic constipation, a bowel movement stimulated by an enema (or an appropriate dose of Ex-Lax) will evacuate more stool than a spontaneous poop. Early in treatment, it typically takes two stimulated bowel movements per day to appreciably decrease the rectal stool burden.

Pooping once a day may prevent symptoms from worsening and decrease accidents, but in significantly constipated children, progress is likely to be incomplete and temporary. Exhibit A: the 7-year-old mentioned above, whose rectum still contained stool after six months of twice-daily enemas. His rectum emptied enough to halt poop accidents but not enuresis.

#3: You can expect bedwetting to linger for months after daytime wetting stops.

In enuresis-only children (those who never had encopresis), daytime wetting often diminishes within a month or two of starting treatment and sometimes stops altogether.

However, nighttime wetting typically lingers far longer, for a cluster of reasons described in The Long Lag: Why Bedwetting Takes Longer to Fix Than Daytime Accidents.

This doesn’t mean nothing can be done during the Long Lag. In many cases, this is the perfect time to introduce bladder medication. While bladder meds won’t speed up rectal healing, the dry nights they can provide often give kids confidence and peace of mind as they wait for the rectum and aggravated bladder nerves to heal.

In certain cases, bladder Botox is warranted.

#4: You can’t expect linear progress.

Setbacks are a common source of frustration. A child might experience two weeks of daytime dryness and then . . . boom — four straight days of pee accidents. Or maybe a kid had three consecutive months of bedwetting improvement — say, 6, 10, and then 15 dry nights — and then started to backslide.

Parents ask: We’ve been so diligent — how can this be happening? What are we doing wrong?

But it’s not anyone’s fault. When a child’s bladder nerves have gone haywire and signals to pee are on the fritz, recovery is an uneven process. It’s simply the nature of enuresis.

Sometimes there’s a specific explanation, like the family had to dial back treatment on vacation and the child’s rectum started to refill. But often there’s no rhyme or reason.

#5: You can’t expect kids to spontaneously poop shortly after starting treatment.

I often hear: “Before starting M.O.P., my child was pooping on his own, but now he never poops except after an enema.”

Parents worry their child has become “dependent” on enemas. But that’s not the case. It simply means the child’s rectum hasn’t regained the sensation and tone needed to evacuate daily.

A rectum stretched for years won’t bounce back overnight. In my experience, it takes a good three months for the rectum, once emptied, to regain full tone and sensation. And before that, it may take several months for the rectum to fully empty.

Accidents stop well before rectal healing has occurred. In the case of encopresis, especially, parents expect kids to start pooping on their own once accidents have stopped. But it’s just not realistic. These kids just aren’t feeling the urge yet.

Even when they do regain sensation, it often takes time and practice for them to respond immediately and consistently. Kids with a long history of overriding that urge may still have the withholding instinct. This can be overcome with methods I discuss in the M.O.P. Anthology. Senna is a particularly useful tool.

But parents need to give kids time.

#6: You can expect trial and error before finding the regimen that works best for your child.

Over the years, M.O.P. has evolved from a specific regimen into a broader, enema-based treatment approach. We now have six distinct M.O.P. variations, involving a mix of enemas and osmotic and/or stimulant laxatives, and many parents have had success with hybrid variations.

I tell families: Here’s a reasonable place to start, but be prepared to shift gears. You just can’t predict how a particular child will respond to a particular enema or laxative or a particular combination. And a regimen that worked well at first may become less effective over time, requiring a change.

My rule of thumb: Assess your child’s progress every 30 days. If the child has stalled or is backsliding, make a change. The M.O.P. algorithms—our treatment roadmaps for bedwetting, encopresis, and the trifecta—are designed to help you make treatment decisions. You can find them in the Anthology.

#7: You can expect backsliding if you stop treatment early or taper too quickly.

I advise families not to begin tapering off enemas until the child has been 100% accident-free, day and night, for at least 30 days. And then I recommend a very gradual taper.

Yet I often hear: “I’m not bothered by my child’s bedwetting, so we started weaning off enemas when his daytime accidents stopped.”

Or, “Our doctor told us to get off enemas asap, so we switched to Miralax when he started getting dry.”

Cutting treatment short is a mistake.

Even if parents aren’t bothered, children are often far more self-conscious about wearing pull-ups to bed than their parents realize, especially as they get older and get invited to sleepovers.

But even if the child genuinely doesn’t mind wetting at night, halting treatment before the child is reliably accident-free or stopping enemas abruptly is an express ticket to worsening symptoms.

Daytime accidents are likely to return and achieving overnight dryness will take a lot longer than it otherwise would have.

As I’ve explained, just because accidents have stopped doesn’t mean the rectum has bounced back. In those early months, the rectum is highly prone to refilling. And in children with a sensitive bladder, even a tiny bulge in the rectum can trigger accidents. So, it’s imperative to keep the rectum empty.

Accidents do sometimes return even after a child has been accident-free for 30 days and after a very slow taper. However, the odds are much lower, and beating back a recurrence will be much easier if you follow the treatment protocols all the way through.