By Steve Hodges, M.D.
The mom of an 8-year-old with both bedwetting and encopresis (poop accidents) recently told me she doubts constipation could be the cause of her son’s accidents.
“He has a bowel movement at least once a day, often twice a day, and has never had constipation, to our knowledge,” she emailed. “He doesn’t fit the standard picture.”
Actually, he does!
Many of my chronically constipated patients poop every day or even more often. In fact, pooping multiple times a day is a red flag for constipation, a sign the rectum is never fully emptying.
Yet most folks, including many health professionals, assume a kid who is “regular” can’t be chronically constipated. Because of this assumption, countless children miss out on treatment for enuresis and encopresis entirely or go under-treated because their constipation is considered mild and temporary. What's more, the results of scientific studies on bedwetting and daytime accidents are skewed.
Constipation is all about complete evacuation. Pooping frequency may or may not accurately depict what’s going on inside the rectum, so keeping a bowel diary or otherwise tracking a child’s pooping patterns often tells you nothing.
Certainly, a child who poops three times a week is constipated — no argument there. The human body is designed to poop daily, so when the doesn’t happen, stool necessarily piles up.
However, while infrequent pooping signals constipation, you can’t assume the inverse is true — that a child who poops daily has fully evacuated. That’s a bit like assuming a person who smiles is happy: You may not be getting an accurate picture of what’s going on inside.
Often, when the rectum is clogged, newly generated, soft poop simply wends its way around the hard mass that is stretching the rectum and aggravating the bladder nerves. Therefore, the child’s regular bowel movements fool parents and doctors alike into thinking the child is “not constipated.” They fruitlessly look high and low for alternative explanations for the child’s accidents. In other cases, regular bowel movements fool doctors into thinking a severely clogged-up child is only mildly constipated and needs nothing more than fiber and Miralax.
Pooping frequency is not the only popular but unreliable method of assessing constipation status. Feeling a child’s belly, as physicians often do, also can be highly misleading.
Sure, in some kids, the abdomen is bloated, and sometimes a doctor can feel a hard mass. But often, the mass is undetectable, as I know from loads of experience. The rectum is elastic; there’s plenty of room for stool to hide, even in a small, wiry child.
The Bristol Stool Scale also can be misleading. This scale rates poop consistency from a 1, “separate hard lumps” (aka rabbit pellets), to a 7 “liquid consistency with no solid pieces” (aka diarrhea).
Absolutely, stool in the 1 to 3 range — firm, formed poop — indicates constipation. Poop that is evacuated daily does not have the chance to get hard and dried out. However, “smooth, soft sausage of snake" (a 4 rating) does not preclude constipation. This is true even in some children who produce soft, smooth stool on a daily basis.
A pelvic floor physical therapist emailed seeking advice for a 7-year-old with persistent bedwetting, stating, “He is not constipated (daily BM, Bristol 4).”
I advised her against making that assumption, explaining that x-rays often tell a different story.
One mom in our private Facebook support group posted that she was “incredibly surprised” to learn, via x-ray, that her daughter’s rectum was clogged with stool. “She went every single day, sometimes multiple times a day. It never, ever occurred to us that she could still be constipated.”
Another mom, whose daughter poops at least 5 times a day (yes! 5 times!), posted: “For two years, doctors told us over and over she could not be constipated because nothing hard was coming out. Her first x-ray showed that she was full.”
Likewise, the famous “corn test” and “beet test” — common tools for diagnosing constipation — often prove as deceptive as pooping frequency and consistency.
Corn (which doesn’t get fully digested) and beets (which turn poop reddish pink) are used because they are easy to identify in stool. You can’t miss ‘em! However, even if a child’s “transit time,” the time it takes to poop out food you ate, is less than 24 hours, the child’s rectum can still harbor a stool mass, so these tests reveal nothing of use.
The corn and beet tests are basically home versions the Sitz marker test, commonly used in GI practices. Early in my career, I would send my toughest bedwetting cases to GI colleagues to assess whether these kids were constipated. Patients would swallow capsules containing special markers, known as Sitz markers, that show up on an X-ray. Results would indicate these kids’ poop traveled through the colon in a timely manner, so the GI docs would pronounce my patients “not constipated.”
That verdict never made sense to me, since I knew that in children with an intact spinal cord, chronic constipation was virtually the only explanation for enuresis. How could these kids not be constipated?
Ah, but they were. Eventually, I began doing my own assessment via x-ray and measuring rectal diameter. The results were consistent: I’d see rectums full of poop and stretched to 2 or 3 times a normal diameter.
That’s when I realized we have a definition problem. The very word “constipation” is interpreted in wildly different ways. The conventional understanding of the word — “infrequent pooping” — is simply inadequate.
Recently, a mom in our private support group made that exact point, posting:
“Both of my kids pooped every day, never had a hard poop, never withheld their poops. I swear to this day, there needs to be another word for what is going on with my kids because the word ‘constipation’ doesn’t fit well.”
To this day, the only reason she believes her children’s rectums are clogged is that M.O.P. (the Modified O'Regan Protocol, a daily enema regimen) has led to significant improvement in the kids’ enuresis and encopresis. Obviously, if a child’s accidents were not caused by a clogged rectum, then unclogging the rectum would not stop the accidents! But it does.
I agree we need a better term than “constipation.” But “rectal dilation due to incomplete evacuation” doesn’t exactly roll off the tongue.
The larger issue is that we should not be relying on pooping frequency, abdominal exams, or “transit time” studies to diagnose and treat constipation. Children aren’t just missing out on effective treatment; scientists also are publishing studies I believe are misleading — studies that physicians use to guide their own understanding of enuresis and encopresis. The misinformation trickles down to parents.
For example, the Journal of Urology recently published a study on the use of Prozac (fluoxetine) to treat bedwetting. Prozac performed poorly (no surprise there, since enuresis is caused by constipation, not a brain chemistry imbalance). But the authors nonetheless concluded that Prozac is a “reasonable” treatment for children for whom other enuresis treatments don’t work and whose accidents are unexplained.
The scientists who trialed Prozac seem convinced there’s a significant group of bedwetting children who are not constipated. They asserted in the paper that they had excluded constipated children from their study, including only unexplained cases that were resistant to treatment.
But they never x-rayed their subjects! All they did was ask the children’s parents to maintain a bowel diary, presumably excluding children with infrequent bowel movements.
Countless other studies on enuresis and encopresis make the same mistake, rendering the results unreliable.
I guarantee that if the scientists studying these conditions would x-ray their subjects ad measured their rectal diameter, they would find clogged, stretched rectums. And if they prescribed an enema-based treatment protocol such as M.O.P., the stretched rectums would recover and the accidents would stop.
I'm not saying every child with enuresis needs an x-ray. If a child is having nighttime or daytime pee or poop accidents (and that child has an intact spinal cord), you can reasonably assume the child has significant and chronic constipation. I don't bother x-raying children with encopresis, because there is literally no other explanation besides constipation. However, if you or your doctor question whether your child's accidents are due to constipation, an x-ray will give you the answer, and pooping frequency will not.
The bottom line: If a child is having pee or poop accidents but is also pooping every day, that child is almost certainly has a pile-up stool in the rectum. You won’t convince me otherwise without an x-ray.