Why Is My Child Still Wetting the Bed?

Snapshots of life at home.
March 6 2012 6:40 AM

The Real Reason Your Kid Wets the Bed

The simple cause your doctor probably missed.

Bed-wetting can have a surprising cause
Bed-wetting can have a surprising cause

Photograph by David De Lossy/Thinkstock Images.

In late 2010, Zoe Rosso and her mom, Betsy, were escorted off the premises of Zoe’s school in Arlington, Va. The principal told them not to return until Zoe stopped having potty accidents. Zoe had wet her pants more than eight times per month, the school’s limit, and therefore was considered “not potty trained.” Zoe was 3½ years old.

The incident made the front page of the Washington Post and incited extremely hostile (and foolish) comments. Betsy, who fought to keep her child in school, was called a “lazy person who wants to dump the kid off so she can shop” and told to “quit blaming others for her failures.”

Zoe is now 4½, and my patient. I can tell you it’s not Betsy Rosso who failed; the system failed her. Not just the Arlington Public School system, which operates the preschool Zoe attended, but also the medical system, which failed to detect something actually was amiss with Zoe.

Zoe’s pediatrician told the Rossos their daughter was fine. Unconvinced, Betsy took Zoe to a pediatric urology clinic, where Zoe’s urine was tested for infection and her belly examined. According to the clinic’s report, Zoe’s abdomen was soft, with “no masses palpable.” The report indicated Zoe “may have some underlying constipation contributing to her urinary symptoms” but concluded that “aggressive evaluation and treatment is not recommended.”

Turns out, everyone involved in Zoe’s case had it wrong. Zoe was fully potty trained, but she had no chance of staying dry because her entire colon was stuffed with poop, including a mass in her rectum the size of a Nerf basketball. This mass, visible in an X-ray I requested, was pressing against Zoe’s bladder and had caused the nerves feeding her bladder to go haywire. Constipation wasn’t “contributing” to Zoe’s urinary symptoms; it was the main cause.

Our culture has two reactions to potty problems: Either these problems represent a parental failure, or they are not actually problems but rather a normal (if bothersome) part of growing up. Parents are led to believe that kids are kids—they get busy playing and forget to go potty. They wet the bed, but that’s normal for their age.

In reality, potty-trained kids should not have accidents any more often than you or I do. And while overnight dryness often happens well after a child is toilet trained, bedwetting at age 6 should not be dismissed with, “You’re a deep sleeper. Be patient—you’ll grow out of it.”

Accidents and bed-wetting have the same root cause: chronically holding poop or pee or both. A rectal poop mass squishes the bladder and messes with its nerves; holding pee thickens the bladder wall, shrinking the bladder’s capacity to hold urine and triggering hiccuplike contractions. The upshot: wet undies and bed sheets.

These problems cause more than stress and extra laundry. Left untreated, some kids develop chronic medical problems, including damaged colons and, eventually, pain with sex. But toileting troubles are highly treatable—if only the medical profession would treat them.

The notion that constipation causes wetting is hardly new. This link was demonstrated in the 1980s by Sean O’Regan, a pediatric kidney specialist baffled by his 5-year-old son’s persistent bed-wetting. Back then, bed-wetting was considered either a psychological issue or an anatomical problem of the bladder. O’Regan, practicing at the Montreal’s Hôpital Ste.-Justine, didn’t accept either explanation.

Suspecting constipation, O’Regan had a colleague perform a balloon-inflation procedure, anal manometry, on his son to find out whether the boy’s colon had been stretched by impacted stool. Using a catheter, the colleague inserted a small balloon into the child’s bottom and gradually inflated it, waiting for the boy to report discomfort. But the child felt nothing. O’Regan’s colleague reported, “The kid’s got no rectal tone.”

O’Regan gave his son an enema nightly for a month, then every other night. Within two months, the boy had stopped wetting the bed. Figuring he was onto something, O’Regan tried this therapy with several hundred wetting patients and published a series of remarkable studies. These showed convincingly that children with wetting problems were severely constipated and that treating constipation resolved the wetting in dramatic fashion.

Here’s the interesting part: O’Regan noted in his papers that the parents of his patients had no inkling their children were backed up. Yet these kids were so clogged that they could not feel, in their rectums, the presence of balloons inflated to the size of a small cantaloupe.

O’Regan’s research tells you why constipation is so easily missed. Often, the rectum simply expands to compensate, like a squirrel’s cheeks or a snake’s belly. So much poop builds up that even though the child may still poop regularly, she never completely empties. Many severely clogged kids poop two or three times a day. Parents and doctors are fooled into thinking all is well.

In the years following publication of the O’Regan papers, urologists and pediatricians began to recognize the link between constipation and urinary problems. But they missed one of O’Regan’s main points: Constipation is associated with a stretched-out rectum, not the frequency of bowel movements. Doctors routinely ask parents whether their children are pooping regularly, but since most constipated children do poop daily, nothing gets solved.

And so, few doctors diagnose constipation in children who come in with wetting problems. When docs do suspect constipation, they rarely order X-rays to see the extent of the problem, and they fail to prescribe aggressive treatment. They may recommend a small daily dose of laxative, fiber supplements, and frequent trips to the potty and call it a day.

Intrigued by O’Regan’s studies, a colleague and I conducted similar research. In one study published in Urology, we reviewed the records of 30 bed-wetting patients, average age 9. Few of these kids demonstrated signs of constipation; all were shown by X-ray to be severely constipated. Aggressive laxative therapy cured all five of the teenagers in our study within two weeks. Laxatives and/or enemas stopped the bed-wetting in 20 of the 25 younger children within three months. Based on O’Regan’s studies and my own, as well as my years of experience, I am convinced that the majority of bed-wetting cases are due to a rectum stuffed with poop.

Many parents don’t want to hear this. I’ve upset more than a few folks after evaluating their children for wetting issues and then sending the family home with a therapy for constipation. “But my child isn’t constipated” is a common response, followed by, “What does constipation have to do with accidents, anyway?”

The other day a mom whose 7-year-old son chronically wet the bed insisted I prescribe bladder medication for her son. I explained that clearing up his constipation was a necessary first step and medication a last, and usually ineffective, resort. She told the checkout nurse she wasn’t going to bring her son back for follow-up. This happens all the time.

Fortunately, Betsy Rosso was willing to treat Zoe’s constipation aggressively, with high doses of laxatives and physical therapy to retrain her pelvic-floor muscles.

Zoe and her family have experienced multiple setbacks and frustrations, and Zoe’s bladder continues to spasm, though only on occasion. Her case has been among the most difficult I’ve encountered and illustrates the serious and persistent medical consequences that can develop when “accidents” are dismissed as normal.

Not long ago, I tracked down Sean O’Regan, who today treats adults outside of Mesa, Ariz. He said he was not surprised that his message has been overlooked by doctors and dismissed by many parents.

“If a discovery is made,” he told me, “and the world wants to take notice, they will. But constipation is a distasteful subject. People don’t even want to think about it.”

Steve Hodges is an assistant professor of pediatric urology at Wake Forest University.

Suzanne Schlosberg is a health and parenting writer in Bend, Ore.