By Steve Hodges, M.D.
When a child develops type 1 diabetes or a urinary tract infection, nobody says the child is “lazy” or has anxiety or is “seeking attention.” Nobody sends the child to a therapist.
Yet when a child well past potty-training age has daytime accidents or wets the bed — conditions also outside a child’s control — adults often assume the root cause is psychological.
I hear this daily. Parents will tell me, “He’s too lazy to get up in the night” or “I think it’s because he’s being bullied.” A school will issue an ultimatum to one of my patients: See a behavioral therapist or find a new school. A parenting expert will write that accidents are “a reaction to heartache.” A child will quit soccer because his coach thinks his constant toilet trips are an excuse to avoid practicing.
Just last week a bedwetting teenager emailed me: “I cannot feel any urine going out, but I wake up wet every day. My mom thinks I'm stubborn and I don't want to wake up at night.”
I’d like to set the record straight: Bedwetting and daytime accidents are almost always caused by chronic constipation — not behavioral or psychological issues (and not “deep sleep,” an “underdeveloped bladder,” or “hormonal imbalance,” the other common explanations I debunk in It’s No Accident).
When children delay pooping, as they often do, stool piles up in the rectum, forming a large, hard mass. I mean, large! On X-rays I routinely see stool the size of a softball. The mass may stretch the rectum to triple its diameter — I take measurements. The stretched rectum presses on and aggravates the bladder, which in turn hiccups without warning, before the child can wake up or sprint to the toilet.
Eventually, the stretched rectum may also lose tone and sensation, becoming floppy like a stretched-out sock. The child can’t feel the urge to poop, and stool just drops out, sometimes on the floor of the school gym.
No amount of behavioral therapy will change these facts.
Medicine has advanced in so many ways over the last half century, but in my specialty — bedwetting and accidents — we’re stuck in the dark ages.
The constipation-bedwetting link was first documented back in the 1980s, in a series of studies by pediatric kidney specialist Sean O’Regan, M.D., practicing at Hôpital Sainte-Justine in Montreal.
At the time, bedwetting children were blamed by their parents and shrugged off by their doctors. “These kids were told that it was all in their heads, that they were psychologically disturbed,” Dr. O’Regan told me.
Dr. O’Regan, searching to explain his own son’s bedwetting, knew that was not the case. Ultimately he tested several hundred children with a procedure called anal manometry, whereby a balloon is inserted into the child’s anus and inflated.
A child with normal rectal tone will notice a balloon inflated with just 5 to 10 ml of air, whereas a constipated child might not even detect the balloon until it’s inflated with 40 ml of air. Dr. O'Regan's bedwetting patients could withstand an astonishing 80 to 110 milliliters of air without discomfort.
Dr. O’Regan’s studies also showed that when his patients’ rectums were cleared out with daily enemas, the accidents resolved. My own published research shows the same thing.
And yet, psychological explanations for bedwetting and accidents persist — not just among parents and school administrators but also among many in the medical community.
Many of my patients have been referred to behavioral therapists by their own pediatricians. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V) states, “Enuresis [bedwetting] can be triggered by separation from a parent, the birth of a sibling or family conflict.”
The evidence? The DSM-V cites exactly one study, published in an Indian medical journal, which itself cites no evidence.
A number of studies claim to have found a link between “difficult temperament,” “behaviour problems in early childhood” and bedwetting, but almost none of them considered whether the children were constipated. The omission alone renders these studies useless. And even the rare studies that have considered (and dismissed) constipation as a cause are of no value because their methods of detecting constipation are highly unreliable.
How do they check children for constipation? They have parents fill out a questionnaire asking whether their children a) poop fewer than three times a week and b) strain to poop.
I cannot emphasize how unhelpful these questions are. First of all, pooping frequency is a poor gauge of constipation. MANY chronically constipated children poop every day — even two or three times a day — because they never fully empty. Though these kids appear to be "regular," X-rays prove their rectums are chock full of poop.
Second, how many parents know whether their school-age kids are "straining" to poop? I don't know many moms who hang out in the bathroom while their 5th graders have a bowel movement. I was severely constipated throughout childhood and strained plenty to poop. I never mentioned this to my parents.
Dr. O’Regan conducted anal manometry on his patients because he knew parent reports were unreliable. I X-ray my patients for the same reason. Well over 90% of my bedwetting patients prove to be severely constipated, yet only about 5% of the parents had any idea.
Most of their pediatricians missed the constipation because they did nothing more than ask the parents how often the child poops and feel the child’s belly. But even small, wiry children can harbor massive amounts of poop in their rectum without anyone noticing.
To some extent, I can understand why adults seek psychological explanations for accidents. It’s just hard to believe a perfectly healthy 8-year-old could poop in his pants and not notice. Or that a 10th grader could fail to outgrow bedwetting, like most of his friends, or suddenly start wetting the bed.
But when you perform the right tests and ask the right questions, you can see why.
When I have a patient with "secondary enuresis" (bedwetting that starts after a long period of dryness), I don't assume the bedwetting actually came out of the blue. And I don't simply ask how often the child poops. In addition to doing an X-ray, I ask more relevant questions, such as whether the child has any history of daytime urgency, or frequency or extra-large poops, and whether the child has recently been in an environment, such as school, where he or she won't use the bathroom.
In talking with these families, I usually find the child has shown signs of constipation over the years — signs that went unrecognized — and that some relatively recent event has caused the child to use the bathroom less often.
A typical scenario: A kindergartener suddenly starts wetting the bed or having accidents after being dry since age 2 or 3. The parents attribute the accidents to the “stress” of starting a new school. In reality, the child was too intimidated to use the school bathroom (or was restricted by school rules) and started withholding pee and poop.
Something similar often happens in high school, because students encounter stricter bathroom policies, are grossed out by bathroom conditions, or fear being bullied in the bathroom. Many of my patients never use the restroom between 7:30 a.m. and 3:30 p.m. In kids with a history of moderate constipation, that change is enough to trigger bedwetting.
Of course, I always rule out medical causes for bedwetting, such as an anatomic or neurological condition or diabetes. On very rare occasions, the cause turns out to be something other than constipation.
But virtually all the time, constipation is the culprit, and aggressively treating the rectal clog resolves the accidents. They key is to keep the rectum clear on a daily basis so it has time to shrink back to size and stop bothering the bladder. A one-time clean-out will not do the trick.
While it is clear that stress and behavioral issues do not cause bedwetting, it’s also clear that bedwetting can cause children tremendous stress. These kids get teased by peers and blamed and shamed by adults. They avoid sleepovers and camping trips and feel crummy about themselves. They sit in my office and hang their hands.
But when they get properly treated and their accidents resolve, their entire demeanor changes. They brighten up, become more social, regain their confidence, and start participating in activities they’d avoided for years.
About the Author
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and co-author, with Suzanne Schlosberg, of Bedwetting and Accidents Aren’t Your Fault, Jane and the Giant Poop, It’s No Accident, and The M.O.P. Book. http://bedwettingandaccidents.com/