By Steve Hodges, M.D.
Does resolving chronic constipation stop bedwetting?
Yes, undeniably. I’ve treated enuresis (bedwetting and daytime wetting) for 20 years, and everything I’ve learned — from my patients, my research, and the scientific literature as a whole — points to a clear answer.
And yet, a reader recently sent me a Swedish study that would seem to challenge my position.
The paper, published in the Journal of Pediatric Urology, is titled: “Fecal disimpaction in children with enuresis and constipation does not make them dry at night.”
Furthermore, the authors assert, children with enuresis “should not be given the false hope that this approach alone will make them dry at night.”
I don’t know whom the Swedish authors believe is giving children false hope — they don’t specify. However, it’s possible they are referring to me, as their paper references my research, and I frequently assert that resolving constipation stops enuresis.
At any rate, the Swedish paper misses a critical point: Enuresis is caused by chronic constipation, and the conditions that trigger accidents develop gradually. Reversing enuresis is often a maddeningly slow process. The two-week treatment evaluated in the Swedish study, involving enemas and laxatives, had no chance of stopping nighttime accidents.
Still, the study raises important issues. It’s a good springboard for discussion of what it really takes to stop bedwetting and what families can reasonably expect from constipation treatment.
Now, you’re probably familiar with the term “straw man argument.” This is an argument that misrepresents an opposing position and then argues mightily against the distorted version so that it’s easier to attack.
Compared to a real opponent, a scarecrow is easy to knock over.
In my opinion, the Swedish paper makes a straw-man argument. The article seems to take a position I hold (that resolving chronic constipation halts bedwetting eventually) and morphed it into a position I don’t hold (that short-term constipation treatment will halt bedwetting immediately).
On the subject of enuresis treatment, here’s what I believe:
•Bedwetting and daytime wetting result from the same scenario: Over time, the rectum, enlarged by a pile-up of stool, encroaches upon and irritates the bladder nerves. Eventually, the bladder starts to contract and empty without warning, day and/or night. (Children with both daytime and nighttime wetting are typically, but not always, more clogged than those with bedwetting alone.)
•Resolving enuresis requires two steps: 1.) completely evacuating the rectum of stool, and 2.) keeping the rectum clear on a daily basis so the rectum can retract to normal size and stop irritating the bladder. Each of these steps can take months.
•In some children, daytime enuresis diminishes with two weeks of daily enemas, but bedwetting rarely improves that quickly. The treatment regimen I advocate, the Modified O’Regan Protocol (M.O.P.), involves daily enemas for at least 30 consecutive days and as long as it takes the child to become reliably dry. Then you gradually taper off enemas, over a period of months.
In fact, in the M.O.P. Anthology 5th Edition, I state: When families start M.O.P., they assume enemas are so powerful, like a dynamite blast, that the child’s rectum will be emptied out within a day or two. Thirty days of enemas seems nuts! But reality can be sobering. Some children are so stubbornly clogged with stool and have so completely lost the urge to poop that a month of enemas achieves little or nothing. Heck, a kid can administer enemas every day for a year and get nowhere if the enema isn’t doing the job.
•Different children respond best to different enema solutions. Some kids get emptier with liquid glycerin, and others with phosphate (Fleet), or docusate sodium. I did not realize this earlier in my career, when I assumed any enema would work fine in any kid. These days, I urge my patients to experiment.
•Children with enuresis who poop twice a day (with the help of enemas alone or enemas plus laxatives) tend to empty and overcome accidents more quickly than those who poop just once a day. Some kids can achieve two daily bowel movements with an enema plus an osmotic laxative, whereas others need either an enema plus a daily stimulant laxative (such as Ex-Lax) or two daily enemas (which can safely be done using liquid glycerin or docusate sodium). Again, this is something I didn’t realize earlier in my career. Less aggressive treatment regimens will be less effective.
Now let’s take a closer look at the Swedish paper.
The authors start off with a statement I endorse: that constipation treatment “has been shown to be an important aspect of therapy” for children with daytime incontinence. Absolutely! My own published research confirms this.
But the authors insist the picture is murkier for nighttime wetting. So, they set out to assess whether fecal disimpaction — unclogging the rectum — would halt bedwetting in children with both bedwetting and constipation.
“The value of fecal disimpaction, as a part of constipation therapy, in children with enuresis has not been evaluated,” they explain.
This is true. No one has specifically studied the value of disimpaction for enuresis treatment — for good reason! Disimpaction is just the first step in the long process of resolving chronic constipation. The rectum must remain empty long enough to shrink back to size (roughly three months). In addition, children with a deeply ingrained tendency to delay pooping must re-learn to respond to their body’s urge to poop — no easy task. In my opinion, there’s little point in evaluating the first two weeks of a process that typically takes months.
Still, that’s what the Swedish folks did, so let’s look at what transpired.
The authors evaluated 66 children with nocturnal enuresis, ages 6 to 10. They declared 23 of these children (35%) constipated, based on ultrasound or the Rome IV criteria for functional constipation, a list of nine common constipation symptoms, such as pooping less than three times a week and passing toilet-clogging stools.
I consider both diagnostic methods unreliable, as I discuss in my Zoom course for health professionals. In my experience, clinicians who rely on ultrasound or a patient’s pooping history, rather than x-ray or anorectal manometry, will miss many cases of constipation.
Tons of kids who poop every day and pass mushy stools are nonetheless severely constipated, as proven by x-ray. These kids just don’t fully evacuate; it’s incomplete evacuation, rather than pooping frequency, that defines constipation. Also, soft, new stool can ooze around the hardened mass, so the mushy poop that parents observe can obscure the underlying rectal clog.
But more on that later. For now, let’s stipulate that only 23 of the Swedish patients were indeed constipated.
According to the paper, the children with documented constipation were prescribed “daily mini-enemas for three days followed by every other day during one week.” (The authors don’t specify what type of enema solution was used.) After the “initial evacuation,” the children were instructed to poop every day or at least every second day. “If the child did not have bowel movements for two days, additional mini-enemas would be given.” The children also took PEG 3350 (Miralax).
How well did this treatment work? Not well at all!
Prior to the study, they wet the bed 9.8 times, on average, over two weeks; during the two weeks following treatment, they averaged 9.3. bedwetting episodes. In other words, no improvement.
From this, the authors concluded that fecal disimpaction “does not alleviate nocturnal enuresis.”
But that’s like concluding that two weeks of a dietary overhaul “does not alleviate obesity.” I mean, how could it?
In my experience, only a far more aggressive regimen, involving daily enemas for at least a month before gradually tapering, would have a chance of success in children with persistent enuresis.
Interestingly, a study demonstrating the effectiveness of this regimen has been done, but the Swedish authors dismiss it in their paper.
The study, published in 1986, was conducted by Sean O’Regan, M.D., the pediatric kidney specialist for whom the Modified O’Regan Protocol is named and a physician I’ve spoken to multiple times.
In his study, Dr. O’Regan performed anorectal manometry on 25 children with enuresis (nighttime, daytime, or both) and categorized 22 of them as chronically constipated. These kids were so lacking in rectal tone that when a balloon was inserted rectally and inflated, most felt no discomfort, even when the balloon was maximally inflated, to the size of a medium tangerine.
The results suggested the children had, on average, a rectal diameter of 6.5 cm. By comparison, a normal rectum measures no more than 3 cm.
Seventeen of Dr. O’Regan’s patients consented to undergo the treatment regimen that had cured bedwetting in his son: one phosphate (Fleet) enema per day for a month, followed by one enema every other day for a month, and one enema twice a week for a month. (I tell the fascinating story of Dr. O'Regan's son in The M.O.P. Anthology and Emma and the E Club.)
After the three-month regimen, all 17 patients had either improved or stopped wetting. On average, Dr. O'Regan wrote, it took 16 days for the children to report either “cessation or improvement” of enuresis, with a range of 3 days to 6 weeks. (He did not specify whether daytime wetting began to clear up faster than nighttime wetting, but that has been my experience with Dr. O’Regan’s regimen.)
Dr. O’Regan attributed his success to “treatment of constipation in an aggressive manner” — in other words, daily enemas for a month (“for evacuation of the rectum”) and less frequent enema treatment for an additional two months (to maintain the rectum “in empty state until normal rectal tone returned”).
These are terrific results, yet the Swedish authors dispense with Dr. O’Regan’s study thusly: “It can be assumed that the children examined represented a hard-core population that is not directly comparable to our sample.”
That’s an odd assumption! The Swedish children wet the bed five nights a week on average — “hard-core” enuresis by any definition and a scenario that, in my clinic, would absolutely warrant daily enema treatment until dryness. Without aggressive treatment, children who wet the bed five nights a week at age 10 have low odds of spontaneously achieving dryness.
That wasn’t the only odd assumption. The Swedish paper references a study of mine, published in Urology in 2012, in which I looked back at 30 consecutive enuresis patients and analyzed their constipation status via x-ray. The films showed all these kids had an enlarged rectum, consistent with what I’ve seen in the decade since. For unexplained reasons, the Swedish authors consider my sample of patients “highly biased.”
Certainly, all my patients had severe enough enuresis that their parents took them to a pediatric urologist. So, sure, my patients are biased toward “hardcore” cases. But I’ve looked at thousands of x-rays of kids with enuresis, and I can tell you that virtually all these kids have rectums enlarged by a stool mass. It takes pretty severe constipation to cause enuresis. In most cases, the child’s constipation had gone undiagnosed by the referring healthcare provider. (In the Anthology, I discuss the rare medical conditions that cause enuresis in the absence of constipation.)
Also odd: The Swedish authors are convinced that daytime enuresis is caused by chronic constipation but are skeptical that nighttime enuresis has the same cause. They write that “treatment of daytime incontinence in these children will usually only be successful if the constipation is also recognized and treated" but also state: “The link between constipation and enuresis, as opposed to daytime incontinence, is less firmly established.”
I strongly disagree. Dr. O’Regan’s multiple published studies confirm the link and cannot be dismissed. I believe that if the Swedish authors regularly diagnosed constipation with x-ray or anorectal manometry rather than ultrasound or the Rome IV criteria, they would see the connection more clearly.
In my clinic, we x-ray all enuresis patients and conduct follow-up x-rays on children who do not make progress on a daily enema regimen. When treatment stalls, x-rays inevitably show why: rectal stool remains. In some kids, evacuating a hard, crusty stool mass is more difficult than parents ever imagined. For these children, I recommend the more aggressive variations of M.O.P., involving overnight olive oil enemas to soften stool and/or two glycerin enemas per day.
The more aggressive variations of M.O.P. work for almost all kids, but still, there are outliers. Sometimes, combining M.O.P. with bladder medication halts or at least diminishes accidents while we continue with enema treatment. (Medication is pretty useless if the constipation is not simultaneously addressed.)
In the most stubborn cases, I use bladder Botox, a highly effective surgical treatment that lasts longest in children who have done an aggressive course of M.O.P. As I explain here, the effectiveness of Botox provides additional evidence that constipation is the underlying cause of both bedwetting and daytime wetting.
The Swedish authors say they embarked on their study because bedwetting is difficult to treat. I don’t disagree — overcoming enuresis is challenging. However, the authors grossly overstate t the difficulty, asserting that “many children with enuresis, perhaps 25%, are resistant to all therapies.”
This is not remotely true. The problem is that the standard therapies — MIralax “clean outs,” bedwetting alarms, medication — aren’t up to the task. When you include the more aggressive treatments, such as M.O.P. and Botox, you can resolve enuresis in all children. (I recognize that not all children have access to bladder Botox, but the most aggressive versions of M.O.P. can be implemented with nothing more than liquid glycerin, olive oil, and syringes.)
On the other hand, if you consider a two-week enema regimen to be maximally aggressive, you will have a sizeable contingent of patients who continue to wet the bed.
To their credit, the Swedish authors point out a significant flaw in their study: They did not evaluate their subjects for constipation status after the 14-day treatment period.
“We do not know whether the constipation treatment actually worked against the constipation,” they note, adding: “Maybe they were still constipated.”
I would bet on it! Heck, for some of my patients, several months of daily enemas doesn’t make a dent — not until we add overnight olive oil, daily Ex-Lax, and/or a second daily enema. These days, based on x-rays and the child’s age, I start kids off with more aggressive treatment than I did early in my career, so I have more success. With teens and tweens, especially, I tend to go straight to the stepped-up regimens.
READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
You can’t overstate the value of follow-up x-rays. Consider, for example, a study my clinic conducted on daytime enuresis, comparing a PEG 3350 regimen to Dr. O’Regan’s original three-month regimen. The before-and-after measurements explained why certain kids got dry and others didn’t.
Prior to the study, the 60 children in the study had, on average, a rectal diameter of 6 cm, twice normal size (and roughly the same size as the children in Dr. O'Regan's study). After three months of treatment, 85% of the children in the enema group ceased daytime wetting, compared to 30% in the Miralax group.
X-rays showed that among the enema group, rectal diameter had shrunk, on average, to 2 cm, whereas among the Miralax kids, rectal diameter had only decreased to 5 cm — negligible improvement. Even after all the enemas, three of enema kids continued to have daytime accidents. Why? Because their rectums were still clogged with stool and had not shrunk at all. These are the children who need more aggressive variations of M.O.P.
Why didn’t the Swedish authors assess whether their treatment actually resolved constipation?
Their reasons — “resources and logistics” — strike me as weak.
Also, the authors state that extending enema treatment in children with bedwetting is “not defensible” unless children also are experiencing poop accidents (encopresis) or “bothersome bowel complaints.”
I strongly disagree. Certainly, children with encopresis require immediate and aggressive treatment such as M.O.P. But children with enuresis need not have poop accidents or abdominal pain to suffer from their condition.
Bedwetting, alone, often crushes kids’ self-esteem and severely limits their social life, making sleepovers and sleep-away camps too stressful or embarrassing. Just because life could be worse for children with enuresis doesn’t mean these kids don’t deserve the most effective treatment possible.
The Swedish authors describe their therapy as “reasonably intense,” but from where I sit, the two-week treatment wasn’t intense at all.
Furthermore, the authors describe “the current treatment situation” for the children with enuresis as “not satisfactory.” Here, I agree — but the only reason the treatment landscape falls short is because most doctors do not prescribe the treatments that actually work.