Why Undertreating Constipation Can Make Accidents Worse
- 9 hours ago
- 7 min read
By Steve Hodges, M.D.
In life, sometimes less is more. But when it comes to treating chronic constipation in children, sometimes more is more.
I’m talking about more intensive treatment—a stronger dose of senna (Ex-Lax), more frequent enemas—than many parents feel comfortable with.
Understandably, parents often err on the side of less. They worry their child will become dependent on enemas or Ex-Lax, or that these remedies pose a safety risk.
One mom in our support group, treating her 5-year-old for encopresis and bedwetting, worried that daily enemas were becoming a “crutch” for him. “It feels like he’s never going to poop on his own," she said, "because it’s always the enema that makes him poop.”
Likewise, the mom of a 10-year-old with nighttime enuresis and intermittent encopresis stopped senna after two days, instead treating her daughter with ½ cap of Miralax daily and timed toilet sits. The child’s nightly wetting persisted, along with her pooping difficulties.
I emphasized to both moms that undertreating constipation can actually be counterproductive.
What may feel like the safer, more conservative approach often prolongs or even worsens symptoms, ultimately dragging out the very treatment families are eager to finish.
In this post, I’ll explain how half-measures can stall progress — and when to step up treatment so your child can overcome bedwetting, daytime accidents, and encopresis faster.
Early in my career, I relied on the conservative approach I learned in medical school: a Miralax “clean-out” followed by daily Miralax. Maybe a week of Ex-Lax at moderate doses. Enemas only in the most severe cases.
Two decades and 15,000+ cases later, I’ve done a 180.
I know daily enemas and/or daily senna—even when taken for months—do not cause dependence.
I know that in many cases, twice-daily enemas will stop accidents much faster than once daily. (And yes, two-a-day enemas are safe, as long as the solution is glycerin or docusate sodium, not phosphate.)
I know the doses of Ex-Lax that get the job done are far higher than parents—and many doctors — are comfortable with. Some kids need 6 squares, and that’s fine.
I know that for most kids with enuresis and/or encopresis, a Miralax-only regimen—no matter the frequency or dose—is a waste of time. Often, it’s a ticket to worsening symptoms.
I know many doctors will balk at all this—and will continue to recommend the treatments I gave up on 15 years ago.
To appreciate why “more is more,” it’s important to recognize the three steps to resolving pee or poop accidents for good.
Step 1: Empty the rectum.
Kids with enuresis and/or encopresis have more stool piled up in the rectum than most parents can comprehend. (Many are shocked when I pull up their child’s x-ray.) These kids don’t fully evacuate with each bowel movement. So, even if they poop every single day, stool keeps accumulating while the rectum stretches accordingly.
This “rectal stool burden,” as it’s known, cannot be flushed out instantly, the way a colonoscopy prep will empty out an adult. A Miralax “clean-out” is a misnomer. Similarly, a single enema won’t unclog the rectum the way Roto-Rooter unclogs your sink.
In reality, fully emptying the rectum can take weeks of daily enemas, even months. It can sometimes seem as if stool has been Super-Glued to the rectum. Also of note: poop accidents will stop well before the rectum has emptied, so while you can (and should!) celebrate accident-free days, you can’t assume the rectum has cleared out, let alone healed.
Step 2: Keep the rectum empty for several months so it can shrink to normal size.
Once fully emptied, the stretched-out rectum needs about three months to regain normal tone and sensation and to retract enough to stop aggravating the nearby bladder nerves.
Healing can only occur if the rectum remains empty on a daily basis. So, it’s critical to keep up an intensive bowel-clearing regimen during this period. The rectum is still floppy, lacking the oomph needed for complete evacuation unaided. And in the early stages of healing, the child may not feel the urge to poop strongly or consistently enough to poop on their own.
Step 3: Retrain the child to act on the urge to poop.
Once rectal sensation has returned, children with a long history of withholding stool may need help responding to the urge to poop. An osmotic laxative such as Miralax will keep stool soft, but for some kids, that’s not enough. Initially, they need a stimulant laxative such as senna. But soon enough, they’ll taper off that, too.
Key point: resolving chronic constipation is not a one-and-done endeavor. It’s a long haul. The idea that a Miralax clean-out, a few enemas, or a week-long course of Ex-Lax will suffice is simply unrealistic.
Yet that’s what doctors tend to prescribe, either because they don’t understand the severity of their patients’ stool accumulation (as I didn't) or because they believe extended use of enemas or senna is unsafe.
I’ve written plenty about the safety of enemas and senna, so I won’t rehash that here.
Instead, let’s consider the perils of under-using these excellent tools.
Why Backing Off Can Backfire
Many parents start weaning their child off enemas before the rectum has fully healed because they fear their child has become dependent on them to poop. As evidence, they’ll say, “He never poops except after the enema. Before we started enemas, he would poop every day.”
My response: When he was pooping every day, he wasn’t fully evacuating. So, stool kept piling up, leading to accidents.
What matters is complete evacuation. Until the child’s rectum empties and heals — both processes are necessary — he may not be able to fully evacuate on his own every day. It’s not realistic to expect him to do so right now.
If a child tapers off enemas before the rectum has healed, constipation is likely to creep back until boom—accidents recur. The best way to avoid this frustrating scenario is to follow the complete treatment plan. The rule of thumb with the Modified O’Regan Protocol, the approach I favor, is to delay tapering off enemas until the child has been 100% accident-free for at least 30 days and nights and to taper very gradually.
The various taper plans spelled out in the M.O.P. Anthology have built-in mechanisms to make sure the child is pooping on their own before stopping treatment. For kids who have trouble responding to the newly restored urge to poop, senna is an excellent tool, as I explain in the Anthology.
But back to enemas. When a child’s accidents persist and the kid is not pooping except after an enema, the instinct among many parents is to back off the enemas. My instinct is the opposite: add a second daily enema (as long as it’s glycerin, glycerin + water, or docusate sodium).
The original Modified O’Regan Protocol—the regimen developed by Dr. Sean O’Regan back in the 1980s—began with a month of daily enemas.
While this regimen, now known as Standard M.O.P., is infinitely more effective than a Miralax-only regimen and, for most kids, far better than senna-only treatment, I’ve found that it does not suffice for many of my patients. These kids are essentially treading water—building up new stool at the same pace they’re emptying. They’re not making an appreciable dent in the stool burden.
That’s where a second daily enema makes a real difference. (And yes, it’s safe, as I detail in the Anthology.) Many of my patients don’t see improvement in accidents until they start pooping twice a day with the help of two enemas (the Multi-M.O.P. regimen) or one enema plus an appropriate dose of senna (the M.O.P.x regimen).
In my practice, Multi-M.O.P. has proven so much more effective than Standard M.O.P. that I recommend it as the starting point for children with daily encopresis, daytime + nighttime enuresis, and especially for kids with the “trifecta” — bedwetting, daytime wetting + poop accidents. I also recommend it for bedwetting-only kids whose x-rays show a substantial stool burden.
Now let’s turn to Ex-Lax — specifically, why taking too little back backfire.
Many parents will limit their child to 1 or 2 squares—even if the dose doesn’t trigger a bowel movement—because they’ve been told that too much senna is “toxic.” (Untrue.) Or, they’ll limit the child to a low dose for fear the child will experience cramping or nausea.
What children actually need is a dose that will reliably trigger a bowel movement within 5 to 8 hours. For some children (not many), 1 chocolate square will do the trick; most children need significantly more.
The problem an inadequate dose is that it won’t trigger a strong enough urge for a complete and timely bowel movement. Many kids will subconsciously fight the urge and experience underwear smearing. Other kids won’t feel anything and just won’t poop, defeating the whole purpose of taking senna.
So, ironically, giving too little senna in an effort to avoid side effects can create problems of its own. A child may spend weeks taking Ex-Lax without ever getting the bowel movement we're trying to achieve.
A note about side effects: Some cramping or nausea comes with the territory, especially in early stages of treatment, when the child’s rectum is super full. So, senna isn’t for every child. Many kids prefer two enemas per day to one enema plus senna.
My larger point applies whether we’re talking about senna or enemas: Don’t mistake less treatment for safer or better treatment.
If your child’s accidents persist or recur, the answer may not be to back off or give the regimen more time. It may be to intensify treatment so you can finally make headway against the stool burden.
I realize that can feel counterintuitive, especially when you’re eager to get your child off enemas or senna. But undert-reating chronic constipation only prolongs the process. Treating intensively enough to empty and heal the rectum is what ultimately allows you to taper—and finish treatment without looking back.
The M.O.P. Anthology includes algorithms for enuresis, encopresis, and the trifecta—treatment roadmaps that recommend when to intensify treatment.