I recently spoke to Dr. Steve Hodges, author of the Urology study which found that most bedwetters had extra stool in their rectums (stay with me), and that their bedwetting was cured by taking laxatives. Hodges says the cure result rate with laxatives was 83 percent. That’s high! He offered me some tips to try to deal with not only bedwetting but daytime accidents as well. I’m a bit skeptical about whether or not they’ll work, because bedwetting has a large genetic component. I know this because my daughter’s pediatrician told me, because both my mother and I were bedwetters (yay!), and because a new study in the Canadian Medical Association Journal confirms it. In other words, peeing the bed is something that runs in families, and if you come from a long line of bedwetters, there’s not much you can do but wait it out. If you’ve got a bedwetter in your house, you’ve likely tried everything from no drinks after dinner to bed-wetting alarms, which the CMAJ says are the most effective in treating the problem. Here’s my interview with Hodges, and what he says will work to get through this trying time:
Carolyn Castiglia: I have a friend who didn’t really potty train her daughter; she basically let her daughter choose when she was ready to use the bathroom, which happened right when she turned 4. Things have been pretty accident-free for them as a result. I know you advocate not pushing the potty until at least 3. Can you explain why you think that works best?
Dr. Steve Hodges: This is actually a very controversial topic, but why I favor late training is based on my observations and research in my clinic. I have looked into what ages of toilet training are most associated with toileting problems in children. What my data showed was that if children trained very young (typically before 2 years) or if they trained very late (after 3) then they were more likely to have bladder overactivity and accidents. This mirrored the results of previous studies. Actually several studies have shown worse outcomes with late training. This didn’t make physiologic sense to me because from other studies and pathologic bladder models we know that uninhibited voiding (meaning not postponing going to the bathroom) leads to greater bladder growth and compliance, which should lead to less accidents. Training at a young age (when children may be more prone to delay voiding or defecating) makes sense as a cause of bladder accidents, and it does cause bladder issues when these young children put off going to the bathroom chronically right during the time of greatest bladder growth (first 3 years of life).
Looking deeper we found that the only reasons late trainers have problems with voiding is that they had concurrent missed constipation. So we have proven (at least to ourselves), and it fits all the models of bladder physiology, that uninhibited voiding leads to bladder growth and less bladder problems (accidents, etc.) as long as there is no concurrent constipation. Early training can be a risk factor. Also, if problems arise in children, such as severe constipation, it is easier to resolve while in diapers. Two more anecdotes help support this: I have never seen a urinary tract infection in a child in diapers, and I see hundreds in kids that have recently trained. Also, the therapy for bladder dysfunction in children is to place children on a voiding schedule and laxatives, in other words take the decision of when to go to the bathroom out of their hands!
CC: I potty trained my daughter somewhere between age 2 and 3 and things went well for a while, but her father and I got divorced when she was 3 and she still has peeing accidents now at age 6. Any tips for someone in my situation?
SH: There are several steps (that can be quite complicated) involved in the therapy of accidents in children, but most children are improved with a few simple steps. First of all, dealing in a positive way with the stress related to the divorce if it is still a stressor is important. From a purely urologic perspective two simple things help most kids. First, place the child on a voiding schedule, meaning she should void upon awakening, and then every 2 hours through the day, and then again before bed. It is important she goes even if she doesn’t feel like it, and that she goes for long enough to empty the bladder. Secondly, even if it isn’t clinically apparent, constipation or the accumulation of a stool burden in the rectum is a major contributor. I usually get plain x-rays on these children as a baseline and then use laxatives to reduce the rectal stool burden in these children. This is a complicated process and is covered in my book, It’s No Accident.
CC: What about bedwetting? My daughter has nighttime accidents, and I’ve heard they’re genetic to some extent. (I wet the bed as a kid and my mom did, too.) Our pediatrician has suggested waking her up before I go to bed (between 11 and midnight) and asking her to go then, which does work. Anything besides avoiding drinks at night and making sure kids go to the bathroom right before bed that you’d recommend to curb nighttime wetting?
SH: Firstly, waking children at random times in the evening is not a reliable way to treat bedwetting. In addition to the efforts you mentioned, there are three causes of bedwetting that can be addressed. The most important is bladder overactivity, almost always caused by constipation, which needs to be diagnosed and treated aggressively. This fixes 80% of kids when done correctly. Secondly, enuresis alarms, which awaken the child upon wetting, are highly successful when used appropriately. Finally, there are medicines that can be used to decrease the amount of urine produced at night, but I don’t like using these except in extreme circumstances, or on an as needed basis.
CC: Many children deal with constipation issues, and – shockingly! – my daughter had those as well. We used enemas, fiber drinks. We went through a very trying 2-year period where she was pooping her pants all the time. What advice do you have for parents dealing with poop problems?
SH: Constipation is very common, but shockingly most cases are not apparent clinically. When there are poop accidents going on, you have a case of severe constipation that needs aggressive therapy right away! The important thing is to not let constipation become an issue in the first place. Parents need to make sure bowel movements are soft and small and I’m talking mushy like hummus and no wider than two centimeters! Once constipation has developed, aggressive Miralax use is the easiest way to address it, but enemas and suppositories may be needed. X-rays are very useful to monitor progress which is not obvious clinically. This is a very important point that I can’t stress enough.
For more tips on how to deal with bedwetting, visit Babble’s Bedwetting Guide.