Anthology --- 5th Edition

Essential
The NEW
Guidance!

Book
Updated and Overhauled

The Proven Way to STOP Bedwetting, Daytime Enuresis,

Encopresis, and Chronic Constipation in Toddlers Through Teens

“Our doctor couldn’t help

us, but M.O.P. did. Now “M.O.P. saved my sanity
my son is accident-free.” and my daughter’s
– Lucia Gonzalez,
Monterrey, Mexico
self-esteem.”
Hey, you’re – Marta Bermudez,
Sugar Land, Texas
getting on
my nerves!

Bladder
nerves Poop pile-up

By Steve Hodges, M.D.,

with Suzanne Schlosberg
Illustrations by Cristina Acosta
 Anthology --- 5th Edition

The

Book
Updated and Overhauled

The Proven Way to STOP Bedwetting, Daytime Enuresis,

Encopresis, and Chronic Constipation in Toddlers Through Teens

Hey, you’re
getting on
my nerves!

Bladder
nerves Poop pile-up

By Steve Hodges, M.D.,

with Suzanne Schlosberg
Illustrations by Cristina Acosta
 Disclaimer
The information contained in this book is intended to supplement, not substitute for,
the expertise and judgment of your physician or other health-care professional.

The M.O.P. Book: Anthology Edition (5th Edition)

Text Copyright © 2023 Steve J. Hodges and Suzanne Schlosberg
Illustration Copyright © 2020 Cristina Acosta
Book design: [Link]

ALL RIGHTS RESERVED. No part of this book may be reproduced or transmitted in any
form by any means, electronic or mechanical, including photocopying and recording, or by
any information storage and retrieval system, except as may be expressly permitted by the
publisher. Requests for permission should be sent to permissions@[Link].

Library of Congress Cataloging-in-Publication Data is available on file.

979-8-9866795-3-2
 This book
o o k ’s
b
This you! is dedicated to
for
all the kids
----- and parents -----
who’ve been
blamed or judged
or told to
“just wait it out.”
About the Authors
Steve Hodges, M.D.
Steve Hodges is a professor of pediatric urology at Wake Forest University School of
Medicine and an authority on childhood toileting issues. He has authored numerous
journal articles and co-authored eight books with Suzanne Schlosberg. His mission
is to dispel the myths, pervasive in popular culture and in medical literature, about
enuresis and encopresis and to communicate to families that accidents are never a
child’s fault. Dr. Hodges lives in Winston-Salem, North Carolina, with his wife and
three daughters. He blogs at [Link].

Suzanne Schlosberg
Suzanne Schlosberg is a health and parenting writer who specializes in translating
clinical mumbo jumbo into stuff that’s fun to read. Years ago, on a mission to achieve
a diaper-free household in record time, Suzanne potty trained her twin boys too
early. She used Steve Hodges’ methods to undo the damage and went on to found
[Link] with Dr. Hodges. The author or co-author of 20 books,
Suzanne lives with her husband and teenage boys in Bend, Oregon. Her website is
[Link].

About the Illustrators

NOTE: Most of the illustrations in the M.O.P. Anthology were drawn by Cristina Acosta. Those drawn
by Mark Beech are identified.

Cristina Acosta
Cristina is a painter and designer known for her lyrical artistry and bold use of color.
The author and illustrator of Paint Happy! and illustrator of When Woman Became
the Sea, Cristina has taught painting, drawing, and design. Cristina also designs home
decor and contributes to interior-design magazines. Though Cristina’s daughter is
long past potty accidents, Cristina is excited to help children grow up confident and
healthy. Cristina lives in La Quinta, California. Her website is [Link].

Mark Beech
Mark Beech is a U.K.-based illustrator whose work is popular in the world
of children’s publishing. Mark has been illustrating professionally for over
20 years and has been scribbling since he was old enough to hold a
pen. He has illustrated books for Sir Terry Pratchett, Jo Nesbo, Anthony
Horowitz, and Enid Blyton, to name a few. Emma and the E Club was
Mark’s first foray into the world of constipation. You can see more of
Mark’s work at [Link].
 Also written by Steve Hodges, M.D.,
and Suzanne Schlosberg
Emma and the E Club
“Clever, validating, and informative all at once — brilliant!”
– Tina Payne Bryson, Ph.D., New York Times best-selling co-author
of The Whole-Brain Child and No-Drama Discipline
“My daughter devoured this book in one gulp!”
– David Spieser-Landes, Ph.D., Wilmington, North Carolina
“A beautifully compassionate book. Children will learn they aren’t
alone. Parents will learn how to approach this common medical
issue with the respect all humans deserve.”
– Laura Froyen, Ph.D., Respectful Parenting Educator,
The Balanced Parent podcast, Madison, Wisconsin
“Absolutely adorable! Perfect for my school-aged patients with pee
and poop accidents.”
– Austin Grayce Hester, M.D., Pediatric Urologist,
Charleston, South Carolina

Bedwetting and Accidents Aren’t Your Fault

“Every family dealing with accidents or bedwetting should own this
engaging and eye-opening book!”
– Amy McCready, founder of Positive Parenting Solutions and author of
If I Have to Tell You One More Time…
“Terrific! The illustrations are so much fun they remove any possible
embarrassment, and the tone is friendly and supportive.”
– Laura Markham, Ph.D., author of Peaceful Parent, Happy Kids:
How to Stop Yelling and Start Connecting
“Dr. Pooper is a ROCKSTAR!!! I’d remind my son, ‘What does Dr. Pooper
want you to do every day?’ and that would convince him to give it a try!”
– Amazon verified purchaser

Jane and the Giant Poop

“A must-read for grown-ups, too!”
– Sally Kuzemchak, R.D., [Link]
“Very cute & engaging book. My kids read it 3 times the first day
it arrived. Helped ‘normalize’ their issue and bring humor to the
process we are experiencing.”
– Amazon verified purchaser
“Terrific! The illustrations and humor are priceless.”
– Angelique Champeau, CPNP, Director, Pediatric Continence Clinic,
UCSF Benioff Children’s Hospital, Oakland and San Francisco
 M.O.P. for Teens and Tweens
“This teen guide is a wonderful addition to the original M.O.P. book
because my teen was able to personally read real-life experiences
from other teens in the same boat.”
– Amazon reviewer
“The description of the digestive system was more informative than
what I learned in my biology class!”
– teenager who implemented M.O.P.
“Because of this book, I know I’m not the only teenager dealing with
bedwetting, and it is not my fault.”
– teenager on M.O.P.
“The book explained everything without making me feel uncomfortable.”
– teenager on M.O.P.

The PRE-M.O.P. Plan

“Mandatory reading for all pediatric care providers! Delivered with
a humorist’s tone that invites smiles and relief about a topic that’s
usually embarrassing.”
– Rob Paynter, M.D., Pediatrician, Novant Health Forsyth Pediatrics,
Winston-Salem, North Carolina
“This book will make potty training easier for both parent and child!”
– Michael Garrett, M.D., Family Physician, Direct MD, Austin, Texas
“This book gave me the confidence and reassurance to do what
needed to be done to relieve my 2.5 year old’s constipation.”
– Amazon reviewer
“A book that will change lives! So many of the problems I treat
could be prevented by Pre-M.O.P.”
– Irina Stanasel, M.D., Pediatric Urologist,
UT Southwestern Medical Center, Dallas, Texas

Dr. Pooper’s Activity Book and

Poop Calendar for Kids
“A great resource for kids with constipation and potty accidents!
It helps them talk about it without embarrassment.”
– Mike Garrett, M.D., Family Physician Direct M.D., Austin, TX
“My 5 y.o., who is following M.O.P,, loves this activity book. . . He likes
the mazes and ‘spot the difference’ pictures, and it’s good for getting
him talking about his potty issues.”
– Amazon verified purchaser
"My daughter sure loves the puzzles and word games! There is really
a lot to do in this book."
– Amazon verified purchaser

Available on Amazon or at
 Table of Contents

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
• What’s New in the 5th Edition
• Welcome to M.O.P.
• Glossary of Terms

PART A: The Story and the Science Behind M.O.P.. . . . . . . . . . . . . . . . 11

SECTION 1: The Research Supporting M.O.P.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
• The Curious Case of the Bedwetting 5-Year-Old
• Fictional Medical “Causes” of Bedwetting: Deep Sleep, Small Bladder, and More
• Nope, Accidents Aren’t Behavioral or Psychological, Either
• Five Strategies That Do More Harm Than Good
• Why Enemas Work Better Than Oral Laxatives
• “Dependence,” “Damage,” and Other Myths About Enemas
• “But Laxatives Aren't Natural”
SECTION 2: Diagnosing Constipation in Your Child. . . . . . . . . . . . . . . . . . . . . . . . . 33
• Why Constipation Goes Unnoticed
• Autism and Accidents
• Clues Your Child Has Chronic Constipation
• Outlier Cases and Medical Conditions to Rule Out
• Seven Reasons to X-Ray for Constipation
• How to Get an Accurate X-Ray Evaluation
SECTION 3: What's Driving Childhood Constipation. . . . . . . . . . . . . . . . . . . . . . . . 47
• “How Did My Kid Get So Constipated?”
• Genetics and Temperament
• Life in the 21st Century
• Our Rush to Potty Train
• Restrictive School Restroom Policies

PART B: Putting M.O.P. Into Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

SECTION 4: The M.O.P. Process From Start to Finish. . . . . . . . . . . . . . . . . . . . . . . 59
• What to Expect From M.O.P.
• When to Consider Alternative Versions of M.O.P.
• The Four Phases of Standard M.O.P.
• The Slow Taper: An Alternative Plan for Weaning off Enemas
• How to Administer (or Self-Administer) an Enema
• Troubleshooting M.O.P.: Answers to Common First-Timer Questions
• After M.O.P.: Pooping Happily Ever After

M.O.P. Anthology Book

SECTION 5: Alternative Variations of M.O.P.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
• Choosing a M.O.P. Variation
• Cheat Sheet of M.O.P. Variations
• M.O.P.+: The Large-Volume Approach
• M.O.P.x: Adding a Stimulant Laxative
• Double M.O.P.: Overnight Oil Enemas for Impacted Stool
• Multi-M.O.P.: The Full-Court Press
• Pre-M.O.P. for Constipated, Accident-Free Kids
SECTION 6: A Guide to M.O.P. Supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
• Enema Overview: Store-Bought and Homemade
• Store-Bought Enema Options
• DIY Enemas: Liquid Glycerin and Large-Volume
• Osmotic Laxatives: Options, Timing, and Dosing
• Is Miralax Toxic for Children?
• Stimulant Laxatives: Options, Timing, and Dosing
• Pooping With a Footstool
SECTION 7: Adjuncts to M.O.P.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
• Oral Laxative Clean-Outs
• Bedwetting Alarms
• Bladder Medication
• Pelvic Floor Therapy
• Bladder Botox
SECTION 8: Tracking Your Child’s Progress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
• How Monitoring M.O.P. Saves Time
• M.O.P. Tracking Tips
• Involving Your Child in the Tracking Process
• Monthly and Weekly Tracking Calendars
• Poop Poster for Young Children
• Color Your Poop
SECTION 9: Your Family, Your Doctor, and M.O.P.. . . . . . . . . . . . . . . . . . . . . . . . . . 131
• Overcoming Apprehension About M.O.P. — Yours and Your Child’s
• Five Important Messages for Your Child
• “Help! My Spouse Thinks M.O.P. is Crazy!”
• If Your Doctor Opposes M.O.P.
• Frustration, Guilt, and Family Tension: Q&A With a Psychologist
• Managing M.O.P. on Vacation
SECTION 10: An Anthology of Guides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
• Enema Rescue Guide
• The M.O.P. Maestro Guide
• The Physician’s Guide to M.O.P.
• The M.O.P. Parent’s Guide to Advocating for Your Child at School

BONUS EXCERPT: Emma and the E Club, Chapter 1

Table of contents
Introduction

1
What’s New in the 5th Edition
I did not plan to publish the 5th Edition of the M.O.P. Anthology less than three years
after publishing the 4th Edition. I was hoping version 4.0 would last a good while longer!
I’d planned to publish a short supplement with new treatment recommendations, but as I
began collecting my thoughts, I found I had too much to say.
As I often tell families, I take the term “medical practice” literally. I’m always on the lookout for better
treatment approaches, and when I hit upon something useful, I’m eager to share it. I learn a lot from my
patients and from the parents in our private Facebook support group. The group serves as a fantastic
laboratory, where I can test my hunches and receive real-
time feedback from around the world, from the U.S. to the
U.K. to the UAE. At my clinic, patients typically return every
few months, but on Facebook, parents post daily, whether it's The 5th Edition includes
"NOT working - help!" or "1st dry night ever!!" So, patterns that
insights that I’m confident
might otherwise take me years to notice become evident far
sooner. I’m able to improve my treatment recommendations will help resolve enuresis,
faster than I did before establishing the group. encopresis, and chronic
The 5th Edition includes numerous insights that I’m constipation more quickly,
confident will help resolve enuresis, encopresis, and chronic
constipation more quickly, effectively,
effectively, and permanently.
and permanently. The updates include
specific adjustments to the Modified
O’Regan Protocol (M.O.P.) — new
guidance pertaining to enemas and laxatives, the key elements of the regimen.
To be sure, my fundamental opinions hold. I continue to believe enuresis and
encopresis are misunderstood and vastly undertreated. I’m dismayed these conditions
are considered by some health professionals to be “normal” and are considered by
others to have psychological and/or behavioral roots. Truly, it’s shocking that enuresis
and encopresis are still included in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5). As always, I shake my head that bladder drugs and bedwetting
alarms are the go-to treatments for enuresis and that doctors routinely push Miralax
(PEG 3350) in cases where enemas are clearly superior. I still marvel at the brilliance
of Dr. Sean O’Regan, whose studies in the 1980s changed the way I practice medicine.
When it comes to treating enuresis, encopresis, and recurrent urinary tract infections
(UTIs), Dr. O'Regan understood far more back in the Bon Jovi era than the medical
community at large recognizes today! I wish his research was required reading in
medical school.
However, I also believe treating these conditions sometimes requires more nuance
and a more aggressive approach than is reflected in Dr. O’Regan’s original protocol.
I recognize that children with the exact same symptoms may need entirely different
variations of M.O.P. — different enema solutions and volumes, different laxative
You can save types and doses, different tapering plans. For some children, chronic constipation is
money by a far more stubborn condition than even I realized, and I’ve always taken constipation
making your own more seriously than most doctors. The standard M.O.P. regimen, described as “overly
liquid glycerin aggressive” by many physicians, simply does not suffice for some kids, and even the
suppositories. variations introduced in previous editions of this book can be improved upon. Overall, in
Illustration by recent years, I've taken a more hard-hitting stance on treating enuresis and encopresis.
Mark Beech

2 | M.O.P. Anthology — 5th Edition

At the same time, I’ve taken more notice of ways to make M.O.P. easier
on families — logistically, financially, and emotionally. The 5th Edition of the
Anthology includes valuable new advice on all these fronts, courtesy of
parents in the trenches and a psychologist, Amanda Arthur-Stanley, Ph.D.,
who works with families dealing with enuresis and encopresis. Below, I
highlight new content in the 5th Edition. If you’ve read previous editions,
you may want to head directly to the new sections. If you’re new to
M.O.P., I urge you to read the whole book.
• Multi-M.O.P. This new variation involves administering two or three
docusate sodium mini-enemas per day (yes, it’s safe) and has been
an absolute game changer for many kids, especially teens and Our newest regimen,
tweens. See Section 5. Multi-M.O.P., is showing
great promise for the
• The Slow Taper. I introduce a more gradual approach to weaning a toughest cases.
child off enemas, with the goal of reducing the risk that accidents
Illustration by Mark Beech
will recur. See Section 4.
• DIY LGS. You can make your own liquid glycerin suppositories for a fraction of the cost of store-
bought LGS. In Section 6, parents explain how they do it.
• Pre-M.O.P. for Accident-Free Kids. Many children who never have accidents nonetheless struggle with
rectal bleeding, painful pooping, rectal prolapse, or persistent stomachache. See Section 5 for the
treatment regimen I recommend.
• Bladder Botox. Injecting Botox into the bladder is the quickest, most effective way to halt accidents.
But, it’s surgery, and it’s expensive. Who’s a good candidate? See Section 7.
• Autism and Accidents. In autistic children, enuresis and encopresis are often dismissed as “part of the
deal,” so these kids miss out on a proper diagnosis and treatment plan. See Section 2 for details.
• Q&A With a Psychologist. Dr. Arthur-Stanley offers guidance on diffusing the family friction that can
arise from accidents and treatment. See Section 9.
• Updated Tracking Calendars. Based on parent feedback, we've updated our all-purpose 30-day
M.O.P. tracker and added calendars for Multi-M.O.P. and for teens.
• The M.O.P. Maestro Guide. Do you have two or more kids on M.O.P.? Learn how to orchestrate
your family’s M.O.P. regimen without going bonkers. See Section 10.
• The M.O.P. Parent's Guide to Advocating for Your Child at School. To ease your child's stress at
school, I offer five strategies for gaining the support and cooperation of your child's educators.
There’s plenty more inside, too! As always, I welcome your input.

Unless otherwise
indicated, the quotes
placed in circles throughout
the book are from parents
Steve Hodges, M.D.
in our private Facebook
Professor of Pediatric Urology,
support group.
Wake Forest University School of Medicine

introduction | 3
Welcome to M.O.P.
Have you been assured your child will outgrow bedwetting or daytime accidents? That
accidents are a “normal part of childhood development” and don’t require treatment until
age 5, 7, or even older? That bedwetting is caused by an underdeveloped bladder, deep
sleep, a hormonal imbalance, or stress? Or that pee or poop accidents are behavioral —
a sign your child is seeking attention or acting out?
None of that is true!
But these myths cause great suffering because they lead families “Our daughter had
down the wrong treatment path. Families spend years on encopresis from age 3.
wild goose chases — fluid restriction, midnight wake-ups, Nothing worked, until we found
strict diets, sleep studies, reward charts, behavioral therapy,
M.O.P. Was it perfect? No. Was it
chiropractic, fiber gummies, bedwetting drugs, years and
years and years of Miralax (PEG 3350). By the time families sometimes slow and frustrating?
land in my clinic, children and parents alike feel distressed Yes. Does it work? YES. For parents
and discouraged. Many of my patients are teased at school, who think there is no hope, I
terrified friends will discover they sleep in pull-ups, and promise there is. Patience,
feeling down on themselves. Many teens feel hopeless, even consistency, and sticking
depressed, and steer clear of school overnights and sleepovers.
to the plan are key.”
Families are tired of waiting for that magical day when the
accidents stop. A day that never seems to come.
In reality, an unlucky minority of children do not outgrow accidents, for
reasons I will explain. And the most common remedies don’t address the root of the problem, so they work
temporarily, if at all. The good news: Enuresis (wetting, day or night) and encopresis (poop accidents) can
be resolved permanently if you understand their cause and implement appropriate treatment.
In this book, I introduce you to what I consider the only reliable method of resolving enuresis and
encopresis: the Modified O’Regan Protocol. I didn’t invent this method. I wish I were that smart! I merely
adapted it from the published research of Sean O’Regan, M.D., a pediatric kidney specialist, now retired,
who practiced in Montreal in the 1980s. Dr. O’Regan advanced medicine in phenomenal fashion while on
a mission to resolve his own son’s bedwetting. What Dr. O’Regan discovered, after scrutinizing decades of
scientific literature and conducting studies of his own, is that enuresis and encopresis, as well as chronic
urinary tract infections, have the same root cause: chronic constipation. In other words, a rectum clogged
and stretched by a pile-up of stool. Furthermore, Dr. O’Regan proved that reversing the constipation
— cleaning out the rectum and allowing it to shrink back to normal size — resolves the accidents and UTIs.
Some health professionals portray enuresis and encopresis as unrelated and even consider nighttime
wetting and daytime wetting to be distinct and mysterious conditions. Nonsense! My own research and
15 years of medical practice have confirmed everything Dr. O’Regan demonstrated in his day. I x-ray all my
enuresis patients, and the images show that virtually all these kids are chock-full of poop. I mean stuffed.
A normal rectum is no wider than about 3 cm in diameter. My enuresis patients have rectums stretched to
6 cm, even 8 cm. I routinely see softball-size masses in kids declared “not constipated” by other doctors.
In addition, in some cases I treat enuresis by injecting Botox into the bladder, a highly successful surgery
that would fail if enuresis had a cause other than constipation.
Many parents are shocked to learn a clogged rectum is causing their child’s bedwetting or daytime
accidents. They’ll say: “No way! My kid isn’t even constipated. She poops every day!” I explain that pooping
frequency isn’t what defines constipation. As Dr. O’Regan noted, the culprit is incomplete evacuation.
When kids delay pooping, as they so often do, stool piles up and dries out. The rectum stretches to
accommodate the hardened stool mass, the way a snake’s belly stretches to accommodate the rat it

4 | M.O.P. Anthology — 5th Edition

devoured for lunch. Over time — months, years — an enlarged rectum can wreak all kinds of havoc.
Among the symptoms:
» Bedwetting. The poop-swollen rectum
irritates the bladder nerves, causing the
bladder to spasm forcefully and empty YUM! Rat
abruptly. Also, by encroaching upon the
bladder, the enlarged rectum can create a
for lunch.
real-estate problem: A squished bladder is a
smaller bladder, with a diminished capacity to
hold urine overnight.
» Daytime Pee Accidents. As with bedwetting,
the bladder goes haywire, contracting and
emptying before it’s full, without rhyme or
reason. An accident comes on like a hiccup
When stool piles up, the rectum stretches, the way a
or a sneeze — there’s no stopping it. Parents
snake’s belly expands to accommodate its lunch.
get frustrated when children insist, “I don’t
have to pee,” and then promptly wet their
pants. But this is easily explained.
» Poop Accidents. With encopresis, the rectum becomes so stretched that the internal sphincter, a ring of
involuntary muscle inside the anal canal, weakens and poop drops out. Compounding the problem, the
pelvic floor muscles tire and weaken from excessive holding, and the stretched rectum loses sensation.
So, the child can’t feel the poop falling out or sense the urge to poop, allowing more stool to pile up.
» Chronic UTIs in Girls. Guess what’s in that hefty poop pile-up? A gazillion bacteria. In girls, who have
shorter urethras than boys, the offending bacteria have an easy journey to the urinary tract, crawling
over the perineal skin, into the vagina, and up near the urethra and the bladder, where they set up shop
and multiply, triggering infection.
All these conditions — bedwetting, daytime pee accidents, poop accidents, and chronic UTIs — have
the same remedy: cleaning out the rectum daily and keeping it clear for months. This process allows the
rectum to shrink back to size, stop aggravating the bladder,
and regain the tone and sensation needed for complete
evacuation. That’s when accidents and infections stop.
Just as enuresis, encopresis,
But here’s the catch: You must treat constipation
and chronic UTIs have the aggressively. Most doctors don’t. Those who recognize
same cause, they have the constipation as the culprit typically just prescribe PEG
3350. But that’s like attempting to clean a food-encrusted
same solution: fully evacuating dinner plate with a trickle of water. When a child is
the rectum daily and keeping constipated to the point of having accidents, a daily dose
it clear for months. of laxative powder, even if preceded by a high-dose clean-
out, will rarely suffice. I know, because I used to be one
of those doctors prescribing laxatives! I didn’t grasp how
clogged these kids are. I was just following what I’d been
taught in medical school, and many of my patients did not improve, at least not for long. I figured enuresis
just wasn’t very treatable. But I was wrong. Fifteen years later, I know what works: M.O.P.
The Modified O’Regan Protocol has numerous variations, but at its core, the regimen involves a daily
enema and, in most cases, a daily oral laxative. Once accidents stop, the child starts weaning from
enemas and, eventually, from laxatives. Hold on! Did I just say "daily enemas"? Yes, I did! M.O.P.
does indeed call for your child to insert a small tube into the rectum every day, releasing a liquid that

introduction | 5
will trigger a bowel movement. Depending on your
child’s age and maturity level, either you or your child How to Navigate This Book
will do the insertion.
I realize enema is not a word any parent wants to hear, If you’re familiar with M.O.P. and simply
and many physicians discourage families from trying this want to start, head straight to Part B,
approach. I recently received an email from a mom whose which covers the different M.O.P. variations
7-year-old son had been treated for enuresis at a children’s and supplies needed. Though most kids start
hospital. The child had taken oral laxatives for years with Standard M.O.P., I suggest perusing
and tried multiple Miralax clean-outs, all to no avail. The all the options before you begin, so you can
child's doctor opposed enemas, and the mom was losing be thinking ahead. You may even want to
patience. She told me: “We may go rogue with M.O.P.” start with one of the variations.

I assure you, M.O.P. is hardly “going rogue”! At my clinic, If you’re new to M.O.P., if you’re unsure
M.O.P. has been the go-to treatment for over a decade. your child is constipated, or if you have
Thousands of my patients have administered daily questions about the safety or wisdom of
enemas with great success and no problems. For most daily enemas, begin with Part A. This part
kids, M.O.P. is not a big deal and comes as a relief. As delves into the supporting science and
one mom in our support group posted: debunks popular myths about the causes of
and treatments for enuresis and encopresis.
Before the first week was over, my son was begging
for enemas because they made him feel better. I never
realized how bad he felt, and I don’t think he did, either, because he had grown up feeling that way. I was
amazed how easy it was once we got on a routine. Two years ago, our doctor had told me not to do
enemas because it was too traumatic. My only regret is that we wasted two years on Miralax.
M.O.P. works far better than Miralax — no question. Still, the regimen is not a quick fix. After all, chronic
constipation is ... chronic. A mass of hardened stool is harder to excavate than most folks think. A child
who habitually delays pooping won’t suddenly become a poop machine, and a rectum stretched for years
won’t rebound overnight. M.O.P. requires trial and error and patience. As you embark on M.O.P., prepare
for slow progress and setbacks, and keep two facts in mind:
» Fact #1: Bedwetting and daytime accidents aren’t a normal part of childhood. Accidents are common,
but common isn’t the same thing as normal or healthy. Accidents signal an underlying issue that needs
attention, the sooner the better. I believe toilet-trained children of any age, even as young as 2 or 3,
should be treated for daytime enuresis. For children who only have bedwetting, I encourage treatment
at age 4. I have a large caseload of teenage enuresis patients whose constipation, looking back, was
apparent at age 3 but whose symptoms were dismissed. Most of these kids were told by their physicians,
year after year, “Don’t worry, you’ll outgrow it. No one goes off to college wetting the bed.” That’s untrue!
The longer accidents persist, the less likely they are to spontaneously stop. Left untreated, research
suggests, most kids wetting at age 9 will be wetting at age 18 as I explain in Section 1.1
» Fact #2: Bedwetting and accidents are never a child’s fault. Like UTIs, enuresis and encopresis are, straight
up, physiological conditions — issues children can’t control and should never be shamed or blamed for. This is
critical for families to understand. Our children’s books emphasize this point, with lots of humor, and help make
kids feel less alone. If your child is younger than 10, I suggest reading Bedwetting and Accidents Are Not Your
Fault with your child. Emma and the E Club resonates with kids ages 8 to 12 and sometimes younger.
(Show your child the first chapter at the back of this book!) M.O.P. for Teens and Tweens will reassure middle
school and high school students they're doing nothing "wrong" and their condition is totally fixable.
OK, let’s get your child started on the path to dryness!

1 Yeung, C., Sreedhar, B., Sihoe, J., Sit, F., & Lam, J. (2006, April 6). Differences in characteristics of nocturnal enuresis between
children and adolescents: a critical appraisal from a large epidemiological study. BJU International, 97(5), 1069-1073. doi:
[Link]

6 | M.O.P. Anthology — 5th Edition

Glossary of Terms
LGS, KUB, SP — the world of constipation treatment has its own vocabulary. You’ll catch
on quickly! Here, in alphabetical order, are terms used frequently in the Anthology and
in our private support group. I explain these terms in detail in the book.
Double M.O.P.: A regimen that involves overnight olive oil or mineral oil enemas, followed in
the morning by a large-volume stimulant enema. This double-whammy softens and washes
out crusty, old stool.
Encopresis: Recurrent poop accidents, which happen without the child noticing. Often
mistaken for a behavioral or psychological condition, encopresis develops when the rectum
is stretched to the point of losing tone and sensation. With M.O.P. treatment, encopresis
typically resolves faster than enuresis.
Enema: A treatment to stimulate a bowel movement by
Olive oil, squeezing fluid into the rectum via a flexible plastic tube or
when syringe. Enemas typically prompt the child to poop within
inserted
10 minutes. You can purchase ready-made enemas or make
rectally
your own. Common solutions include phosphate, glycerin, and
and left
overnight, docusate sodium as the active ingredients.
can soften Enuresis: Daytime or nighttime wetting. The rectum, enlarged
crusty, old by a pile-up of stool, presses against and aggravates the
stool. bladder nerves, triggering “hiccups” the child cannot control. Though Fleet
KUB: An acronym for "kidney, ureter, and bladder," KUB is the enemas (and generic
type of x-ray we order to assess equivalents) are
the amount of stool in a child's labeled "saline
rectum and the rectal diameter. laxative enema,"
phosphate is the
Large-volume enema: Used in active ingredient.
M.O.P.+, these enemas hold more
solution than store-bought enemas and allow you to adjust
the stimulant type and dose. You buy a reusable enema kit
and mix the solution yourself. May work better for encopresis
than enuresis. In some children, the large-volume keeps the
rectum stretched, so wetting persists even when the rectum
has emptied.
Liquid glycerin suppository, or LGS: A mini-enema
containing pure glycerin. You can purchase ready-made LGS
or make them
yourselves with You can
A large-volume enema kit is purchase
easier to use than it appears. a syringe or old
liquid glycerin
enema bottle.
suppositories
M.O.P.: The Modified O’Regan Protocol, a treatment for enuresis or make your
and encopresis that involves enemas and laxatives. M.O.P. is own. For many
named for Dr. Sean O’Regan, the physician who developed the kids, LGS are
regimen in the 1980s, and has been “modified” by Dr. Hodges. as effective as
phosphate and
M.O.P.+: An adjustable variation that involves large-volume more gentle.
enemas with saline solution plus stimulants such as glycerin
and Castile soap.

introduction | 7
 M.O.P.x: A variation that combines a small enema with daily Ex-Lax
or other senna-based stimulant laxative. Useful for children who have
difficulty with pooping without enemas.
Multi-M.O.P.: A highly effective variation that involves two or three daily
docusate sodium mini-enemas.
Osmotic laxative: An oral medication draws
water into the colon to keep stool mushy,
so pooping is less painful. Osmotics come
in powder, liquid, gummy, or tablet form.
The most commonly used with M.O.P. are
PEG 3350 (Miralax, Osmolax), lactulose,
PEG 3350 is a controversial Adding Ex-Lax to a daily
osmotic laxative. magnesium hydroxide (milk of magnesia,
Pedia-Lax chewable tablets), and enema regimen is a game
Illustration by Mark Beech changer for many kids.
magnesium citrate (Natural Vitality Calm).
Potty sit: A 5-minute attempt to poop, ideally done after a meal, when the body is most primed for a
bowel movement. Potty sits are helpful if the child is willing to try but are not worth arguing over.
Pre-M.O.P.: A regimen for chronically constipated babies and toddlers and for constipated older children
who don’t have accidents. Involves a daily osmotic laxative plus an enema or liquid glycerin suppository if
the child has not pooped or fully evacuated in the previous 24 to 48 hours.
Rectum: The end of the colon. Normally, the arrival of stool in the rectum signals to the brain that it’s time
to poop, and the child empties. But if the child overrides the signal or does not receive it, stool piles up,
triggering a range of pooping and peeing difficulties.
Skid marks: Poop smears in underwear. Skid marks are a sign that a
child is overriding the urge to poop — not that the child has poor
wiping skills. The smears indicate the rectum did not fully empty.
Solid glycerin suppository: A bullet-shaped dose of solid glycerin
that is inserted in the rectum and, upon dissolving, stimulates a
bowel movement. Solid suppositories take much longer to kick in
than liquid suppositories and tend to be less effective in children
2 and older. Solid suppositories are not commonly used with M.O.P.
but are recommended in the Pre-M.O.P. regimen for children under 2.
Underwear poop smears signal Spontaneous poop, or SP: A bowel movement initiated by the child
constipation, not poor wiping. at any time other than following an enema. Early on, the goal with
M.O.P. is for children to have a daily SP in addition to pooping after
the enema. Upon tapering, children should have an SP on non-enema
days. Children who become accident-free without reliable SPs are more likely to experience a recurrence
of accidents. Stimulant laxatives are effective for kids struggling with SPs.
Stimulant laxative: An oral medication, derived from the senna plant, that stimulates a bowel movement.
Chocolate-flavored Ex-Lax (or generic) squares are the most popular, but senna-based laxatives also come
in tablet, pill, or syrup form.

8 | M.O.P. Anthology — 5th Edition

How Our Private Support Groups Can Help
The M.O.P. Anthology is intended to provide enough
information for families to implement M.O.P. with confidence.
But this book can’t cover everything! If you find yourself with “This group
questions not addressed here or are simply looking for support and is a wealth
reassurance — from myself and other parents and caregivers in the same
of insight,
boat — consider joining one of our private Facebook groups. Many members
information,
are implementing M.O.P. without support from their own physicians,
relying instead on guidance and encouragement from the group.
kindness, and
connection.”
You can expect total privacy. Our groups are hidden and cannot be found,
let alone read, by the public. Try searching — you won't find anything!
The groups may be particularly helpful if you live outside the United States
and need help finding enema and laxative products that match the descriptions found in this book. We’ve
had members from all over the world, including Canada, the U.K., Australia, New Zealand, Ireland, Iceland,
South Africa, Thailand, Mexico, Italy, Singapore, and many other countries.
We offer three groups: Pre-M.O.P. (children younger than potty-training age), M.O.P. (ages 3 through
9), and Tweens/Teens (ages 10+). Members can belong to more than one group at no additional cost.
Members can:
• Post questions about any aspect of M.O.P.
• Post x-rays for me to evaluate.
“Learning what
• Ask me questions via our periodic Facebook Live events.
other parents are
To find out more, go to the Support Groups page doing was a game
at [Link].
changer and gave
me confidence to try
"Because of this enemas again
group, our child with my son.”
“I felt abandoned didn't have to suffer
by our pediatrician, while we waited
misunderstood by our for a specialist
GI, and judged by my
appointment."
family. With lots of trial
and error and support “Our son's only hope
from this group, we dug was the help we
our way out.” received from this
“Thanks to our
membership, M.O.P. group. Once we joined,
his progress increased
has been a journey that
exponentially. Y'all,
we have been able to
hang in there.”
achieve from the other
side of the world —
New Zealand.”

introduction | 9
PART A:
The Story and
the Science
Behind M.O.P.

SECTION 1: The Research Supporting M.O.P.

SECTION 2: Diagnosing Constipation in Your Child
SECTION 3: What's Driving Childhood Constipation
Section 1

The Research Supporting

M.O.P.
Explanations for enuresis run the gamut: deep sleep, an
underdeveloped bladder, urine overproduction, anxiety, laziness.
With encopresis, it's "attention seeking," behavioral disorders,
"defiance," even family discord or
parental divorce. But research supports
just one prevailing explanation for
both conditions: a chronically clogged,
stretched rectum. In this section, I
review the research behind M.O.P. and
the studies used erroneously to support
other theories. Then, I discuss enuresis
and encopresis remedies — those that
are useless, those that are harmful, and
those that work. Finally, I counter claims
that enemas are unsafe or traumatic for
children and that laxatives are “unnatural”
or cause “dependence.”

13
section 1 : The Research Supporting M.O.P. | 13
The Curious Case of the Bedwetting 5-Year-Old
How can I be so sure chronic constipation is the cause of bedwetting, daytime enuresis,
and encopresis? Because the research is irrefutable. Evidence pointing to other causes
— underdeveloped bladder, stress, deep sleep, attention seeking — either does not exist
or does not hold up to scrutiny. Many studies are shockingly flawed, nothing more than centuries-
old assumptions and biases dressed up in scientific terminology. Any serious discussion of enuresis and
encopresis must include Sean O’Regan’s research, and yet his studies are rarely, if ever, cited in literature
proposing alternate explanations. Dr. O’Regan was not the first physician to connect enuresis with chronic
constipation, or to link enuresis with encopresis, but he was the first to prove these connections. It’s a
fascinating story.
Back in the 1980s, Dr. O’Regan was a young father of three
boys, practicing at a Montreal hospital. His 5-year-old was
wetting the bed, every night, sometimes twice. Often the Dr. O’Regan’s studies shine
boy would wake his parents. Dr. O’Regan, accustomed to a light on the huge flaw in
operating on minimal sleep, would get the elbow from his
wife to help their son change his pajamas. On occasion, Dr. most studies that seek to
O’Regan would find the boy on the floor, having fled his wet explain enuresis: the children
sheets. The boy was self-conscious about his accidents and, were not properly evaluated
understandably, didn’t want to sleep anywhere but home. His
bedwetting was causing tension in the family. Dr. O’Regan — or evaluated at all —
was bewildered by the boy’s wetting, since his other two for chronic constipation.
sons had become dry overnight around age 3. Dr. O’Regan’s
wife made note of the fact that the good doctor was unable
to help his own son.
At the time, children with enuresis were assumed to have either psychological or anatomic problems (not
so different from today). Dr. O’Regan felt neither explanation applied to his son and searched for answers
at the McGill University Medical Library, which famously housed European medical journals dating to the
19th century. There, Dr. O’Regan discovered several articles that reported a high rate of urinary problems
among children with severe constipation. In the 1960s, for example, researchers recognized that children
with Hirschsprung’s disease — a congenital disorder in which certain nerve cells in the colon are missing,
causing chronic constipation — developed all sorts of urinary problems. Contrary to the conventional
wisdom, peeing and pooping seemed to be intimately related. Dr. O’Regan felt he was onto something.
Intrigued, he asked a colleague, Dr. Salam Yazbeck, to test his son for constipation using a procedure
called anorectal manometry. This is not a super fun test. The practitioner inserts a small balloon into the
child’s bottom and gradually inflates it. The more inflation the child can tolerate, the more the rectum has
been stretched by stool build-up. Now, a child with normal rectal tone would notice the balloon inflated
with just 10 ml to 20 ml of air, whereas a severely constipated child might not even detect the balloon
until it’s inflated with 40 ml of air. The O’Regan boy’s results were astounding: Even when the balloon was
fully inflated, to 110 ml, the size of a small tangerine, Dr. O’Regan’s son felt no discomfort. Dr. Yazbeck told
Dr. O’Regan, “The boy’s got no rectal tone.”
So, Dr. O’Regan turned to the standard remedy for severe constipation: enemas. Dr. O’Regan gave his son
so many Fleet enemas — one each night for a month, one every other night for a second month, then
twice a week for a third month — that he negotiated a discount with his local pharmacy. His son would
read Winnie-the-Pooh on his bed while waiting for the enema to kick in. Within a week, Dr. O’Regan’s
son was having his first dry nights. Within two months, he’d stopped wetting the bed completely. Mrs.
O’Regan was pleased with her husband.

14 | M.O.P. Anthology — 5th Edition

 Based on this success, Dr. O’Regan and Dr. Yazbeck began a
series of studies. They got word out to local pediatricians and
attracted virtually the entire French Canadian population of
When I began x-raying children with urinary problems. Advancing previous research
all my enuresis patients, in a significant way, their studies used anorectal manometry
to demonstrate that children with toileting difficulties were
I was blown away by what
severely constipated. For example, in one investigation,
I saw: huge masses of published in 1985, Dr. O’Regan tracked 47 girls, average age
stool in the rectum. 8, who had recurrent UTIs.1 In addition, most of these girls had
encopresis, daytime wetting, and/or nighttime wetting. Every
girl in the study could withstand 80 to 110 ml of air without
discomfort. After implementing the same enema regimen Dr.
O’Regan’s son had used, 44 of the 47 girls stopped having UTIs. Among the 21 girls with encopresis, 20
stopped having poop accidents, and 22 of the 32 girls with enuresis had stopped wetting.
Dr. O’Regan was just getting started. The next year, he published a study of 22 boys and girls — six
with nightly wetting, two with daytime-only enuresis, and nine with both. All were severely constipated.
Dr. O'Regan noted that most could withstand an air balloon inflated to 6.5 cm in diameter. Seventeen
agreed to the enema regimen; five opted out. Within six weeks, wetting had either ceased or significantly
improved in all the children on the enema regimen. Nine months later, Dr. O’Regan reported, 14 of the 17
children had completely stopped wetting, and the other three reported they were wetting once a week
rather than daily. Among the five children who'd opted out of treatment, four continued to wet nightly,
and one was able to control bedwetting via bladder-relaxing medication.2
I came across Dr. O'Regan's studies while trying to solve a medical mystery in my own practice, a patient
I discuss in Section 2. Intrigued by his research, I began x-raying all my enuresis patients. (Plain x-rays are
plenty safe and easier for all involved than anorectal manometry.) I was blown away by what I saw: huge
masses of stool in the rectum, of a size that inevitably would compromise rectal tone.
Dr. O’Regan’s studies shine a light on the huge flaw in most studies that seek to explain enuresis: the
children are not assessed for constipation. A study might find higher rates of bedwetting in kids with
chaotic family lives or restless sleep patterns or “decreased gray matter density in the right dorsolateral
prefrontal cortex” (yes, that’s a study finding!) and then declare family stress, a sleep disorder, or brain
dysfunction a likely cause of enuresis. They draw these conclusions without even looking at whether the
child’s rectum is clogged with stool!
Meanwhile, studies that do pay heed to their subjects’ constipation status often rely on unreliable
diagnostic methods, such as asking parents how often the child poops. So, based on faulty information,
researchers declare their subjects “not constipated” and assume the child’s enuresis must have some other
explanation. In my opinion, no study investigating the cause of enuresis or encopresis has validity unless
the subjects are assessed for constipation via anorectal manometry or x-ray. When it comes to enuresis,
my motto is: Constipated until proven otherwise.
Today, the prevailing notion is that enuresis is a big, giant mystery. The American Academy of Pediatrics
(AAP) offers up a wide range of possible causes, ranging from the physiological (“a delay in the
development” of the bladder, kidney, and/or brain) to the psychological (“stress can cause bedwetting”).3
The AAP’s website for parents lists constipation among eight risk factors for bedwetting. In truth, nearly
all cases of enuresis have just one cause: a chronically clogged, stretched rectum. I discuss the exceptions
in “Outlier Cases and Medical Conditions to Rule Out,” in Section 2,
1 O’Regan, S., Yazbeck, S., & Schick, E. (1985). Constipation, bladder instability, urinary tract infection syndrome. Clinical
Nephrology, 23(3), 152–154. [Link]
2 O’Regan, S., Yazbeck, S., & Schick, E. (1986). Constipation a commonly unrecognized cause of enuresis. American Journal of
Diseases of Children. [Link]
3 [Link]

section 1 : The Research Supporting M.O.P. | 15

As for encopresis, most health organizations recognize constipation as the primary cause yet insist, as
the AAP does, that “while most children with encopresis are also constipated, some are not.”4 In these
kids, according to the AAP, poop accidents are “attempts to control some difficult aspects of their lives.”
The myth that encopresis is psychological or behavioral remains deeply embedded in our culture.
The erroneous explanations for both enuresis and encopresis are hugely damaging because they deprive
children of effective treatments and cause much shame, blame, and family conflict. Next, I debunk these
explanations, dividing them into two broad categories: the physiological and the psychological/behavioral.

Fictional Medical “Causes” of Bedwetting:

Deep Sleep, Small Bladder, and More
If your child has nocturnal enuresis, chances are you’ve considered one or more of the
following explanations.

The “Deep Sleep” Theory

“Deep sleep” may be the single most popular explanation. Most parents tell me right off that their child
is a deep sleeper. One mom said, “I could run a vacuum next to my son’s head and he would never wake
up!” Many of my teenage patients were diagnosed with sleep disorders, only to land in my office after the
sleep treatments failed. The American Academy of Pediatrics asserts that being “unable to wake up during
sleep” can cause enuresis, especially in teens. “A deep-sleep pattern can be part of normal adolescent
development, as can a poor sleep schedule and too few hours of sleep.” I think what they’re suggesting
is sleep deprivation leads kids to sleep so deeply that they
can’t sense the urge to pee. This makes no sense because
kids with healthy bladders simply do not need to pee
overnight. It’s not as if light-sleeping kids are awakened
Your bedwetting child may overnight by the urge to pee, whereas deep sleepers fail
very well be a deep sleeper to heed the signal and therefore wet the bed. No child,
whether a light sleeper or a heavy sleeper, should even have
— most kids are — but
the urge to pee at 2 a.m. Your bedwetting child may very
that’s beside the point. well be a deep sleeper — most kids are — but that’s beside
Deep sleep cannot trigger the point. Deep sleep cannot trigger bladder overactivity.
bladder overactivity. Because human beings typically don’t eat or drink overnight,
we don’t produce enough urine to need to pee. A healthy
bladder has the capacity and stability to hold the urine we
do produce. When a person, whether child or adult, needs
to pee overnight, it’s because the bladder is overactive, spasming when it’s not full. In children, virtually
all bladder overactivity is directly caused by constipation. In adults, bladder overactivity is typically due
to changes in bladder function that occur with age, though constipation can contribute. Now, if you,
yourself, feel the urge to pee in the middle of the night, as plenty of adults over 40 do, you may wonder
why you are able to wake up, whereas your child is not. It’s because adults typically experience a type of
bladder activity that comes on gradually and is less forceful, allowing you to wake up and get to the toilet.
Children, by contrast, experience dynamic, abrupt bladder spasms.
The theory that deep sleep causes bedwetting conveniently overlooks the proven connection between
daytime and nighttime enuresis. In fact, in its online entry about daytime enuresis, the AAP itself states:
“Studies show almost ALL children with voiding dysfunction also have some form of constipation or bowel

4 [Link]

16 | M.O.P. Anthology — 5th Edition

 dysfunction.”5 Guess what? So do almost all
In Emma and the children who have accidents overnight! The
E Club, Emma explains vast majority of children with daytime wetting
it’s a myth that kids also have accidents overnight, and about
who have accidents one-third of kids with nocturnal enuresis
are “disruptive” or have daytime accidents, too. Yet daytime
“potty refusers."
and nighttime enuresis are often described as
separate conditions.
In a scenario that bewilders parents, some
children with daytime accidents don't wet the
bed. Parents wonder: If my child can sleep 10
hours without peeing, how can she not stay
dry during the day? They conclude the child
must be “acting out” or ignoring signals to
pee. But overactive bladders don’t follow rules.
Illustration by Mark Beech My guess is the reclining position alters how
the enlarged rectum affects the bladder, and
kids with daytime wetting, but not nighttime, sleep in a position that renders their bladder nerves less
aggravated at night. At any rate, x-rays show these kids are constipated.
To date, no study has shown that children with nocturnal enuresis sleep more deeply than kids who are dry
at night. Try to find one! In fact, several studies have detected more overnight restlessness — that is, less
REM sleep — in kids with enuresis compared to children who are dry at night. Why? Probably because their
bladders are going haywire all night. None of these researchers investigated whether their test subjects
with enuresis were constipated, a huge oversight, but we do know these kids’ bladders are overactive, and
I would bet big money they were super clogged.
Finally, I point to the success of bladder Botox (see Section 8). Botox has halted bedwetting in most every
patient I’ve treated with this procedure, including many whose enuresis was attributed to sleep disorders.
If deep sleep caused wetting, rather than an overactive bladder, why would a bladder-calming procedure
stop accidents? And why would the procedure require a do-over in only the most constipated children?

The “Underdeveloped Bladder” Theory

Kristen Bell of Frozen fame once tweeted that her 5-year-
old’s bedwetting was “pretty normal for a 5 yr old whose
To date, no study has
tiny bladder can’t take the 10 hr challenge yet.” One parent
in my clinic, whose daughter was suspended from preschool shown that children with
for having “too many” accidents, was told the girl's bladder nocturnal enuresis sleep
had “not yet grown to catch up with the rest of her body.”
more deeply than kids
This is a common notion. But, if the girl’s first urology clinic
had x-rayed her, as my office did, they might have detected who are dry at night.
the stool mass in her rectum the size of a Nerf basketball! Try to find one!
The underdeveloped bladder theory is based on a faulty
understanding of how babies come to achieve dryness
overnight. There is a deeply held notion that when you’re a
baby, you pee while asleep, and then, when your brain and bladder mature, you outgrow it. In reality, healthy
mammals typically don’t pee while asleep. Your puppy doesn’t do it, your kitten doesn’t do it, and your
newborn doesn’t do it. Research shows infants usually pee when roused, if only slightly, from sleep. As a

5 [Link]
[Link]

section 1 : The Research Supporting M.O.P. | 17

 study in the European Journal of Pediatrics put it: “Most
voids in infants occur when being awake or the infants
Once children awake immediately before voiding.”6 After peeing, they fall
back into slumber. They do this multiple times overnight,
sleep in a bed and are
because an infant’s bladder is small, and the filling/emptying
toilet trained during the cycle is what stimulates growth.
day, generally by age 4, the It takes a lot of brain power to realize you have to pee.
bladder is plenty large enough So even if babies and toddlers wanted to stay dry overnight
and could hop out of their cribs and walk to the bathroom,
to hold pee overnight. few would have the ability to plan and execute the trip
to the toilet. However, once children sleep in a bed and
are toilet trained during the day, generally by age 4, the
bladder is plenty large enough to hold pee overnight. If a
child’s bladder lacks this capacity, it’s because it’s being squished by the enlarged rectum, not because
the bladder is “underdeveloped.” Dr. O'Regan made this very observation in 1986, pointing to a 1968 study
of constipated children with urinary dysfunction: "[C]ompression of the bladder wall by the distended
rectum might result in decreased bladder capacity." I’ve seen plenty of x-rays that show a dilated rectum
flattening the bladder. With treatment, this scenario is totally reversible. Waiting for the child’s bladder to
“grow” won’t help.

The “Urine Overproduction” Theory

According to the American Academy of Pediatrics, one cause of bedwetting is that “more urine is made
at night.” More than ... what? More than the bladder can handle? The “overproduction of urine” theory
is the basis for treating bedwetting with DDAVP, a popular drug that tricks the kidneys into making less
urine overnight. The theory is that in some children, the body doesn’t produce enough ADH, a hormone
that prompts the kidneys to release less water. So, the theory goes, by artificially restoring the hormone
balance with medication, the child will produce a normal amount of urine and stay dry.
Sounds plausible, except there’s no convincing evidence that bedwetting children underproduce ADH
or overproduce urine. (An exception would be a
child with diabetes insipidus, an extremely rare
hormonal disorder.) If urine overproduction caused
bedwetting, DDAVP would be an excellent cure. • Deep sleep
But it’s not. Only about 30% of patients stay dry • Small bladder
while taking this drug, little better than a placebo, • Hormonal imbalance
and most kids relapse as soon as they stop taking • Emotional stress
the medication. Despite its dismal success rate, • Behavioral issues
DDAVP is considered a “first-line” treatment for
bedwetting. If your doctor insists your child is
overproducing urine, ask for proof, such as a test
of your child’s ADH levels and plasma osmolality
(a measure of the body’s electrolyte-water balance).
Chances are, your doctor will not order such a test,
as it will only come up normal.
This doesn’t mean DDAVP can’t help your child. I
do sometimes prescribe the drug, as I explain in Doctors offer up all kinds of unproven
Section 7. A halt to bedwetting, even if temporary, theories about the causes of bedwetting.

6 Van der Cruyssen, K., De Wachter, S., Van Hal, G. et al. The voiding pattern in healthy pre- and term infants and toddlers: a
literature review. European Journal of Pediatrics, 174, 1129–1142 (2015). [Link]

18 | M.O.P. Anthology — 5th Edition

can provide a psychological boost to a demoralized kid, and I’m all for that. But my patients on DDAVP are
also on M.O.P. They know urine overproduction isn’t the cause of their wetting, and they don’t want to
rely on a daily drug to stay dry.

The Heredity Theory

Research has established a strong family connection with enuresis. It’s absolutely true that children
whose parents had enuresis are more likely to have enuresis themselves. And accidents are so common
among siblings that this book includes an entire guide, The M.O.P. Maestro Guide, for parents
managing multiple children on M.O.P. But none of
this means a child’s genes are the direct cause of
bedwetting or daytime accidents. Children simply won’t
The problem with the heredity have accidents in the absence of constipation. It’s the
focus is that it prevents stretched rectum, not the child’s heredity, that is directly
families from seeking causing the accidents.

treatment. A parent will say, What runs in families, my experience tells me, is the
propensity toward constipation and the propensity of the
“Well, I wet the bed until I was bladder to spasm when aggravated by an enlarged rectum.
10, so I’m sure my son In other words, in some families, a rectum stretched to
5 cm in diameter, while abnormal, may have no effect on
will come around.”
the bladder, whereas in another family, a rectum stretched
to 4 cm, only slightly enlarged, may cause bladder
hiccups. Some bladders are just more sensitive to the effects of constipation, and some families are more
susceptible to constipation in the first place. Sometimes I’ll see the x-ray of a child with mild enuresis —
maybe the kid wets the bed once or twice a week — who is massively constipated. Most kids with that
kind of x-ray would be wetting five times a day. That’s genetics at play.
But, so what? The focus on a bedwetting “gene” is a red herring. The problem with the heredity focus is
that it prevents families from seeking treatment. A parent will say, “Well, I wet the bed until I was 10, so
I’m sure my son will come around.”
In reality, you can’t be sure. And anyway, even if a child is destined, by genetics, to become dry at age
10 or 12, why wait to take action when, with a treatment, the child could be dry at age 4 or 5? In my
experience, no one is served when a child spends five additional years wearing pull-ups and avoiding
sleepovers. You can’t change a kid’s genes. But you can heal a stretched rectum and stop the accidents.

Nope, Accidents Aren’t Behavioral

or Psychological, Either
“My biggest regret
Dr. O’Regan once told me he delighted in helping
was how much time I
children whose enuresis and encopresis had been grossly
misunderstood. “These kids were told it was all in their wasted thinking my son’s
heads, that they were psychologically disturbed,” he said. enuresis was behavioral or
Forty years later, society’s tune has barely changed. cognitive or that if I was a
To be clear, there is no legitimate evidence showing enuresis and/or ‘better mom,’ he’d stop
encopresis are caused by stress, anxiety, attention seeking, defiant having accidents.”
behavior, chaotic family life, or parental depression or divorce. None.
Yet these explanations are basically a given in our culture. In the movies,
in books, and on TV, accidents signal a child is emotionally distressed,

section 1 : The Research Supporting M.O.P. | 19

 usually due to having been neglected by Mom. (See: Hulu’s
“Fleishman is in Trouble” and “Borgen” on Netflix.) In politics,
“bedwetting” has come to mean “excessive worry.” One
legal glossary defined “bed wetters” as politicians who I don’t care what behavior
“panic easily when things don’t go their way.” disorder a child does or does
Let me tell you: If my patients are panicking, and many are, not have — kids don’t poop
it’s because they are teased at school, fearful of slumber
in their pants unless they
parties, and terrified the accidents won’t stop before
college. The anxiety that kids with enuresis feel and the have a stretched rectum
“stubbornness” they sometimes display are often perceived and backup of stool.
by adults as a cause of their enuresis rather than what
these emotions and “behaviors” actually are: the upshot of
a medical condition left untreated.
Unbelievably, both enuresis and encopresis are included in the most recent edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5), described by its publisher, the American Psychiatric
Association (APA), as “an authoritative volume that defines and classifies mental disorders.” Both
conditions, too, rate lengthy chapters in the Handbook of DSM-5 Disorders in Children and Adolescents
and countless entries in online resources for therapists and parents.
Enuresis and encopresis do not belong in these resources. They are
not mental disorders!
The mis-categorization of these conditions has serious consequences.
Countless children are referred for behavioral counseling or art
therapy, interrogated about their “potty refusal,” even prescribed
psychiatric drugs, all because their accidents are perceived to be
the result of emotional distress or defiance.
“My biggest regret was how much time I wasted thinking my son’s
enuresis was behavioral or cognitive or that if I was a ‘better mom,’
he’d stop having accidents,” one mom posted. The father of a
17-year-old with enuresis told me a mental health specialist had his
son doing “mind exercises,” but the bedwetting has persisted. “The
poor kid is humiliated and feels trapped and stressed about going
anywhere overnight, including the future he wants in college.”
Many adults erroneously Encopresis accounts for 3% to 6% of psychiatric referrals among
attribute poop accidents school-aged children.7 One mom told me that when her son was
to behavioral disorders. 8, he was medicated with serious anti-psychotic meds because a
doctor thought he had signs of pediatric bipolar disorder. What were
these signs? Poop accidents. The boy, struggling with encopresis and enuresis, had been hospitalized after
a bad reaction to ADHD medication, and the psychiatrist on duty made an unwarranted leap. Over the
years, the boy visited multiple psychologists and psychiatrists, “all of whom were 100% stumped” by
the cause of the boy’s encopresis, his mom recalls. “They made charts to try to correlate the accidents to
stress and other behavioral issues. Of course, none of the theories ever seemed to fit.” Eventually, right
before middle school, a urologist confirmed the boy’s rectum was clogged and dilated. Daily enemas plus
Ex-Lax halted his poop accidents in one week. Five months later, his bedwetting stopped. “We literally
went through torture for years,” his mom told me.
Next, I debunk the most common of the psychological and behavioral explanations for enuresis and
encopresis.
7 Hardy, L. T. (2009). Encopresis: A guide for psychiatric nurses. Archives of Psychiatric Nursing, 23(5), 351–358.
[Link]

20 | M.O.P. Anthology — 5th Edition

The “Stress” Theory
The American Academy of Pediatrics states: “[S]tress can cause bedwetting; treating the stress can stop
the bedwetting.” No research exists to support either statement, yet the “stress” explanation is repeated
all over the place. One online network of mental health counselors asserts: “Enuresis can be triggered
by separation from a parent, the birth of a sibling or family conflict.” A footnote led me to a study
conducted in India — a study that, itself, provided no evidence, stating only that the “birth of a sibling,
parental separation, and family discord [are] some of the common emotional problems which lead to the
persistence of enuretic behaviour.” Repeating an unfounded theory does not make it true! Loads of my
patients have been diagnosed with anxiety or depression. Their x-rays look the same as their happier,
more relaxed peers.

The “Attention Seeking” Theory

As Psychology Today’s “Diagnosis Dictionary” puts it, wetting accidents may signal “a child has deep
feelings they’re struggling to express or a need for attention and care that is not currently being met.”8
This unfounded theme surfaces often in counseling. A mom in our group posted texts from a behavioral
therapist who insisted her son’s accidents were a ploy to get his “wants and needs met” and that this mom
was “reinforcing” her son's attention-seeking behavior by allowing him to wear pull-ups. The therapist told
her: “Urinating on his bedroom floor doesn’t have anything to do with constipation.” School personnel
often subscribe to the “attention seeking” theory and restrict restroom access for the very students who
need to use the bathroom most urgently or frequently. Again, x-ray these “attention seekers” and you’ll
find an enlarged rectum.

The “Behavioral Disorder” Theory

Psychiatry texts repeatedly link encopresis and enuresis with psychiatric disorders. The Handbook of
DSM-5 Disorders in Children and Adolescents connects encopresis to elevated rates of “bullying behavior
(both as a victim and perpetrator), antisocial activities, attention and activity problems, obsessions and
compulsion, and oppositional behavior.” The book continues: “In fact, some studies have found psychiatric
comorbidity [the simultaneous presence of two or more disorders] in as high as 74% of children with
encopresis.” You might think: Wow. That’s really high! Obviously there’s a connection! In fact, it was
a single study that found a 74% comorbidity, and this study is laughable. In the majority of cases, the
“psychiatric disorder” linked with encopresis was ... enuresis!
The U.S. government, too, lumps enuresis and encopresis in with
psychiatric disorders. A chart published by the U.S. Substance
Abuse and Mental Health Services Administration, intended
to help researchers estimate the prevalence of “serious
emotional disturbance,” lists enuresis and encopresis in
“My daughter is a
a column with psychosis and attachment disorders.9 A different kid than she
guide for psychiatric nurses acknowledges encopresis
is caused by constipation, yet states that encopresis was a year ago. We went
“is also a psychiatric diagnosis.”10 Why? Because from daily outbursts and
“anecdotally, [encopresis] may have some association
with psychiatric problems.” That’s right: “Anecdotally.” heightened anxiety to
“May have.” “Some association.” This is not science. cooperation and logical
The DSM-5 divides encopresis into two types: a type
“with constipation” and a type in which “there is no discussions.”
8 [Link]
9 [Link]
[Link]
10 [Link]

section 1 : The Research Supporting M.O.P. | 21

 evidence of constipation on physical examination or by history.” This second
type, according to the book, is “usually associated with the presence
“I wasted of oppositional defiant disorder or conduct disorder.” Bollocks, as the
British would say! Encopresis is always caused by constipation. I
years on ‘behavior’ don’t care what behavior disorder a child does or does not have
responses and trying — kids don’t poop in their pants unless they have a stretched
rectum and backup of stool. Over 15 years, I’ve treated thousands
to ‘train’ my son to wake of patients with encopresis. I’ve seen everything. If there were a
up and pee. Treat the subtype of encopresis “without constipation,” I’d have seen it at
least once. If a physician can’t find evidence of constipation in a
poop.” child with encopresis, it’s because a physical examination and pooping
history are worthless diagnostic tools, not because the child’s rectum is
empty. Want proof? Get the child x-rayed.
Nothing good comes from treating these kids for behavioral problems. On the
other hand, treating them for constipation often alleviates the behaviors that parents find so problematic.
The mom of a girl with encopresis and enuresis posted: “My daughter is a different kid than she was a year
ago. We went from daily outbursts and heightened anxiety to cooperation and logical discussions. My
daughter is happy and grateful for the peace and freedom [treatment] has afforded us.”

The “Laziness” Theory

I often hear from parents wondering whether their child has accidents because they just don’t feel like
using the toilet. The mom of a 5-year-old wrote: “I’m torn between thinking my son is just lazy when
he’s at home and soils his pants and thinking it’s not his fault as possibly he’s less aware of the leakage.”
Another mom was similarly torn, even after an x-ray confirmed her daughter’s rectum was stuffed with
stool. She wrote: “I’m not 100% convinced [her enuresis]
isn’t just laziness/attention. In the last 12 months we have
moved to a new house in a new town, and we’ve had
another baby. Recently she’s been complaining of tummy As long as enuresis and
aches, but she does seem to mention them at really
encopresis occupy space
‘convenient’ times.”
in mental health literature,
Many parents report their kids appear “unconcerned” by
their accidents, and they wonder how to motivate their no matter how much the
kids to use the toilet. One mom posted: “My son, now 5, is entries hedge or qualify their
so used to wetting his pull-up at night and so unbothered
by it that I’m not sure if he really tries to stay dry at
statements, kids will
night. How do you know if bedwetting is still a physical be shortchanged.
limitation or has become behavioral?” Another mom had
an excellent response: “If I had a way-back-machine, I
would treat my son for constipation and let the bed
wetting resolve itself through healing. I wasted years on ‘behavior’ responses and trying to ‘train’ him to
wake up and pee. Treat the poop.” Well put.

The “Parental Negligence” Theory

Sometimes it’s the parents’ behavior, not the child’s, that is deemed the culprit in enuresis and encopresis.
After Kristen Bell revealed her 5-year-old was wearing diapers to bed, a psychologist tweeted Bell was
“too lazy to toilet train her child.” The Twitter trolls piled on. When the news reported that British
kindergarteners were having potty accidents at school, a blogger posted that parents were forcing
teachers to fulfill “a duty that a family member should have properly performed before the children arrived.”

22 | M.O.P. Anthology — 5th Edition

 What sort of “evidence” is used to support the idea that
parents are to blame? Alarmingly terrible evidence. A
major psychiatry textbook cites as evidence a case report
When you treat a of four teens admitted to the medical-psychiatric unit of an
Israeli children’s hospital.11 The authors, two psychiatrists,
child’s dilated rectum, describe the teens’ family backgrounds and dynamics like
rather than a child’s behavior this: The mother “was pedantic and obsessive,” the father
“came from a low-social class,” “the father was an alcoholic,”
or family background, the
“the mother lived a Bohemian life, reluctant to set any limits
prognosis is excellent. for her children.” You get the idea.
After a two-week stay in the hospital, the teens, who’d
been unsuccessfully treated for six years, experienced
“complete remission.” To what did the authors attribute
this success? Several factors, including “admission to our inpatient unit” and “separation of the parent
and child.” To what do I attribute the success? Enemas! As part of the treatment, the kids had enemas
after dinner if they had not pooped during the day. If you read the study, it is obvious that these kids had
accidents because they were constipated, not because anyone’s mother lived a “Bohemian life.”
Among the most discouraging themes in the psychiatry literature is that for many children, the prognosis
is grim — that only 30% to 50% of children with encopresis, for example, may recover after a year. The
Handbook cites particularly poor treatment outcomes in children with parents of “low education level,
low socioeconomic status” or with families “characterized as divorced, disorganized, or chaotic.” That’s
insulting and ridiculous. Only one factor leads to a poor prognosis: ineffective treatment. I have plenty of
patients whose parents are divorced or have limited education. I have plenty of autistic patients, patients
with ADHD and anxiety, and patients who’ve experienced trauma. All these kids do great on M.O.P.
When you treat a child’s dilated rectum, rather than a child’s behavior or family background, the prognosis
is excellent. And once again, I'd point to the success of bladder Botox. If psychological or behavioral issues
played a role in enuresis, why would calming the bladder with Botox immediately halt accidents?

How Well-Informed Therapists Can Help

As long as enuresis and encopresis occupy space in mental health literature, no matter how much the
entries hedge or qualify their statements, kids will be shortchanged. The die has been cast. Often, mental
health professionals don’t question the “mental disorder” classification until their own children develop
these conditions. Over the years, several parents employed as therapists have joined our private
support group, only to realize their training and assumptions were off base. One mom posted: “Part of
my experience about learning about this with my own kid has been to feel pretty devastated about how
terribly some encopresis situations were managed with kids I worked with over the years. It makes me
feel nauseated to think about a sticker chart.”
Another mom recounted that in her decade as a therapist, she and her colleagues treated encopresis “as
a symptom under the anxiety or behavioral or trauma umbrellas. We didn’t consider encopresis a medical
issue. Until I started dealing with it with my own son, I had no clue.” That’s understandable! After all,
therapists rely on authoritative manuals such as the DSM-5.
Many physicians do, too. Ironically, the misclassification of these conditions has created a role for well-
informed therapists. Many families I work with could use help managing the fallout from years of blame
and shame shouldered by kids (and parents), including poor self-image and a reluctance to comply with
yet another treatment. That’s an arena for mental health professionals, not pediatric urologists like me. Just
make sure you find a therapist who understands that constipation is the root cause of accidents!

11 Fennig, S. (1999), Management of encopresis in early adolescence in a medical-psychiatric unit. General Hospital Psychiatry.
Sep-Oct;21(5):360-7. [Link]

section 1 : The Research Supporting M.O.P. | 23

Five Strategies That Do More Harm Than Good
Many enuresis and encopresis remedies are merely useless, whereas others, like the five
listed below, can backfire.
Rewards: Overactive bladders do not respond to the
1. promise of M&Ms or extra screen time! Praise, rewards,
and sticker charts for dryness send the message that
staying accident-free is within the child’s control. But
it’s not, so kids are set up to feel like failures when
they have an accident. If a child resists an aspect of
treatment, such as enemas or laxatives, I think it’s fine
to offer kids a reward, such as screen time or toys,
for following through. That is totally different from
rewarding a child for dryness.
Sending a child to bed in underwear rather than
2. pull-ups: The discomfort of wet sheets won't calm
Rewards and disincentives don't
help children stay dry and often
an overactive bladder and only serves to disrupt
just lead to frustration.
everyone's sleep and make kids feel like they've
failed. I've heard of doctors recommending parents
withhold pull-ups as a way of making the child "take responsibility" for the bedwetting by doing
the laundry. Yikes! I’m all for kids doing their own laundry, but never as a reprimand or disincentive
for having accidents. It should go without saying, but children should not be shamed or punished
for bedwetting.
Limiting liquids: Restricting fluids irritates the bladder and contributes to constipation, the very
3. condition we’re aiming to prevent. Children should drink plenty of water throughout the day, and
there’s no need to restrict beverages in the evening. One mom worried that when her son’s soccer
coach challenged the players to drink 1 gallon of water per day, the boy might start wetting the
bed again. But he didn’t. Another mom chimed in: “When my daughter started drinking a lot more
during the day, we saw a huge reduction in overnight wetting.”
Holding urine to “strengthen” the bladder: This old-school remedy is still making the rounds.
4. A while back, first-grade teachers in Las Vegas sent parents a letter stating that “students are
wasting valuable learning time on bathroom breaks” and insisting 6-year-olds need only pee
once or twice during the school day. The teachers asked parents to help their children “increase
bladder endurance” by overriding their urges to pee. After a backlash from parents, the principal
retracted the letter and conceded that unfettered restroom access is “a basic human right and
need.” But clearly the school’s teachers, like many adults,
misunderstood some basic facts about bladder health. In
fact, holding pee can thicken and irritate an overactive
bladder, exacerbating enuresis.
I’m all for kids doing
Waiting: Parents are frequently urged to “be patient”
5. and assured their child’s accidents will spontaneously
their own laundry, but
disappear. But left untreated, enuresis and encopresis never as a reprimand or
often worsen and become more difficult to resolve. If your disincentive for having
bathtub drain pipe was clogged with hair, would you wait
accidents.
around for the pipe to unclog itself? Chances are, you’d
buy Drano or call the plumber.

24 | M.O.P. Anthology — 5th Edition

 No doubt you have plenty of friends whose children outgrew enuresis. Most kids eventually do, a
fact that gives many parents enough hope to keep delaying treatment. But it’s important to take a
hard look at the statistics. The fact that most kids outgrow accidents doesn’t really matter because,
at this point, your child hasn’t. A better question to ask is: When a child is still wetting the bed at
this age, what are the odds the accidents will stop? Another key question: Which kids are most
likely to stop wetting?
That second question has a clear answer: The children most likely to outgrow enuresis are those
who a) wet infrequently and b) do not have daytime enuresis or encopresis. The unluckiest ones
are those who wet nightly, or nearly so, and those who also have daytime accidents. These are
among the findings from a study of more than 16,000 children conducted in Hong Kong.12 As for
the first question — what are the odds a child will stop wetting? — the Hong Kong researchers
offer insight there, too. At age 5, 16% of children surveyed wet the bed, a finding consistent with
other studies. With each successively older group, the percentage of bedwetting children dropped
— until it didn’t. After age 8, the drop-off was small. After age 10, it vanished. The percentage of kids
wetting at age 11 (2%) was the same as the percentage of adults with enuresis.
Consider the percentage of children who wet the bed at each age:

Age 5 Age 6 Age 7 Age 8 Age 9 Age 10 Age 11

16% 13% 10% 6% 3% 2.6% 2%
Now let’s fast-forward:

Age 17 Age 18 Age 19

2% 2% 2%
If you do some fancy statistical math based on this
data, you’ll find that a 9-year-old who wets the bed
has about a 70% chance of becoming a 19-year-old
The kids least likely to who wets the bed. Given those odds, I don’t advise
outgrow bedwetting waiting around.
spontaneously are those Even if the odds were better, I wouldn’t recommend
who wet nightly and those waiting. The older children get, the more distressed
they become. I hear parents say, “Oh, she doesn’t care,
who also have daytime and we don’t make a big deal out of it.” But many
pee or poop accidents. children care more than their parents realize, and
they find the whole situation mortifying. When their
friends start attending slumber parties and school
overnights, their distress often escalates. In my experience, “waiting it out” benefits no one and
carries a lot of costs, for children and parents alike.
The mom of one of my patients told me: “Through age 5, 8, 10, the pediatrician kept saying,
‘Don’t worry, he’ll grow out of it.’ When he was 14, he wanted to go to Rome with the Latin club.
I was so stressed. Six months before the trip the urologist put him on medication, but that didn’t
work. I sent him to Rome with nine garbage bags for the bed.” Doctors diagnosed the boy with
anxiety and sleep disorders, and all treatments failed. His mom told me she was stunned to learn
that constipation causes bedwetting and that her son, who’d had encopresis at age 5, was still
constipated. “I was like, ‘WHAT???’ We thought the constipation was under control because

12 Yeung, C., Sreedhar, B., Sihoe, J., Sit, F., & Lam, J. (2006, April 6). Differences in characteristics of nocturnal enuresis between
children and adolescents: a critical appraisal from a large epidemiological study. BJU International, 97(5), 1069-1073.
[Link]

section 1 : The Research Supporting M.O.P. | 25

 he wasn’t having poop accidents anymore.” Eventually, the kid’s accidents resolved, with the
combination of M.O.P.+ and medication. The ordeal that began with him delaying kindergarten
due to encopresis concluded with him taking a gap year at age 18 — all because his constipation
went unrecognized and untreated for years.

Why Enemas Work Better Than Oral Laxatives

Even if you are persuaded that constipation is the root cause
of enuresis and encopresis, you may still wonder: Aren’t enemas
going too far? Won’t laxative powder suffice? Or how about one
of those pre-colonoscopy beverages that humorist Dave Barry
describes as a “nuclear laxative.” Wouldn’t a colon power wash
do the trick? If only!
Back in 2011, when my first book, It’s No Accident, was published, I was still
advocating Miralax — a high-dose clean-out followed by a daily maintenance
dose — as a decent, if somewhat inferior, alternative to enemas. A few years
later, I changed my mind. It’s clear that enemas work far better, and I want
to offer my patients the best treatments. Certainly, daily oral laxatives play
a useful role by keeping poop soft. High-dose clean-outs can sometimes be
helpful as an adjunct to M.O.P. but are a short-term help at best, as I explain
in Section 7. Often, the liquid cleanse washes right past the impacted mass The recommendations
of stool, so the child ends up with both diarrhea and constipation. Enemas are in my 2011 book,
flat-out better. It's No Accident,
don't reflect my
What if you or your child unequivocally oppose enemas? I would never force current opinions.
a child to do enemas or insist a family embark on a treatment they are
uncomfortable with. I’m just telling you what works best. What works second best — but sometimes
doesn’t work at all — is a daily regimen of a stimulant
laxative such as Ex-Lax or senna. With this approach,
it’s critical to use a strong enough dose to stimulate
Often, the liquid cleanse a bowel movement. In my experience, Ex-Lax alone,
washes right past the without enemas, is most likely to suffice for kids who have
infrequent accidents. Most kids with daily or near-daily
impacted mass of stool, so
accidents need a daily enema plus an osmotic or stimulant
the child ends up with both laxative to see significant and lasting progress. You may be
diarrhea and constipation. surprised to learn that many kids prefer enemas (reliable and
quick) to Ex-Lax (cramp-inducing and long-acting) and many
Enemas are flat-out better.
choose Multi-M.O.P. (docusate sodium mini-enemas two
or three times per day) over M.O.P.x (one enema plus a
stimulant laxative).

The Case for Enemas: "Highly Effective" and "Rapid and Easy to Perform"
In making the case for enemas, I tend to focus on Dr. O’Regan’s studies because they are so compelling,
original, and comprehensive, pertaining to enuresis, encopresis, and UTIs. But Dr. O’Regan wasn’t the only
researcher of his era who deployed enemas to stop accidents. In 1985, the year Dr. O’Regan published his
first study, a team of physicians affiliated with Johns Hopkins University, tracked 58 kids with encopresis.13
These kids were in dire straits, averaging 13 poop accidents a week and suffering profound distress.
13 S.P. Lowery et al., Habit training as treatment of encopresis secondary to chronic constipation, Journal of Pediatric
Gastroenterology and Nutrition, June 1985; 4(3):397-401. [Link]

26 | M.O.P. Anthology — 5th Edition

 For 21 weeks, the children were asked to comply with the following
regimen: They would try to poop after a designated meal, usually
breakfast, and if they went two days without pooping, they’d
"We knew the receive an enema. The treatment was a striking success: The
root cause of 43 kids who stuck with the plan dropped from 13 poop
bedwetting was accidents per week, on average, to 0.5. The kids whose
accidents did not completely resolve — who’d started with
incomplete rectal more severe cases — were averaging 16 fewer accidents per
emptying, and enemas week than when the program began. When the researchers
were the only way to followed up three years later, most of the parents reported
that their children had sustained excellent results with
solve the problem."
minimal, if any, maintenance. The Hopkins team described its
– Dr. Sean O’Regan regimen as “highly effective,” “rapid and easy to perform,” and
“involv[ing] minimal risk,” concluding the plan “appears to be the
treatment of choice for encopresis.”
Now, neither the O’Regan nor Hopkins teams set out to test the
effectiveness of enemas in particular. They were on a more important mission: to show accidents were
caused by chronic constipation rather than psychological problems. Both teams used enemas in their
studies simply because, at the time, enemas were the go-to remedy for constipation. PEG 3350 wasn’t even
approved by the FDA until 1999. Other oral remedies existed, including senna, magnesium, and castor oil, but
when I asked Dr. O’Regan why he chose enemas, he told me, “We knew the root cause of bedwetting was
incomplete rectal emptying, and enemas were the only way to solve the problem.” To him, enemas were a
no-brainer.
That’s hardly the case today, and I understand why. PEG 3350 is readily available, and it’s easier to hand
a child a glass of water mixed with a tasteless, odorless powder than to insert a tube up a child’s bottom
or have kids do it themselves. Nevertheless, after years of experience with both Miralax and enemas,
it became obvious to me that “easier” did not equal “better.” I was curious to know how much better
enemas would fare, so I embarked on a study comparing the two.14
In this study, my clinic tracked 60 patients, ages 4 to 11, with daytime enuresis. (Most of these kids also
had nighttime enuresis, but this study focused on the daytime accidents, which I knew would resolve
much faster.) Forty patients followed standard
therapies, including daily PEG 3350 and a pee
schedule. Another 20 patients agreed to daily enemas
for 30 days before tapering, plus daily PEG 3350.
Three months later, 30% of the patients treated with
standard therapies had stopped daytime wetting,
according to their parents, compared with 85% of
the enema patients.
I wasn’t surprised. Our data on rectal diameter reveals Enemas are as old as medicine and
why enemas worked better. At the start of the study, are referenced in the Ebers Papyrus, a
the average rectal diameter in both groups exceeded compilation of medical texts circa 1500 B.C.E.
6 cm — twice the maximum normal measurement. Illustration by Mark Beech
After three months of treatment, the rectums of
the Miralax patients remained stretched, to 5 cm on average, while the rectums of the enema group
had rebounded dramatically, averaging 2.15 cm. You can’t tell me Miralax is just as effective as enemas!
What about the three children in our enema group whose daytime wetting persisted? These kids were still

14 Hodges, S. J., & Colaco, M. (2016). Daily Enema Regimen Is Superior to Traditional Therapies for Nonneurogenic Pediatric
Overactive Bladder. Global Pediatric Health, 3, [Link]

section 1 : The Research Supporting M.O.P. | 27

 clogged, according to our follow-up x-rays. These are the kids who
need more aggressive variations of M.O.P., as many kids do.
Most of my patients As far as I know, I'm the only researcher who has directly
can’t get anywhere compared enemas with PEG 3350 for the resolution of enuresis.
However, at least two studies, one conducted in Amsterdam and
near accident-free in the other in Kansas City, have compared the two treatments in
the long-term without kids with fecal impaction. The Dutch study demonstrates both
persistent enema the effectiveness of enemas and today’s anti-enema bias.15 The
researchers tracked 90 children determined by rectal exam to
treatment. have impacted stool. For six consecutive days, half the kids
received daily enemas, and the other half received high doses
of Miralax. The upshot: Among the enema group, 80% of the
children had a successful disimpaction, compared to 68% of the PEG 3350 group. One extra enema led
to success in another three kids, increasing the success rate among the enema kids to 87%. Compared to
the PEG 3350 group, the enema group “reported fewer episodes of fecal incontinence” — 3.4 accidents
compared to 13.8 accidents.
It’s clear enemas fared better. The researchers themselves noted that since poop accidents are miserable
— “associated with lower quality of life”— children and parents should be informed that PEG treatment “is
likely to cause more episodes of fecal incontinence,” compared with enemas. Yet, the same researchers
concluded enemas and Miralax were “equally effective” and “should be considered equally,” adding that
“enemas should not necessarily be withheld to prevent anxiety.” That’s a backhanded endorsement if I’ve
ever heard one. Why not just state the obvious? Enemas do a better job without any downside, and
Miralax causes poopy leakage.
This type of leakage is no small problem. One mom in our private support group reported that at age 4,
her daughter was having up to 20 accidents a day, which caused “ulceration of the skin around her anus.”
And yet, she posted, for three years, “our pediatrician and pediatric GI specialists did nothing other than
recommend more Miralax and clean-outs, which would help for a couple of days, then she would regress
again. I was at the end of my rope. It was so stressful and emotionally draining.” Another mom posted that
her son took PEG 3350 for three years “and was a big,
poopy mess” whereas on enemas, the accidents stopped
right away.
What matters most is the
The Kansas City study compared the effectiveness of
enemas and PEG 3350 for 79 impacted kids who landed follow-up, not the method
in the pediatric emergency department, concluding of disimpaction. That’s
that “disimpaction by enema may be superior to PEG for
why M.O.P. involves
immediate relief of symptoms.”16
daily enemas for at least
Notably, in the Dutch study, six days of enemas did not
have lasting results. After the six days, both groups were 30 days, even if poop
instructed to take daily doses of Miralax for two weeks. accidents stop on Day 2.
During that time, the Miralax kids averaged 5.9 accidents
per week, compared to 5.4 accidents for the enema kids,
confirming everything I’ve ever learned about treating
encopresis: What matters most is the follow-up, not the method of disimpaction. That’s why M.O.P.
involves daily enemas for at least 30 days, even if poop accidents stop on Day 2, and the enema program

15 Bekkali, NLH, et al., Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG,
Pediatrics (2009) 124 (6): e1108–e1115. [Link]
16 Miller, M. K., et al. (2012). A randomized trial of enema versus polyethylene glycol 3350 for fecal disimpaction in children presenting
to an emergency department. Pediatric Emergency Care, 28(2), 115–119. [Link]

28 | M.O.P. Anthology — 5th Edition

 lasts at least three months. The Johns Hopkins encopresis
study, you might remember, lasted five months. Most of my
patients can’t get anywhere near accident-free in the long-
A chronically stretched term without persistent enema treatment.
rectum will not shrink back to Nonetheless, the medical establishment approves of
normal in one or two weeks. enemas only in very limited circumstances.
For example, the American Academy of Pediatrics states:
“For the first week or two the child may need enemas,
strong laxatives or suppositories to empty the intestinal
tract so it can shrink to a more normal size.” But here’s the thing: A chronically stretched rectum will not
17

shrink back to normal in one or two weeks.

Several studies show enemas are highly effective for treating pee and/or poop accidents caused by
chronic, severe constipation. No study shows PEG 3350 is superior, and the two studies that have
compared the two treatments for fecal impaction have found enemas work better. So, why do most
physicians oppose enema treatment? That’s our next topic.

“Dependence,” “Damage,” and Other Myths

About Enemas
One argument against enemas goes like this: “Yeah, they might be highly effective, but
they’re going to damage or traumatize my kid.”
I understand that “effective” is not the same as “safe” or “a good idea.” The concept of giving a child an
enema every day just sounds ... wrong. Plenty of doctors reinforce that notion. One doctor told a mom,
“There’s no way I would do that to my child.” Others have
called M.O.P. “borderline abusive.” What’s with the fierce
opposition? Well, one mom posted a theory that sounds
In the medical literature,
about right to me: “I wonder if the shift toward viewing
enemas as ‘abusive’ and last resort over the last 30+ years you can trace a shift
is connected to the greater awareness of child sexual abuse in how enemas are
and a subconscious connection between that and enemas.
perceived — from benign
Obviously, greater awareness of child sexual abuse is a
good thing, but I do wonder if enemas have been tainted by and useful in the O’Regan
association.” era, to coercive and
Enemas are as old as medicine. The procedure was traumatic today.
referenced in the Ancient Egyptian Ebers Papyrus and was
touted by Hippocrates himself circa 400 B.C.E. (If you’re
seriously bored one weekend, check out The History of the
Enema.18) In a 1955 article published in the Journal of the American Medical Association, three Virginia
physicians observed that enema popularity has waxed and waned. The 18th century marked “a particularly
low point in their extent of use,” whereas “today, the value of a satisfactory enema solution properly used
is well nigh universally recognized as a desirable procedure.”19
In the medical literature, you can trace a shift in how enemas are perceived — from benign and useful
in the O’Regan era, to coercive and traumatic today. Here’s a really telling example: In its 1985 study
17 [Link]
18 [Link]
19 [Link]
CGw0tqZnao?key=JAMA

section 1 : The Research Supporting M.O.P. | 29

 of children with encopresis, referenced earlier, the Johns Hopkins team
emphasized that enemas were well received by the participating families,
noting the treatment’s success “seems to gratify parents and to
“The urgent care encourage them to cooperate with the treatment regimen.” Yet in a
doctor told my son 2017 book chapter on encopresis, a psychologist describing that very
enemas at his age are study wrote that the children “were made to use enemas.”20 As in,
they were “forced.” Who says?
dangerous and said
Sometimes enema opponents cite a risk to the child’s mental health;
he just needs a stool other times, it’s the child’s physical health. I recently met with a
softener.” bedwetting 16-year-old with enuresis and his mom, after the boy
became so constipated that he landed in urgent care. “The urgent care
doctor told my son enemas at his age are dangerous,” the mom reported,
“and said he just needs a stool softener.” The idea that a stool softener
could resolve this child’s enuresis was preposterous. By the way, many folks with
congenital conditions such as spina bifida require enemas every day for their entire lives and are no
worse for the wear.
When I asked Dr. O’Regan if any of his patients ever suffered complications on his regimen, he told me,
“Our only complication was a 7-year-old girl who clogged the toilet at our hospital after an enema. She
was legendary.” In other words, the damage was to the plumbing, not the patient! Nonetheless, many
doctors today insist enemas are damaging to a child’s physical and/or mental health. Below I address the
most common concerns I’ve heard from parents and physicians.

Dependence
Even WebMD warns that if you use enemas long-term, “your bowel may stop working normally and
you may have ongoing constipation.” But do enemas really cause “lazy bowel”? No. In a chronically
constipated child, the bowel is already not working normally. Once the rectum regains the tone needed to
empty fully, the child will no longer need enemas.
One of the goals for a child on M.O.P. is to poop spontaneously once a day, in addition to pooping after
each enema. If the child is only pooping after enemas, this is NOT a sign of dependence on enemas. It
is a sign your child’s rectum hasn’t fully recovered. Dependence is something different. A patient with
type 1 diabetes, for example, will always be dependent on insulin to live. Your child will not always rely on
enemas or suppositories to poop, though it may take many months to wean off them. In the meantime,
if enemas are what it takes for your child to fully evacuate every day, what’s wrong with that? Certainly,
pooping with the help of an enema is a lot healthier than not pooping.

Electrolyte Imbalance
First off, this issue applies only to phosphate (Fleet) enemas. So, if you “It is way more
have the slightest concern, simply use another type of enema, such as traumatic to poop in
glycerin or docusate sodium. the middle of class and
As for electrolytes, they are chemicals in the blood that regulate our stink up a room full of
nerve and muscle function, hydration level, and blood pressure. One kids who don’t yet have
of these electrolytes is phosphate, an ingredient used in many over-
a verbal filter.”
the-counter enemas. Certainly, an electrolyte imbalance would be a big
deal, potentially causing serious damage to the kidneys and heart. But the
human body does an excellent job of controlling our electrolyte levels. A
child with normal kidney function will simply pee out the extra phosphate. I have
never had a patient develop an electrolyte imbalance from enemas. Among healthy children who receive
20 [Link]

30 | M.O.P. Anthology — 5th Edition

one enema per day, electrolyte imbalance is practically unheard of. A review of 39 studies conducted over
50 years found a total of only 15 cases of electrolyte imbalance in children ages 3 through 18.21 Over 50
years. The vast majority of these cases involved children who had a chronic disease or were given more
than one phosphate enema in a day.

Sphincter Damage
Your child’s sphincter, the ring of muscle surrounding the anus, is safe. An enema tip is about the
diameter of a pencil. The stool of a constipated child is as wide as a jumbo sausage! Your child’s sphincter
is plenty used to stretching wider than it does when an enema is inserted. What’s more, enema tips are
made of flexible materials, and you can add gobs of lubricant to help the tip slide in. Children are far more
likely to experience anal tearing and bloody stools from straining to poop on their own than from pooping
with the help of an enema. I do advise parents to help their children relax during enemas, because when
the sphincter is tense, the nozzle won’t slide in easily, and the child may feel discomfort.

Damage to the Intestinal Mucosa

The mucosa is the inner lining of the colon, and in some kids, phosphate enemas can irritate this lining,
a condition called colitis. If your child feels internal burning with phosphate enemas (this is different from
discomfort upon inserting the nozzle), switch to liquid glycerin suppositories, docusate sodium mini-
enemas, or large-volume saline enemas with glycerin.

Elimination of Helpful Gut Flora “Our GI was fine with

Will enemas wash out the intestinal bacteria that promote M.O.P., although she went
immunity and good digestion? It’s a good question, for on and on about how enemas
are so traumatic for most kids. My
which there is little evidence to provide a good answer.
daughter, who’s 10, looked at her like
I believe that for chronically constipated children, the
she was crazy and told her it was really
benefits of stimulating full evacuation every day far
no big deal. I kept thinking to myself: Well,
outweigh any reduction in helpful gut bacteria. My
yeah, if you drum it into kids that enemas are
patients who get daily enemas are no more prone to
going to be traumatic, maybe they will be.
illness than other kids. Many parents put their children
But if you act like it’s no big deal, well,
on probiotics while on M.O.P. to prevent elimination of
it’s really no big deal! You know what’s
good bacteria. I don’t know if this helps, but I don’t see
traumatic? Wearing diapers to
any harm in probiotics.
school every day in
5th grade.”
Emotional Trauma
Doctors who issue this warning to parents seem to have no actual
experience with enemas and are likely just guessing. In the Dutch
study described earlier, the physicians noted, “It is often assumed that children strongly dislike enema
administration.” And yet, in contradiction to their own expectations, their study found the opposite!
It seems that some doctors don’t like their assumptions questioned. One mom posted: “When my child
told the doctor she liked enemas because she felt better, her statement was immediately dismissed with
‘No, you don’t. No one likes them.’” Yet another mom wrote: “When I told our doctor we were getting good
results with enemas, she told us to ‘stop that right away.’ The most upsetting thing was her language
around the ‘trauma,’ which has not been our experience at all. Enemas are just part of our evening routine,
like brushing teeth.”
Countless parents have reported that enemas are a lot less traumatic than the alternatives. “It is way more
traumatic to poop in the middle of class and stink up a room full of kids who don’t yet have a verbal filter,”
one mom posted. “A quick, painless enema is much easier. My daughter asks for enemas and has increased
21 Mendoza, J., Legido, J. Rubio, et al., Systematic review: the adverse effects of sodium phosphate enema. Alimentary
Pharmacology & Therapeutics, 26: 9-20. [Link]

section 1 : The Research Supporting M.O.P. | 31

confidence five-fold because she’s not smelly. She used to be unsure and would ask me in a whisper if she
smelled OK. It broke my heart. Now THAT was traumatic, especially when you’re in middle school.”
Certainly, many parents and children are apprehensive, if not downright afraid, when they start doing
enemas. Mostly they fear enemas will hurt, and sometimes they do hurt. This is usually because the child
isn’t relaxed or lying in the right position or because there’s not enough lubrication on the tip. The Enema
Rescue Guide, found in Section 10, has lots of ideas for making enemas easier for your child.

“But Laxatives Aren't Natural”

When folks object to M.O.P., it's almost always because of the enemas. However,
occasionally parents express more concern about the safety of laxatives than of enemas.
They worry it’s not “natural” to give children laxatives and wonder whether prune juice and a healthy, high-
fiber diet could substitute. My response: It’s not “natural” for a child to carry around a belly load of poop,
and the sooner children get cleaned out, the sooner they can get back to their “natural” state.
For many kids, osmotic laxatives are an important part of M.O.P., and these laxatives perform a job that
prune juice and broccoli cannot. Stimulant laxatives, a key component of M.O.P.x, also can play a big role
in helping kids overcome the habit of delaying pooping.
The main question I hear from parents about both types of laxatives is: “Could my child become
dependent upon them to poop?” The answer is no. When children cannot achieve that spontaneous poop
without laxatives, it’s not because they have become dependent on laxatives; it’s because the rectum is
stretched and not operating as it should.
Osmotic laxatives are not habit forming — any doctor will tell you that. As for stimulant laxatives,
according to the conventional wisdom, these products can lead to dependence and should be used
sparingly. Years ago, I, myself, repeated this “wisdom,” having heard it from pediatric GI colleagues.
However, I have not found any scientific evidence to support this notion, and neither did a review article
by a team at Nationwide Children’s Hospital, in Columbus, Ohio. The article considered eight studies on
senna safety in constipated children, finding “no evidence of tolerance.”22
What about side-effects? With stimulant laxatives, the most common side-effects are stomachache, cramping,
diarrhea, and nausea. These symptoms subside when the dose is reduced. But keep in mind that a certain
amount of discomfort is necessary to stimulate the bowel movement and to alert the child that it’s time to
poop. It can take experimentation to find a dose that is both tolerable and strong enough to do the job.
A more rare side-effect is blistering in the perineum (around the anus). In its review of the literature, the
Nationwide Children’s Hospital team found 28 reported cases of perineal blisters. “All of the blistering
episodes were related to high dose, nighttime accidents, or intense diarrhea with a long period of stool to
skin contact,” the team reported. In a review of the hospital’s own patients, the team found that among
640 patients who’d taken senna, 17 (2.2%) developed blistering.

Will Enemas Make a Comeback?

Despite the current anti-enema sentiment among physicians, I remain hopeful the
medical community will come back around. In our private groups, more parents are reporting that
their healthcare providers support their use of enemas. Perhaps the enema will once again be recognized
for what it is and has always been: the single best tool for resolving enuresis and encopresis. I think kids
with these conditions deserve nothing less.
22 Vilanova-Sanchez, A., Gasior, A. C., Toocheck, N., Weaver, L., Wood, R. J., Reck, C. A., ... Levitt, M. A. (2018, April). Are Senna
based laxatives safe when used as long term treatment for constipation in children? Journal of Pediatric Surgery, 53(4), 722-
727. doi:[Link]

32 | M.O.P. Anthology — 5th Edition

Section 2

Diagnosing Constipation
in Your Child
Constipation is too often overlooked in children. That’s because the
conventional understanding of the term is problematic and because the
most common diagnostic methods are unreliable. Autistic children face an
additional barrier to diagnosis: their accidents are often dismissed as “part
of the deal” with autism. This section explains the lesser-known signs a
child’s rectum is clogged and the benefits of evaluating constipation via
x-ray. You’ll find the section useful if:
• You’ve heard constipation
defined as “infrequent
pooping.”
• Your child has accidents
but does not display
the "traditional" signs of
constipation.
• Your doctor does not think
your child is constipated.
• You’re concerned that x-raying
for constipation is unsafe.
• You want to ensure your child’s
x-ray is accurately evaluated.

33
section 2 : Diagnosing Constipation in Your Child | 33
Why Constipation Goes Unnoticed
Many years ago, I had a patient who prompted me to rethink everything I’d been
taught about diagnosing constipation. She was 6 years old and had a condition called
vesicoureteral reflux, also known as urinary reflux. Now, in kids with urinary reflux, the
valve at the junction of the ureters and bladder is faulty, allowing some urine to flow
back up into the kidneys when the child pees. So, the child’s bladder never fully empties, leading
to chronic UTIs. In most kids, reflux resolves with time (the bladder and
ureters grow into the correct orientation). In the meantime, UTIs can
be prevented with low-level antibiotics and a regimen to avoid
constipation, since an idle mass of poop supplies the bacteria “The doctor
needed to trigger an infection. said wetting is
But the usual approach didn’t work for this 6-year-old. usually behavioral and I
She took laxatives and pooped like a champ, and when was ‘barking up the wrong
her parents filled out questionnaires designed to detect tree’ about constipation. He
constipation, she passed with flying colors. Yet her
examined her tummy and said:
UTIs persisted, and she developed the urgent need to
pee. According to what I’d been taught, her only option nothing there. He begrudgingly
was surgery to reposition the ureters. It’s not a risky agreed to an x-ray. Lo and
procedure, but still, it’s surgery. I felt that her regimen behold, she’s completely
— laxatives and a pee and poop schedule — should have backed up with poo, all
bought her the time to outgrow the reflux.
the way up to her
Nonetheless, I went ahead with the operation and was
intestines.”
startled when I cut open her abdomen. Her rectum was chock-
full of poop! A grapefruit-size mass of stool was squishing her
bladder into a position that explained the reflux. I had totally missed it.
Intrigued, I began asking parents, via a standard questionnaire, whether their children showed signs of
constipation, and then, for comparison, I’d x-ray the kids. Among the first 50 enuresis and UTI patients I
x-rayed, all had normal pooping habits, according to their questionnaires, yet the films showed every kid
was stuffed with poop. I thought I’d made an epic discovery and could finally prove to my wife I was a
genius! To further satisfy my curiosity, I began delving into the published research on constipation and
urinary problems. That’s when I learned something else: My epic “discovery” had already been discovered
30 years earlier, by one Sean O’Regan.
Since that time, some 15 years ago, I’ve made a practice of x-raying all my enuresis patients, and I’ve
learned a ton. The way I see it, there are two reasons
chronic constipation is routinely overlooked by parents
and physicians alike: 1.) The conventional understanding
Many severely constipated
of constipation is inadequate, and 2.) The common
children poop every day, diagnostic methods are highly unreliable.
even two or three times a day, Let’s start with the word constipation. Ask anyone
because their floppy rectums to define it, and they’ll probably say something like
“infrequent pooping” or “pooping less than three times
can’t fully empty. Fresh poop a week.” Problem is, many severely constipated children
just oozes around the poop every day, even two or three times a day, because
large, hard lump. their floppy rectums can’t fully empty. Fresh poop just
oozes around the large, hard lump. So, while infrequent
pooping is certainly a sign of constipation — any poop

34 | M.O.P. Anthology — 5th Edition

that isn’t shoveled out the door piles up inside — the
inverse isn’t necessarily true. You can’t assume a child
who does poop daily is all clear. The focus on pooping I suspect that if doctors
frequency spotlights what is not happening (pooping) regularly x-rayed patients and
while obscuring what is happening: the rectum is being
could see just how enlarged
stretched and is encroaching upon the bladder.
these kids’ rectums are, they
When it comes to enuresis and encopresis, the common
understanding of constipation simply is not relevant. would understand why PEG
Of course, Dr. O’Regan recognized this definition problem 3350 so often fails and would
when I was about 10 years old, and he made note of it in his
studies, suggesting the term should be defined as incomplete
more readily accept enemas.
evacuation. That was total genius. Dr. O’Regan insisted on
using anorectal manometry to detect constipation, knowing
this test, uncomfortable as it was for the patients, was the gold standard for detecting a stool pile-up. In his
studies, he noted that feeling a child’s belly and talking to parents were not useful.
Dr. O’Regan’s diagnostic approach was consistent with what medical textbooks at the time recommended.
Boy, have times changed! If you read urology textbooks published over the last half-century, you can see
how recommendations for diagnosing constipation in children have shifted, from an emphasis on rectal
exams and anorectal manometry to less invasive and less reliable methods. Recent publications simply
recommend feeling the patient’s belly and taking a patient history. Some textbooks even oppose the use
of x-rays because they don’t correlate well with pooping frequency!
Feeling the patient’s abdomen doesn’t tell you much because the rectum stretches to accommodate the
extra poop. Sure, in some kids, you can feel a hard mass or see the child’s belly pooching out, yet a small,
wiry child can harbor massive amounts of stool without anyone noticing. When I receive records from
referring physicians, I often see, “No masses palpable.” Yet the child’s x-ray shows a mondo load of poop.
For example, one mom posted that her 6-year-old, with daytime and nighttime enuresis, had complained
of a stomachache on and off for 18 months, and the doctor “dismissed it as a common complaint,” insisting
the girl would outgrow the wetting. “He said wetting is usually behavioral and I was ‘barking up the wrong
tree’ about constipation. He examined her tummy and said: nothing there. I said I’d read that a child can be
impacted even if you can’t feel it, and he said, ‘not in a child with no fat on them.’ He begrudgingly agreed
to an x-ray. Lo and behold, she’s completely backed up with poo, all the way up to her intestines.”
Also useless are “colon transit” studies, which measure how long it takes food to travel the length of the
digestive system. The DIY version, which many of my patients have been instructed to do (not by me!)
is the “corn test.” The child eats corn, then reports how long it takes the bright yellow kernels to appear
in the kid’s poop. Corn is used because it doesn’t get fully digested and is easy to identify in poop. Beets
are used, too, because they turn poop bright red. A more sophisticated version of this test, conducted at
medical clinics, is the Sitz marker study. The patient swallows capsules containing special markers (known
as Sitz markers) that show up in an x-ray. Often, doctors mistakenly interpret normal transit-study results
as evidence a child is not constipated. No wonder constipation routinely flies under the radar!
To its credit, the U.K. government’s guidance for diagnosing constipation in children (known as the
NICE guidelines, for National Institute for Health and Care Excellence) states, “Do not use transit
studies.”1 Unfortunately, the same guidance also says, “Do not use a plain abdominal radiograph to make
a diagnosis.” Instead, the guidance advocates relying on a patient history (whether the child poops
infrequently, strains to poop, has hard stools, and so on) and patient examination. Of course, parents are
often unaware of their child’s pooping habits, and, as I’ve mentioned, a child can be plenty clogged despite
pooping frequently and even have soft poop. And given that patient exams are clearly unreliable, it’s
inevitable that huge numbers of constipation cases will be missed.
1 [Link]

section 2 : Diagnosing Constipation in Your Child | 35

In the years following the publication of O’Regan’s studies, many urologists and pediatricians began to
recognize the connection between constipation and urinary problems, but they generally did not — and
still do not — take sufficient measures to diagnose the condition or treat it aggressively enough. Those
NICE guidelines state, “Do not use rectal medications for disimpaction unless all oral medications have
failed,” and for maintenance following disimpaction, enemas are not even mentioned as an option. I
suspect that if doctors regularly x-rayed patients and could see just how enlarged these kids’ rectums are,
they would understand why PEG 3350 so often fails and would more readily accept enemas.

Autism and Accidents

Recently, in a single morning, I met with a 12-year-old autistic girl whose bedwetting
had been attributed to a developmental delay and a 6-year-old boy in diapers whose
parents assumed the boy “couldn’t potty train because of his autism.” These are common
assumptions about autistic kids, but they are incorrect. In both kids, x-rays showed a
rectum enlarged by a hardened mass of stool.
I have many autistic patients, and I can tell you that by the time these kids arrive in my clinic, their
encopresis and/or enuresis is, on balance, more severe than in my neurotypical patients. This is because
enuresis and encopresis in autistic kids are often perceived as “part of the deal” with autism. Also, autistic
kids may offer fewer clues that they are clogged. They may not be able to verbalize the stomach pain
they feel or explain that they can’t sense the urge to poop. For several reasons, chronic constipation in
autistic children goes unexplored and untreated.
Research shows autistic children are more likely than
neurotypical kids to land in the emergency room for
But here’s the thing:
constipation and are far more likely to be admitted to the
hospital after an emergency visit for constipation.2 This isn’t It doesn’t matter that autistic
surprising. Autistic kids, like children with ADHD, do have kids are more prone to
elevated rates of chronic constipation, and this may well be
constipation. They need
related to aspects of autism — I don’t know. That’s not my
area of expertise. But here’s the thing: It doesn’t matter that the same treatment as
autistic kids are more prone to constipation. They need the any child with constipation.
same treatment as any child with constipation.
This fact is not commonly accepted. In the hospital study
referenced above, the researchers identified “a need for
developing more effective outpatient therapies for constipation in children with ASD.” I would frame the
issue differently. Extremely effective outpatient therapies already exist. It’s just that autistic kids are not
offered them.
Instead, enuresis is expected and normalized. In fact, I recently received a press release from a diaper
manufacturer that had teamed up with an autism advocacy organization to “provide solutions for families of
children with autism who are in need of a longer-term bedwetting solution.” The news release asserted that
children with autism and/or ADHD “may face a longer experience with nocturnal enuresis.” Well, yes, enuresis
may linger for these kids — but that’s only because they’re not diagnosed or treated in a timely manner.
According to the press release, a survey of 1,000 U.S. parents of children with autism and/or ADHD found
that about 60% expressed feelings of anxiety and helplessness, and 50% said their children’s bedwetting
had made them feel like a failure as a parent. Some 40% reported that enuresis had made their child
anxious and lowered their child’s self-esteem. I don’t doubt these statistics, and they probably apply to all
2 B. Sparks et al., Constipation in Children with Autism Spectrum Disorder Associated with Increased Emergency Department
Visits and Inpatient Admissions, The Journal of Pediatrics, 202, 194–198. [Link]

36 | M.O.P. Anthology — 5th Edition

parents of children with enuresis and/or encopresis. But it doesn’t have to be this way. Enuresis in autistic
children, like enuresis in all children, can be totally and permanently resolved. It’s unfortunate that the only
“solution” being offered is more absorbent pull-ups.
This book does not include a section called “How to Treat Enuresis and Encopresis in Autistic Kids”
because I treat all kids with the same approach. But wait: Is it really OK to give enemas to an autistic kid?
Sure, it is. Most of my autistic patients do very well on M.O.P., often to the surprise of their parents. One
mom posted that her autistic, minimally verbal 7-year-old came up to her after his third enema and said,
“Bum.” The mom reported: “I actually found him trying to open a Fleet enema and use it on his own.”
Some autistic kids, just like some kids who aren’t autistic, won’t try enemas (at least at first) and prefer to
use high doses of Ex-Lax instead. Sometimes Ex-Lax works. Sometimes it doesn’t. So, we go from there.

Clues Your Child Has Chronic Constipation

If you know what you're looking for, you can detect constipation in your own child
without an x-ray. Following is a list of red flags besides enuresis and encopresis. Just keep
in mind that accidents are, themselves, signs of constipation. Many parents tell me, “My child wets the bed
but has no signs of constipation.” That’s like saying, “My child can run a mile in 5 minutes but shows no
signs of athleticism.”
Extra-large poops. This is the top sign! If your child periodically clogs the toilet, like Jane in our
book Jane and the Giant Poop, that’s a big red flag. If you find yourself shocked at how much
poop could come out of a child so small, you have a constipated kid. Many parents mistakenly
think large poops are a good sign — they insist their child can’t be constipated because she
makes “big, healthy poops.” But “big” just means poop has been piling up in the rectum, big time.
Firm poops. Most folks don’t realize poop should be a pile of mush, like pudding or frozen
yogurt or a cow patty. Thin snakes or mushy blobs are A-OK, too. But if your child’s stool
resembles a log, a kielbasa sausage, or rabbit pellets, your child is constipated. It means the poop
has been sitting there long enough to be drained of water by the intestines.
Super-loose poop. Ironically, what looks like diarrhea is often a sign of constipation. Runny
poop may be all that can ooze around the large, hard rectal clog. Taking osmotic laxatives can
exacerbate this problem, which is why enemas are the most important part of M.O.P.
Recurrent UTIs. I have patients who get urinary tract infections practically every month.
Chronic UTIs are caused by the double whammy of holding pee and holding poop. A child
who withholds poop harbors extra infection-causing bacteria in the rectum, allowing the
bacteria easy access to the outside world.
Frequent peeing. If you find yourself saying, “Wait, but you JUST peed! How can you possibly
need to go again?” your child has urinary frequency. That rectal clog causes the bladder nerves
to send faulty and terribly frequent signals to the bladder that it’s time to pee. Urinary frequency
often shows up in 4-year-olds, probably because it can take a year or two after potty training for
constipation problems to reach critical mass, but children of all ages can develop the condition.
Adults often attribute urinary frequency to attention seeking. In an advice column I read, a
schoolteacher wrote: “I have a student who will literally ask to use the bathroom 48 times in 4
hours. (I kept a tally.) This child does not have a medical condition. This child is not bored. This
child just wants attention.” Untrue and unfair!

section 2 : Diagnosing Constipation in Your Child | 37

 Urgent peeing: The same process that causes urinary frequency — a stool-stuffed rectum ag-
gravating bladder nerves — also triggers urgency, the overwhelming need to pee. On M.O.P.,
both frequency and urgency will resolve before accidents do. That’s a sign of progress.

Infrequent pooping. As I’ve mentioned, a child can poop every single day and still be extremely
constipated. However, a child who poops infrequently is definitely constipated. The body
generates new poop daily, so if it's not exiting, it's piling up.

Pooping more than twice a day. Many parents think, “But my kid is totally regular! She can’t be
constipated!” In reality, excessively frequent pooping means the child’s stretched rectum lacks
the tone to fully evacuate. In one article I read, a mom frustrated by her son’s “potty refusal”
dismisses the idea that he’s constipated, stating: “Dealing with a steady stream of poop filled
diapers assures me that my son is having regular bowel movements.” But that “steady stream”
is itself a sign of constipation! The author inadvertently confirms her son is constipated by
describing the contents of his diaper, including “huge poops” and “tiny poop nuggets.”
Belly pain. Many doctors dismiss stomachaches in children
because the complaint is so common. But again, common
does not mean normal! Not all constipated children
experience belly pain or complain about it, so silence tells
you absolutely nothing. However, children with frequent
stomachaches usually turn out to be constipated.
Decreased appetite. Some kids feel so bloated and
uncomfortable from hauling around their rectal cargo that
they just don’t feel like eating much. Often this lack of Constipation is the
appetite goes unnoticed. It’s only when the constipation is most common cause of
stomachaches in children.
resolved and the child starts chowing down that the parents
realize what had been going on.
Skid marks or itchy anus. Parents often assume poop smears on a child’s underwear indicate
the child needs work on wiping. But what skid marks really indicate is that the child is (probably
without realizing it) fighting the urge to poop. Frequent bottom scratching is another red flag.

Bloody stools. Passing a hard or large stool may cause anal tearing to the point where
the child bleeds a bit. So, stool may arrive with bright red blood on the edge. While this is,
understandably, alarming to parents, the tearing heals quickly, usually within a couple days, as
long as you’re able to soften the child’s stool and continue treating constipation.
Reluctance to poop in the toilet. I refuse to use the term “potty refusal,” which implies the
child is being obstinate, stubborn, willful — “refusing” to do what is asked, in protest of your
parenting. In reality, when a child avoids pooping in the toilet it’s usually because the child
fears pooping will be painful, probably because it is painful or has been in the past. Of course, a
child might also “refuse” to poop in the toilet because the child’s rectum has lost sensation and
the kid isn’t even sensing the urge. When kids don’t poop in the toilet, parents often become
exasperated. Try to remember that the child has a good reason.
Hiding to poop in diapers. When young children in diapers poop in the closet or behind the
sofa, this doesn’t mean the child is shy. Hiding is a red flag for painful pooping,

38 | M.O.P. Anthology — 5th Edition

12 Signs
Your Child
is Constipated
XXL poops. We’re talking “Holy cow!” poops
1 – larger than ¾” x 6.”

Firm poops. Logs or pellets = bad;

2 thin snakes or mushy blobs = good.

Poop accidents. When the rectum

3 is overstuffed, poop just falls out.

Bedwetting and pee accidents.

4 A big ol’ poop mass squishes the bladder.

Recurrent UTIs. Extremely frequent and/or

5 Bacteria from overflowing 6 urgent peeing. You think, “AGAIN?
poop crawl up to the bladder. But you JUST peed!”

7 Infrequent pooping. But daily pooping doesn’t rule out constipation.

Pooping more than 2x/day. A stretched-out
8
rectum lacks the tone to evacuate fully.
9 Belly pain. Constipation is the #1 source of tummy ache in kids.
Skid marks or itchy anus. Clogged kids can’t fully empty
10 —> bottom is hard to wipe
—> poop stains.

Super-loose poop.
11 Some poop can ooze around
the large, hard rectal clog.

Continued trouble toilet training.

12 Your child may fear pooping or hide
[Link]
to poop in diapers.
Design by [Link] Illustration Copyright © 2020 Cristina Acosta © Steve Hodges and Suzanne Schlosberg 2020

section 2 : Diagnosing Constipation in Your Child | 39

Outlier Cases and Medical Conditions to Rule Out
You’ve probably heard the common medical aphorism, “When you hear hoof beats,
think horses, not zebras.” This definitely applies to enuresis and encopresis. In virtually
all my patients with no known neurological or anatomical conditions, accidents can be
explained by garden-variety constipation, and M.O.P. will solve the problem. But there
are exceptions. On occasion, hoof beats actually do come from zebras.
I divide the exceptions into two broad categories: 1.) The child is not constipated, and a different medical
condition explains the accidents. 2.) The child is clogged, but the constipation has an underlying medical
cause that requires treatment beyond M.O.P., usually surgery. Let’s look at both scenarios.

Medical Conditions That Cause Enuresis in the Absence of Constipation

To repeat, zero medical conditions cause encopresis in the absence of constipation. Even though the
American Academy of Pediatrics and the DSM-5 claim such a condition exists, attributing accidents in these
rare cases to psychological or behavioral issues, no evidence has ever supported this contention. X-ray any
child who has poop accidents, and you will find a clogged, stretched rectum. Period. On the other hand, in
rare cases, such as the following, wetting accidents can occur despite a normal, empty rectum.
Posterior Urethral Valves. With this condition, membranes that develop in utero block the flow of urine
through the urethra, causing frequent pee accidents. If not repaired surgically, this condition, which occurs
only in boys, can damage the bladder and kidneys. Posterior urethral valves are almost always picked up
on prenatal ultrasounds, but some cases slip by. Twice I’ve seen cases that were previously undiagnosed.
After x-rays showed a normal-sized, empty rectum, an ultrasound revealed the culprit.
Type 1 Diabetes. In patients with untreated diabetes, excess glucose builds up in the blood, forcing the
kidneys to work overtime to filter and absorb the excess glucose. This scenario sometimes leads to
accidents due to an overproduction of urine. To rule out diabetes (and UTIs), I order urine tests for my
enuresis patients. In my entire career, only one previously undiagnosed patient has turned up positive for
type 1 diabetes. If your child has type 1 diabetes, you’ll likely notice other symptoms, such as extreme
thirst, weight loss, and fatigue.
Diabetes Insipidus. This is a rare kidney filtering disorder that causes a massive overproduction of urine,
as much as 10 times the normal volume. Children with this disorder also typically feel severe thirst, fatigue,
and nausea, and it’s obvious they have a condition other than enuresis. I have diagnosed a few cases.

Medical Conditions That Cause Constipation and Require Treatment Beyond M.O.P.
Sometimes, a neurological or anatomical condition is the root cause of a child’s rectal clogging. So, even if
the child has the same symptoms as a child with garden-variety constipation, such as poop and/or pee accidents,
the underlying poop pile-up has an origin that requires surgery or more radical treatment than M.O.P.
The following is not an exhaustive list but includes the more common of these anomalies. In addition to
the conditions listed here, diseases such as cystic fibrosis and hypothyroidism can cause constipation
and incontinence. So can celiac disease, an inflammatory disease of the small intestine spurred by eating
gluten. In cases such as celiac, where the cause of constipation is a dietary intolerance, dietary changes
alone don’t usually resolve the accidents but are important for preventing a recurrence. When chronic
constipation has already set in, treatment such as M.O.P. is usually needed to repair the rectum.
Spinal Cord Abnormalities. Children with nerve damage in their lower spine have abnormal bowel
function, known as “neurogenic bowel,” because of faulty communication between their brain and bowels.
So, their bowels move at a pokey pace, and these kids can’t sense the rectum is full and/or can’t fully
empty. Conditions that cause neurogenic bowel include spina bifida and tethered cord syndrome. Spina

40 | M.O.P. Anthology — 5th Edition

bifida, in which part of the spinal cord is exposed through a gap in the spine, is almost always diagnosed
before or just after birth. With tethered cord syndrome, the spinal cord, which normally floats freely inside
the spinal canal, is stuck and can become stretched and damaged. Telltale signs include a dimple or tuft of
hair on the lower back, poor reflexes, a deviated spine, and leg weakness.
I’ve seen plenty of patients with spina bifida for incontinence issues, but all were diagnosed long before
visiting my clinic. As I've mentioned, these children typically need daily enemas for life and are not
"traumatized" or "damaged" by this routine treatment. So, I shake my head when doctors insist that a
few months of enemas will somehow harm constipated kids with a healthy spine. I’ve had two patients
with previously undiagnosed tethered cord syndrome, a 4-year-old and a 13-year-old. In both cases, their
accidents suggested routine constipation. It was only upon examination and further questioning that I
discovered these kids were outliers. The 4-year-old had
the telltale lower-back dimple and the off-kilter lower
spine, and when I asked about leg weakness, his mom
said, “Oh, yeah, his left foot sometimes goes numb.” The If your child continues to have
13-year-old had no dimple and a barely deviated spine. I
poop accidents after several
only thought to ask about foot weakness, which he did
report, because his accidents began during a growth months of M.O.P.x or Multi-
spurt in puberty. With both kids, surgery to untether the M.O.P., I advise consulting
spinal cord resolved the wetting.
with a GI motility specialist.
Hirschsprung’s Disease. Children with Hirschsprung’s
disease are missing nerve cells from the colon and the
rectum. So, instead of getting pumped along through
the bowel, stool gets stuck. When a newborn doesn’t
poop within 48 hours of delivery, that’s a red flag. Babies with Hirschsprung’s also tend to have a swollen
belly, pencil-thin stools, failure to thrive, explosive and bloody diarrhea, and they vomit a green or brown
substance. Though Hirschsprung’s is usually diagnosed at birth, children with a mild version sometimes go
undiagnosed for a while. Surgery to remove part of the colon is needed. I’ve never had a case in my clinic,
though I encountered a child with Hirschsprung’s disease when visiting the clinic of a colleague.
Congenital Anorectal Malformation. When the anus or rectum doesn’t develop properly, children have
serious pooping problems that must be corrected surgically. Anorectal malformations are almost always
diagnosed at birth and quickly repaired, although these children may still have difficulties pooping and
need enemas. Anorectal malformations include imperforate anus, where the opening to the anus is
missing or blocked; anal stenosis, a narrowing of the anal canal; and an anteriorly displaced anus, where
the anus isn’t located in its normal position. When the rare case is referred to me, it’s because the child
has resulting bladder issues.
Redundant Colon. Some children have a colon that is excessively slow-moving and long and has extra
twists and turns, known as “colon redundancy.” A portion of the colon simply stops working, and a daily
enema regimen such as M.O.P. will not fully control encopresis. In the more severe cases, surgery is
needed to remove the non-functioning portion of the colon. I’m inclined to believe colon redundancy
develops after years and years of chronic constipation, though it’s possible some cases exist at birth.
If your child continues to have poop accidents after several months of M.O.P.x or Multi-M.O.P.,
I advise consulting with a GI motility specialist. One example of a redundant colon is the case of
Harmony Spieser-Landis, a 10-year-old who tells her own story on the next page. Harmony was not
a patient of mine, but her father, David, communicated with me during her treatment. Persistence by
Harmony’s parents led to motility testing and, ultimately, surgery. I’m grateful to Harmony and David for
sharing their story.

section 2 : Diagnosing Constipation in Your Child | 41

 My Daughter’s Colon Resection
“She had 15 inches of extra colon scrunched up in there!”
Harmony had chronic constipation as a baby, and Eventually, Dr. Dranove
her poop problems got worse when we removed recommended a colon
her diaper, between ages 3 and 4. At age 5, she was resection, the
having poop accidents every 15 minutes or so, and our surgical removal “The absence
pediatric GI prescribed oral clean-outs every weekend. of the non-
of contractions
After a year of this, her accidents didn’t improve, functional part
and we all felt desperate. It was especially hard for of her colon. It
plus the extra bends
Harmony, who thought she was the only one with this turned out she and turns likely
problem. James Parkin’s book A Girl Like You (there is had 15 inches of explained why M.O.P.
also a version for boys) saved Harmony’s mental state extra colon all was not enough.”
by showing her she was not alone. scrunched up in
When she was 6, we came across The M.O.P. Book. there! Incredible. The
It was a turning point and a life-saver — at first. But surgeon added a
then, the accidents returned. Our new pediatric GI cecostomy port, a tube
specialist, Dr. Jason Dranove of Charlotte, North in her large intestine, that enables Harmony to
Carolina, initially told us to continue with M.O.P., which thoroughly flush her colon every day and hopefully
was a great validation that we had done the right will help the colon learn to function on its own.
thing. Still, Harmony had accidents. Harmony does daily flushes through this tube by
herself, and the cecostomy also doesn’t affect her
When Harmony was 9, advanced motility testing day-to-day activities. Her experience with M.O.P.
(colonic manometry with sensors) revealed that made this a piece of cake.
Harmony’s sigmoid colon, the portion right before the
rectum, was not contracting at all and had lots of extra At some point, Harmony may not need the cecostomy
bends and turns. The absence of contractions plus anymore and will be free from all this. We can't know,
the extra bends and turns likely explained why M.O.P. but we do know that right now, she is feeling very
was not enough. These bends and turns could have good and no longer has accidents. She says her life
been there from birth or could have developed due to couldn't be "more perfect." In this regard, she is
Harmony’s constipation — our medical team expressed already free!
multiple opinions.

In Harmony’s Words
“I used to be afraid of surgery, but now, surgery is my friend!”
Hi, my name is Harmony, and I am 10 years old. I’ve movies and going to the bathroom. When the day of
had encopresis my whole life, and whatever we did, the colon motility test arrived, a nurse woke me up
nothing worked. We went to countless doctors, met at 7 a.m. and reviewed what was going to happen: I
with a dietitian, and even did oral clean-outs every would be under anesthesia for a short time for them
weekend, which meant I couldn’t enjoy my weekend. to insert the sensor tube, and then I would be awake
Even with M.O.P., I still had accidents. for several hours while the sensors measured my
colon activity.
So, we did a colon motility study. When I got checked
in at the hospital, I was freaked out, not knowing Later we found out that a colon resection, where you
what to expect. Deep breaths seemed to help. cut out the part of the colon that doesn’t work, would
The first obstacle was the IV. An iPad gave me a be best. We scheduled the surgery for one day after
good distraction from the pain. The IV was nothing my 10th birthday. (I was mad about that.) Surgery
compared to the NG tube (a tube that's inserted was hard, but it’s the best thing that happened to
through your nose and into your stomach), which me in my whole life. I am no longer afraid of having
was 100 times worse than a covid test and the IV accidents every single minute of every single day!
combined. So, then it was two days of watching

42 | M.O.P. Anthology — 5th Edition

Seven Reasons to X-Ray for Constipation
We don’t think twice about x-raying a child to diagnose a broken arm, an injury that
will heal in six weeks. Yet many doctors won’t order an x-ray to diagnose chronic
constipation, a condition that can cause children years of suffering. Some don’t see the
point, as they don’t believe constipation causes enuresis. Others feel certain they can
diagnose constipation by feeling a child’s belly and believe x-rays pose an unwarranted
health risk. One mom emailed me: “My son’s pediatrician said an x-ray would expose my son to radiation
that could later cause cancer.” Another posted: “Our doctor said he couldn’t ethically send a girl with
developing ovaries for an x-ray of the colon.”
This is an overreaction. The radiation dose of a plain abdominal
“My 17-year-old x-ray matches the exposure you get simply
daughter has never from living on this planet for three to six months, thanks
demonstrated symptoms to radioactive materials in our environment and cosmic
of constipation, and exams with rays from outer space. The type of x-ray we use to
her pediatrician have never given detect constipation is called a KUB, for “kidney, ureter,
any indication otherwise. She was on and bladder.” I am absolutely opposed to the overuse
medication for years with no success. Lots of these x-rays in children. However, the amount of
of laundry and self-confidence issues. Her good you can do for a child with bladder problems
first x-ray revealed her rectum measured by accurately diagnosing constipation far outweighs
over 7.5+ cm! Her last x-ray showed she the risks of a plain x-ray. (For children with encopresis,
was cleaned out, and she has had only there’s no reason to x-ray, since constipation is the
one accident in 3 months. She only explanation.)
leaves for college soon. We If you absolutely don’t want your child x-rayed but still
are so relieved.” want proof of constipation, you can have a pediatric GI clinic
perform anorectal manometry, described in Section 1, I do not
recommend trying to evaluate constipation via ultrasound. In my
experience, ultrasounds are much less reliable than x-rays and anorectal
manometry for this purpose. Following are seven good reasons to get a KUB in a child with enuresis.

You know to search for another cause if constipation is ruled out. When an x-ray reveals a normal
1. rectum, I know to look for other
culprits, such as the outlier
conditions listed earlier. See how the poop
lump in Zack’s Oh, I see.
You can view the extent
2. of a child’s constipation. A
rectum has
flattened his
His bladder is so
squished that it’s
child’s pooping frequency bladder? not big enough
to hold pee all
or symptoms won’t reveal
night.
how much poop is idling in
the rectum or how much the
rectum has stretched. An
x-ray, particularly with a rectal
diameter measurement, will
show you, “This kid is massively
stopped up. The rectum is
stretched to three times a
normal size.” With that kind An x-ray can show the extent of a child's constipation.

section 2 : Diagnosing Constipation in Your Child | 43

 of information, you can see why a course of PEG is likely to be a waste of time and why enema
treatment is warranted. As one mom put it, “For us, the x-ray made us feel less like we were
throwing darts in the dark."

You have proof accidents aren’t your child’s fault. When you see a child’s bladder being squished
3. by a mass of poop, it hits you: This kid can’t possibly stay dry. One mom posted: “Seeing the x-ray
really decreased our frustration with our 5-year-old son. We thought his accidents were a behavior
or anxiety issue.” She stopped rewarding her son for dry nights, and the boy stopped trying to hide
his wet underwear from her. “Now he doesn’t have to feel disappointment for not earning a reward
when he has no control over it,” she continued. “We all have better attitudes, as we view the
wetting as a medical issue.”

Children are more amenable to treatment. Kids old enough to understand an x-ray may be more
4. willing to comply with enemas and maintain a pee and poop schedule. One mom posted: “Now,
when we remind our son to go to the bathroom more frequently, he doesn’t fight it as much.” One
14-year-old said that seeing his x-ray gave him the motivation to start Multi-M.O.P., the regimen
that got him dry.

Skeptical doctors come around. Some pediatricians will give their blessing to enemas only after
5. reviewing x-rays. One mom posted: “My 5-year-old son started having pee accidents often. I
mentioned to the doctor I thought he was constipated. The doctor felt his tummy and said he
wasn’t.” After this mom insisted on an x-ray, the doctor reported that her son “had the most poop
he’d ever seen in a kid” and suddenly approved of M.O.P.

You have a baseline for later comparison. I don’t routinely order second x-rays, but some
6. parents, after diligently following M.O.P. without results, feel certain their child’s rectum is
clear. A follow-up x-ray shows why the child’s wetting has persisted: The rectum is still clogged.
In these cases, the child needs a different type of enema or variation of M.O.P. One mom posted:
“After 35 days on M.O.P. my son was still wetting, so we went back to the pediatrician. He was
shocked that we were using enemas but agreed to take an x-ray. My son was so full of poop it is
rather unfathomable.”

You can make a more informed decision about trying bladder medication. When a follow-up x-ray
7. shows the child’s rectum is empty but remains dilated, we know the child is on the right track and just
needs more time for the rectum to shrink back to size. In these cases, medication to calm an overactive
bladder can halt or diminish accidents until the rectum has fully healed. Bladder medication, discussed in
Section 7, tends to be a lot more effective when the rectum is empty than when it’s full.

How to Get an Accurate X-Ray Evaluation

A while back I reviewed the abdominal x-ray of an 11-year-
old boy with persistent bedwetting. The boy’s rectum was
jam-packed with stool, and the mass extended upward
to his belly button like a column of poop. I told his mom,
“This is one of the more impacted x-rays I have seen
in a while.” Yet the radiologist’s report on the x-ray, taken at a
pediatrician’s office, found only a “moderate amount of stool in the
colon.” How can two doctors come to such different conclusions
about the same x-ray? After all, an x-ray is not a Rorschach test. It’s a An x-ray isn't a Rorschach
test but may be misread.

44 | M.O.P. Anthology — 5th Edition

 precise image of a child’s abdomen, and it shouldn’t mean different
“Our doctor things to different people. But it often does, for a few reasons.
said our son’s x-ray For one thing, when presented with an abdominal x-ray of a
was clear and offered us child, radiologists tend to look for indications of a serious
medical condition, such as an intestinal injury that would
nothing but bedwetting drugs.
cause air to leak out of the intestine into the belly.
My husband works in radiology
That’s called “free air,” and it’s dangerous. If bacteria
and pointed out what looked like from stool leaks into the belly, you can get really sick.
blockage. She said it actually looked The radiologist who looked at the 11-year-old’s x-ray
better than normal. It makes me commented, “There is no free intraperitoneal air.”
think there are a lot of kids in her But x-rays of kids with enuresis rarely show anything
practice that could benefit from dangerous, so for our purposes, that kind of commentary
is beside the point.
enemas but are sent away
with a prescription for Some constipated children experience so much pain
that they end up at the emergency room, where their
medication.”
constipation is overlooked or minimized. The 11-year-old’s
mom, who happens to be an ER nurse, told me that “poop
problems are the LAST thing an ER doctor looks for. Poop is harmless to
them, and if poop is found, then Miralax and discharge home is the final word.” In addition, radiologists and
ER docs aren’t necessarily trained on the significance of stool in specific areas of the colon. They may say,
“The colon will always contain some stool, so what we see here doesn’t mean anything.” But it does. Yes,
the colon may always contain some stool, but the place to look is the rectum. As Dr. O'Regan observed
back in the 1980s, a child who’s chronically constipated will always have stool in the rectum.
Interestingly, when a child is severely backed up, as this 11-year-old was, poop not only accumulates in
the rectum but backs up way into the colon. In my clinic, we use the term “O’Regan sign” to refer to
this common pattern: rectal poop plus an accumulation of poop in
the right (ascending) colon. A back-up in this part of the colon won’t
trigger accidents but is nonetheless prevalent in children with enuresis.
Radiologists rarely comment on this column of poop. It’s not something
they’re taught to look for. Here’s how to maximize the odds your child’s
x-ray will provide valuable information.
» Ask in advance for a measurement of rectal diameter. A normal
measurement is less than 3 cm; the rectum of a typical enuresis
patient in my practice is about 6 cm. To take a measurement, the
radiologist must measure the rectum at its widest point and then
compare that measurement to the scale on the x-ray. Not all x-rays
have a scale, so make sure your request for a diameter measurement
is included in your x-ray order. The diameter can’t be measured after
the fact. Still, you may get nowhere, as this measurement is not
customarily taken. “When I asked for rectal diameter, the x-ray person
looked at me like I had two heads,” one dad posted.
» Ask in advance for a comment on how much stool is in the rectum, In my clinic, we use
as opposed to other parts of the colon. In the absence of a rectal the term “O’Regan sign”
to refer to this common
diameter measurement, an accounting of the “stool burden” in the
pattern: rectal poop
rectum can be helpful but is often not included in the radiologist’s
plus an accumulation
report. So, request it. Better yet, have your doctor do the x-ray of poop in the right
reading, rather than rely on the radiologist’s report. (ascending) colon.

section 2 : Diagnosing Constipation in Your Child | 45

» Use your phone to take a photo of your x-ray while you are in the exam room. It can be exceedingly
difficult to get a copy of your x-ray once you leave the imaging center, and best case, you may be
given some prehistoric CD you can't access. Having your own photo will make it easier to get a second
opinion. Many parents post .jpgs of x-rays in our private support groups so I can assess their child’s
progress. Caution: Some imaging centers balk at parents taking photos, which is ridiculous. You’re the
paying customer, for goodness’ sake! Parents tell me they get around this by asking to see the x-ray
and then whipping out their phone before anyone can stop them.
One mom told the x-ray technician, “My son wants to be a doctor, and he will think the x-ray is so
interesting!’” Another mom, a veteran of multiple x-rays, posted her strategy: “I just say, ‘My daughter
would like to see her x-ray if it’s OK.’ I’ve never had them refuse. I’ll usually take pictures as I walk over
(just in case I don’t get another chance), and say stuff like, ‘Here are your ribs and bones, and your poop
is in here, and that’s what they’re looking at.’ Usually, the tech starts cleaning up at this point, and I’m
able to snap a decent picture without them seeing. Just make sure the sound on your phone is off so
they don’t hear the camera snapping sound!”
» If your child is already on M.O.P., try to schedule your appointment so the x-ray is taken within two
hours of that day’s enema. An x-ray taken shortly after an enema can help you determine if the type of
enema you are using is effective. If the x-ray shows the rectum is particularly full right after an enema,
that’s useful information. I know school and activities make it hard to time an enema within two hours
of an x-ray, and don’t sweat it if the timing doesn’t work out. You can still glean helpful information
with a delayed x-ray. The timing of a child’s bowel movement won’t affect rectal diameter and won’t
significantly change an x-ray evaluation.

The Strange Case of the Misleading X-Ray

In virtually all cases, an x-ray will prove whether or not a child is constipated. But
one oddball case showed me there are exceptions. In this case, an 11-year-old girl
was referred to me for daytime and nighttime enuresis and severe belly pain. Her
pediatrician reasonably assumed the culprit was constipation and prescribed Miralax.
When that didn’t work, he sent her to me.
But here’s the interesting part: Before referring the girl, the pediatrician had ordered a CT scan of her
abdomen, apparently seeking to rule out appendicitis. Now, had my clinic known the girl already had
a CT scan, we would not have scheduled an x-ray. After all, the radiation dose of a CT scan is about
10 times that of a plain x-ray. But in this case, a miscommunication resulted in two images for me to
scrutinize: a CT scan and an x-ray. Remarkably, they told different stories. The x-ray looked normal. The
rectum did not appear to be terribly stretched by stool, a surprising finding given the child’s symptoms.
But the CT scan — wow. It showed a huge impaction in the girl’s rectum, exactly what I would have
expected the x-ray to show. I can't explain why the x-ray missed the mass of stool, but it did.
Should every enuresis patient have a CT scan? Absolutely not! However, if your child has been on M.O.P.
for a while without improvement and you want evidence your child is (or isn’t) still constipated, you may
want to request a contrast enema instead of a plain x-ray. A contrast enema uses a water-soluble fluid
that shows up on an x-ray, and it’s generally as accurate as a CT scan for detecting constipation, but
without subjecting the child to excessive radiation. This test is a fair amount of trouble. It’s done at a
radiology clinic and requires the child to consume nothing but clear fluids for 24 hours prior to the exam.
But on occasion, this test is warranted.

46 | M.O.P. Anthology — 5th Edition

Section 3

What's Driving Childhood

Constipation
Chronic constipation affects children worldwide and has a wide
range of causes. Some may pertain to your child. Others may
not apply at all. In this section, I discuss what I see as the most
common contributors — some individual, some cultural:
• Genetics and temperament
• Life in the 21st century
• Our rush to potty train
• Restrictive school restroom policies

In general, I urge parents to focus

on treatment rather than on trying
to pinpoint the reason your child
developed chronic constipation.
You may never know, and in
most cases, the reason
just doesn’t matter.
What matters a
lot more is getting
your child’s rectum
unclogged!

47
section 3 : What's Driving Childhood Constipation | 47
“How Did My Kid Get So Constipated?”
On a forum for childhood constipation, a mom posted that her daughter had been
struggling with constipation for six years. “I have been to a lot of doctors,” she wrote.
“Now I have an appointment with a new GI, and I want to eliminate each and every
thing that may cause constipation. What kind of blood work and exams should I ask
for to find out the reason for her constipation?”
I hear this a lot! When I show parents their child’s x-rays, they inevitably ask: “How did my kid get so
constipated? What tests should we get?”
Parents often assume there’s a specific medical explanation, such as gluten intolerance, a virus, a colon
motility disorder, or any number of health conditions. And on occasion, the culprit actually is an underlying
medical issue, such as one of the neurological conditions or congenital abnormalities I discuss in Section 2.
But this scenario is rare. In most cases, the answer cannot be found in lab tests or even in a child’s
lifestyle or environment. In fact, quite often the answer cannot be found at all, and the search for an
explanation only drives parents bananas. I hear, “But we’ve never given her processed food!” and "He plays
three sports!" and “She was never pressured to potty train,” and “No one else in the family is constipated.”
All of that is true for many constipated children! And yet, somehow, their rectums became clogged.
I urge folks not to search too hard for an explanation and instead to put their energy into treatment. Still,
I do want to address more generally why childhood constipation is so common, reasons that may or may
not apply to your child. An international research team, reviewing studies from around the world, reported
constipation prevalence rates between 10% and 30% — in the United States, the United Kingdom,
Brazil, Taiwan, Hong Kong, Korea, just about everywhere.1 The researchers called the constipation rates
“disturbingly high,” yet these numbers are probably low estimates, because there’s no agreed-upon
definition of constipation and because most cases go unreported to physicians.
Understanding the various forces — in society, at school, at home — that commonly contribute to
constipation may help prevent a recurrence in your child or may help a younger sibling avoid becoming
constipated in the first place. But again, this knowledge may not make a difference. What’s far more
important is knowing the signs of constipation and jumping on treatment ASAP.

Genetics and Temperament

The longer I practice medicine, the more I believe
One preschooler may feel
some children are just highly prone to constipation
regardless of their eating habits, activity level, or perfectly comfortable
environment. Genetics and temperament appear to marching over to the
play a huge role. In countless families, every child toilet in the middle of
is constipated and has enuresis and/or encopresis.
Many families have multiple children on M.O.P. Plenty of
story circle, whereas
accomplished student-athletes with stellar eating habits are another might find the
extremely clogged up. Some children experience constipation idea unthinkable.
in infancy, well before they could be eating Pop-Tarts and
playing video games all day!
A common scenario is for constipation to develop between ages 4 months and 1 year, when babies wean
from breast milk and/or formula and start drinking cow’s milk and eating rice cereal and other foods. Breast

1 Rajindrajith, S., Devanarayana, N. M., Crispus Perera, B. J., & Benninga, M. A. (2016). Childhood constipation as an emerging
public health problem. World Journal of Gastroenterology, 22(30), 6864–6875. [Link]

48 | M.O.P. Anthology — 5th Edition

milk, formula, and baby food promote mushy, seedy poop because they’re loaded with water and are easily
digested. But cow’s milk tends to thicken poop. In some babies, this thickening comes as an unpleasant
surprise. Suddenly, pooping feels uncomfortable, and the baby starts to avoid it.
Just as different children react differently to new digestive sensations, kids react in different ways to new
environments and situations. One preschooler may feel perfectly comfortable marching over to the toilet
in the middle of story circle, whereas another might find the idea unthinkable. Some kids are cool with
pooping at school or in supermarket restrooms or become more comfortable doing so as they mature.
Others feel self-conscious from the get-go and remain reluctant.
You can’t explain why some kids are natural musicians or debaters and others recoil at practicing the piano
or speaking in public. Some kids are natural poopers, and others aren’t. When kids aren’t, do your best
to meet them where they are. That said, cultural and environmental forces clearly do contribute to our
society’s high rates of constipation. So, next, let’s take a closer look at them.

Life in the 21st Century

Once in a blue moon, medical testing will turn
Humans are too smart for
up an explanation for a child's constipation, but
often the culprit is more basic: We live in the 21st our own good. It would
century. In modern society, many kids need help not occur to a cat, or to
pooping for the same reason so many kids need our prehistoric ancestors,
braces: our lifestyle has changed, but our bodies
to delay pooping when
have not kept up.
the urge strikes.
Back when humans were hunter-gatherers, our roomy jaws
easily accommodated our 32 teeth; impacted wisdom teeth
were not a thing! But over time, as we shifted from foraging
to farming and took to chewing softer foods, our jaws
downsized. However, we still have 32 teeth. Ergo, dental overcrowding. Shifting further south, from our
mouths to our guts, a similar scenario has unfolded. Before the advent of mac and cheese, couches, and
the Nintendo Switch, GI docs were, for the most part, as unnecessary as oral surgeons. But the human
digestive system isn’t adept at handling highly processed food and days spent seated at desks and
on sofas. So, stool often sits idle or moves through at a sluggish pace, leading to all sorts of problems.
That’s not all. Our cultural concept of decency (you can’t just poop anywhere!), our approach to potty
training (must meet that preschool deadline!), the flush toilet (which takes us out of the natural squat
position) — when the modern human brain is
confronted with all of the above, high rates of
constipation are inevitable.
Basically, we’re too smart for our own good. It
would not occur to a cat, or to our prehistoric
ancestors, to delay pooping when the urge
strikes. But today’s humans, particularly
human children, regularly postpone pooping
— sometimes because it hurts, sometimes
because it’s not convenient, sometimes
because school restrooms are dirty or
scary. As I’ve explained, the urge to poop is
Inactivity is linked to constipation, but triggered when stool arrives in the rectum
plenty of super active kids get clogged. and signals the brain, via nerves, that it’s time

section 3 : What's Driving Childhood Constipation | 49

 Is Dairy a Culprit?
Some parents report that their children’s enuresis study is crap” and “No, your study is crap.”
and/or encopresis worsen when they drink milk Personally, I believe dairy does cause constipation
or eat yogurt or ice cream and improve when they in some children. However, even in studies that
eliminate dairy, although not enough to forgo M.O.P. show greatly reduced
“Eliminating dairy had a clear impact within three constipation
days,” one mom wrote. “I thought we were sorted, when kids with
so I stopped the constipation meds, only for the documented "I thought
accidents to start again a week later. We now are full cow’s milk we were sorted,
on with M.O.P. and limit dairy.” allergies stop
drinking so I stopped the
Other parents have reported little or no benefit from
eliminating cow’s milk, cheese, or ice cream. For milk, many constipation meds,
example, one mom posted, “I thought I noticed less kids remain
clogged. This only for the accidents
bloating in my daughter when we went dairy-free,
but it never helped the wetting, so we stopped.” is probably to start again."
Another posted: “Eliminating dairy didn’t help at all.” because they
habitually delay
But don’t some kids have actual allergies to cow’s pooping.
milk protein? That’s what several studies suggest,
though other studies have found no connection. On If you suspect your child has an intolerance to milk,
the pages of prestigious gastroenterology journals, see if eliminating dairy helps. If you don’t notice a
researchers have engaged in arguments that sound difference within a few weeks, I wouldn’t maintain
polite and scientific but basically amount to: “Your the restriction.

to evacuate. But if we’re not near a toilet when we get the signal — if we’re in a car, on an airplane, or in
preschool story circle — or if we’re engrossed in playing house or Minecraft or if we know from experience
that pooping is painful, we’re going to override the signal by tensing our pelvic floor muscles and anal
sphincter. Humans have the capacity to delay pooping for hours, even days. Children, with a lesser grasp
on the importance of daily pooping, are masters of delay.
The most common lifestyle-related question I get is: How much does my child’s diet matter? On the
whole, I haven’t seen much success with dietary changes as a solution to enuresis or encopresis, but I’ve
seen an improved diet help a child keep constipation at bay after accidents cease. Sometimes, diet plays
no role at all. I have many severely constipated patients who have never been to McDonald’s and happily
eat quinoa and kale. Still, among the general population, highly processed food does contribute to
making stool harder, slower, and more painful to pass. Constipation is at least twice as common in
kids with inadequate fiber intake as in kids who consume enough, studies suggest. In many countries,
few children consume the recommended 25 to 38 grams of fiber per day. Most kids eat only about half
that amount.
Why does fiber matter? Well, when you eat a pear, most of it is digested by your stomach, absorbed by
your small intestine, and then converted to energy, so you can do things like walk, talk, and stay awake
while reading this book. But parts of that pear, mostly the skin, are not digestible. Those parts keep poop
soft and slimy by absorbing water and adding bulk to your poop.
Fiber also is found in the pulpy interior of fruits, veggies, and beans, as well as in husks and peels, like the
stringy membranes of an orange and the tiny seeds of a blackberry. The more fibrous foods you consume,
the heftier your stool, the faster poop travels through the colon, and the better the laxative effect. Yet our
kids tend to load up with foods that slow the conveyor belt. Grilled cheese, chicken nuggets, mac and
cheese, burgers, pepperoni pizza — the options on kids’ restaurant menus and at school don’t help the cause!

50 | M.O.P. Anthology — 5th Edition

As with diet, your child’s activity level may play no role whatsoever in their constipation. Still, research
does suggest a society-wide link. For example, a study of 30,000 kids found that kids who exercised
for less than an hour a day and spent more time online and playing video games had higher rates of
constipation.2 No shock there! None of this means that kids who live on mac and cheese and play "Red
Dead Redemption" all day are destined to become constipated, let alone develop enuresis or encopresis,
but these behaviors make constipation more likely in children who are prone to it.

Our Rush to Potty Train

Recently I read an article in Yahoo!Sports headlined “Mom reveals how she potty trained
her baby at 3 months old.” My first thought was: What the heck is this article doing in
the sports section? My second thought was: Makes sense. After all, our culture treats
potty training as a competitive sport.
In books, articles, and TikTok videos about toilet training, the emphasis is inevitably on completing the
process at warp speed. Potty train in three days! In a weekend! In an afternoon!
On social media, moms achieve celebrity status for training their children at
an early age — 18 months, 8 months, 8 weeks. Articles afford breathless
coverage to the performances of both mom and baby, referring to "I bowed to
“miracles” and “breakthroughs.” What’s more, many preschools require
pressure from my
children to be toilet trained by age 3, which prompts parents to train
their children well in advance, lest they lose their spot at school. family, who made me
What’s wrong with all this? First off, the praise heaped on moms who feel guilty that my
train their children early suggests these folks are somehow more caring son wasn't out of
than moms who buy diapers. The mom in the Yahoo!Sports article insisted diapers."
her daughter was “so much more content and
happier” than other babies because she wasn’t
“sitting around in poop.” Second, the media hype
implies that “Hey, if someone’s 3-month-old can use the toilet, then surely
anyone’s 2-year-old can do so, too.” The bar is set higher for everyone else,
placing pressure on parents and leading to feelings of failure when things
unravel months or years later. “I bowed to pressure from my family, who made
me feel guilty that my son wasn't out of diapers,” one mom emailed me after
her toddler had become constipated during early toilet training. From my
perspective, the most damaging notion is that toilet training a baby is a risk-
free proposition — simply a personal choice with no potential downside.
In fact, the risks are considerable, namely the risk of developing chronic
constipation, enuresis, and/or encopresis.
As a father of three, I know the feeling of excitement when a child graduates
Our culture’s rush to from diapers. Sayonara, stinky diaper bag! I understand, too, that it’s convenient
potty train leads to for preschools to have classes full of toilet-trained 3-year-olds. But our pedal-
countless cases of to-the-metal approach paves the way for countless cases of constipation. In
chronic constipation.
a study at our clinic, we found children trained before age 2 have triple the
risk of developing wetting problems compared to children trained later and triple the risk of becoming
constipated.3 This doesn’t mean children are good to go at 25 months of age. There’s no magic cutoff, and

2 Huang, R., Ho, S. Y., Lo, W. S., & Lam, T. H. (2014). Physical activity and constipation in Hong Kong adolescents. PLOS One,
9(2), e90193. [Link]
3 Hodges S, Richards K, Gorbachinsky I, Krane LS. The association of age of toilet training and dysfunctional voiding. Research
and Reports in Urology. 2014; 6:127-130 [Link]

section 3 : What's Driving Childhood Constipation | 51

 the “right” age to toilet train depends a lot on the child’s
maturity level. But in general, the closer a child is to age
The problem is, 2-year-olds 3, the lower the risk for developing problems. By the way,
my research findings apply to all children, not just those
don’t grasp the importance
who may have been pushed to train early. I have plenty of
of using the toilet when patients who, according to their parents, “practically trained
nature calls. themselves” before or around age 2 and went on to develop
severe constipation.
I’m not disputing babies and toddlers can be trained to poop
or pee on the toilet. Obviously, many can. The problem is, 2-year-olds don’t grasp the importance of using
the toilet when nature calls. They think you dash to the bathroom only when you desperately need to. At
preschool, these newly trained kids may feel too shy to tell the teacher they need to pee or poop. Or, they’re
too excited by all the fun or worried another kid will abscond with their truck while they’re on the toilet.
So, instead of heeding the urge to pee or poop, they ignore it time and again, eventually becoming expert
holders. The consequences may not become apparent for a few years, when their constipation becomes
severe enough to trigger urinary urgency, frequency, and/or accidents. I often write letters on behalf of
preschoolers threatened with suspension for accidents. Here's one child's school policy: “If a child has
multiple accidents in a day or over a period of days, and we realize a child is not fully toilet trained, then
we may ask that parents keep the child home for a week or two to complete toilet learning. If accidents
persist, families may be asked to leave school.”
Policies like these may sound reasonable, but they are based on a fundamental misunderstanding of
toileting accidents. Sending these kids home for a week to “work on” their potty skills is like sending
dyslexic children home for a week to work on their reading. It’s going to fail, because accidents have
nothing to do with lack of “training.” When you give children enough time to mature and then let children
lead the way, rather than dictate what month they will be toilet trained, their risk of developing peeing
and pooping problems diminishes greatly. If your child attends a preschool with a toilet-training deadline,
you may want to hand staff members a copy of the Letter to Preschool Directors and Teachers found in
this chapter. I don't know if it will help, but it's worth a try!
It’s not just the rush to potty train that contributes to chronic constipation but also the lack of potty-
training follow-up. Once children are toilet trained, we tend to stop paying attention to their peeing and
pooping habits. This is understandable. After all, we feel liberated! But post potty training is actually
the time when parents and preschool teachers should pay the most attention to signs of constipation,
because once kids habitually delay pooping, reversing the habit is no easy task.
Potty training isn’t a skill, like riding a bike, that gets locked in
once things “click.” Learning to poop on the toilet is different
from learning to heed your body’s urge to poop. The latter
requires daily reinforcement, and that’s not part of our culture.
Sure, we pay cursory attention: When we see kids doing the
“potty dance,” crossing their legs and curtsying, we insist
they go pee. When we notice they haven’t pooped in a while,
we tell them to try. But we don’t explain why. Preschoolers
are capable of understanding what healthy poop looks like
and what happens to the bladder and rectum when you
hold your pee and poop. If healthy toileting were taught in
preschool and reinforced in grade school and if we monitored
our kids for the subtle signs of constipation, we would have a Preschool potty-training deadlines
lot fewer cases of encopresis and enuresis. But none of this is prompt many parents to train their
on our collective radar. children too soon.

52 | M.O.P. Anthology — 5th Edition

A Letter to Preschool Directors and Teachers

Dear early-childhood educator,

As the father of three young girls who attended preschool, I admire the dedication, compassion, and expertise of early childhood educators. And
as a pediatric urologist, I feel compelled to offer guidance on a topic that is fraught among educators and parents: toilet training.
At my Wake Forest University clinic, I treat children of all ages who suffer from enuresis (daytime and nighttime wetting) and encopresis (stool
accidents). These conditions are almost always caused by chronic constipation, a condition that often develops during toilet training but goes
unnoticed by teachers and parents because the symptoms can be subtle. Even when the condition is recognized, constipation is not taken
seriously enough and is vastly under-treated.
Here I’ll summarize the key findings of my research and clinical practice. You can find details and studies at [Link], and
you are welcome to contact me directly.
• The signs of constipation are often subtle and not well known.
Pooping frequency is not a reliable indicator of constipation! Many constipated children poop every single day. They just don’t fully empty, and
incomplete emptying is the root of the problem.
The telltale signs of constipation are extra-large stools and stools formed like thick logs or rabbit pellets. Other red flags: the frequent or urgent
need to pee, hiding to poop, “skid marks” on underwear or diapers, recurrent urinary tract infections, stomachaches, and, most tellingly, pee or
poop accidents. Pooping less frequently than once a day is a sign of constipation, but pooping multiple times a day also can be a sign, indicating
the child is not fully emptying.
It’s important for preschool teachers to become familiar with these signs and alert parents so the child can receive proper treatment. Left
untreated, constipation tends to worsen rather than resolve.
Children, too, are capable of learning that mushy poops are best. I recommend printing our infographic “12 Signs a Child is Constipated” for
parents and posting our “How’s Your Poop?” chart in your school bathrooms. Both charts are available in English and Spanish under Free
Downloads on our website.
• Accidents are never a child’s fault. They are a sign that either a) the child is constipated or b) the child is not ready to toilet train.
Accidents happen because the child’s rectum, stretched by a stool pile-up, is pressing against and aggravating the bladder, causing it to “hiccup”
and empty without warning. In the case of poop accidents, the stretched rectum has lost tone and sensation, so stool just drops out of the child’s
bottom, often without the child noticing.
None of this is within the child’s control! Accidents are not a behavioral or learning issue. Suspending children from school to work on their
potty skills is like suspending children with a speech delay to work on their language skills: It won’t help, because toileting difficulties are not
related to a lack of training. They’re related to a lack of treatment.
The way to resolve the accidents is to resolve the constipation, so the floppy rectum can regain its tone and sensation and stop aggravating
the bladder. Even with aggressive treatment such as suppositories, enemas, and laxatives, this process can take a while. The withholding habit
becomes deeply ingrained in preschool-age children, and a stretched rectum can be slow to heal. It is important to be patient as families work
through these issues and to make sure children have the opportunity to use the bathroom whenever they need.
• Children should not be required to complete toilet training by a certain age or date.
I know it’s easier for preschools when children are toilet trained by age 3! However, deadlines prompt many parents to train their children before
they are ready, dramatically increasing the risk that the child will develop the withholding habit and become chronically constipated.
With regard to toilet training, a child’s maturity is far more important than the child’s age. While plenty of 2-year-olds are able to pee and poop
on the toilet, many do not possess the maturity and judgment to heed their bodies’ urges in a timely manner. A child’s ability to use the toilet
right when the urge strikes — not 20 minutes or 2 hours later — is what matters most. Many children simply do not have that kind of judgment
until after their third birthday. Requiring them to do so earlier can cause lasting damage to their bladder and bowels and can cause them to end
up in a clinic like mine.
Children trained before age 2 have triple the risk of developing chronic constipation and daytime wetting compared to children trained between
ages 2 and 3, my research indicates.1 However, this doesn’t mean training at 2 ½ poses no risk. My research and clinical experience suggest that
for most kids, it’s best to wait until about age 3, and it is critical not to set deadlines!
Please do not hesitate to contact me with any questions!
Sincerely,

Steve Hodges, M.D., shodges@[Link]

Professor of Pediatric Urology
Wake Forest University School of Medicine
1 “The association of age of toilet training and dysfunctional voiding,” Research and Reports in Urology, 2014; 6: 127–130, [Link]
pmc/articles/PMC4199658/

section 3 : What's Driving Childhood Constipation | 53

Restrictive School Restroom Policies
Even kids who avoid constipation during infancy and preschool can develop enuresis,
encopresis, and/or chronic urinary tract infections once they enter the school system.
This is largely because they are not using school restrooms. I have many patients who
go from 7:30 a.m. to 3:30 p.m. without emptying their bladders and who would never,
ever poop in a school toilet.
Some of these kids worry they’ll miss out on instruction or fear displeasing their teachers by leaving the
classroom. Others are too creeped out, scared, or embarrassed to use school toilets. I’ve heard about stalls
littered with toilet paper, hair-clogged sinks, and brown toilet water. One of my patients reported “mystery
smells” and told me: “There were times where I felt completely bloated, and I knew I had to go to the
bathroom, but I wasn’t about to use it. No way.”
The coronavirus lockdowns confirmed to me how much
If a child enters the school the school environment contributes to constipation. Once
school was canceled, many parents reported their kids were
system with a history pooping more and having more dry nights. One mom posted:
of or tendency toward “One day my 8 y.o. went poop at 1 p.m., and I asked him what
he would have done if he was at school. He totally owned it
constipation, conditions
and said: ‘I’d hold it.’ His school is great about allowing him
on campus can tip the to go when he needs to go, but he’s afraid of missing out on
scale just enough to something, and he’s grossed out by the school’s bathroom.”
trigger accidents. Even in schools with clean restrooms, many kids don’t use
the toilet because school policies encourage holding. Some
teachers offer restroom passes for good behavior. Others
dangle prizes — trinkets, “money” for the student store,
even pizza parties — to students who don’t use bathroom passes and instead ignore their bodies’ signals.
Even worse are the schools that restrict restroom opportunities. The mom of one of my patients is an
elementary school teacher who is well aware of the hazards of withholding, yet she is not allowed to give
her own students more than four bathroom passes per quarter!
Research shows how common these policies are. Some 36% of elementary teachers reward students who
don’t use bathroom passes or punish those who do, and 88% of teachers encourage students to hold pee
during class, according to a University of California at San Francisco survey of more than 4,000 teachers.4
Only 18% of teachers receive training in healthy toileting practices, the same study found. Interestingly,
the study was co-authored by a physician, Lauren Ko, who formerly taught second grade at a New York
City school that limited bathroom access. She told me, “I noticed kids having accidents in the classroom,
and I know it was really humiliating for them.”
For a constipated child, holding pee makes enuresis symptoms worse, by causing the bladder wall to
thicken and become overactive. Regular emptying is your child’s friend, yet schools generally do not
recognize this. At a school in Houston, students were told they could earn restroom “coupons” for
good behavior. The school district described the coupons as “simply one of many incentives created by
classroom teachers to motivate and encourage students to maximize their instructional time.”
Some schools lock restrooms at lunchtime or after school, when kids head to the bus (never mind that
students may have a 45-minute ride home), and they close bathrooms in response to behavior problems.
I received emails from several distraught parents after many U.S. schools closed restrooms in response
to the TikTok “bathroom challenge,” wherein middle school and high school students vandalized school

4 Ko L, et al., Lower Urinary Tract Dysfunction in Elementary School Children: Results of a Cross-Sectional Teacher Survey,
Journal of Urology, April 2016; 195 (4 Pt 2):1232-1238, [Link]

54 | M.O.P. Anthology — 5th Edition

restrooms and posted videos about it. For sure, the property damage
was outrageous. Students ripped out toilet seats, shattered
mirrors, clogged toilets, and attempted to unbolt urinals. “I can’t even tell
In response, exasperated administrators shut down many you how much time we
bathrooms entirely. wasted in team meetings,
“My son is angry that kids are being so stupid, but he’s even discussing how many
more livid with the administration,” the mom of a 14-year- [restroom] passes to
old on M.O.P. told me. On his campus of 3,000 students, give. I wanted to make my
all but three restrooms closed, and students weren’t students college-ready and
allowed to use them at the beginning or end of each class career-ready, not police
period. “The administration is not considering medical needs the bathroom.”
at all,” she said. “They have no idea.”
— Shanna Peeples,
I sympathize with school administrators for the countless
high school teacher
challenges they face these days. I can’t even imagine. Still, they
often default to penalizing the majority for the bad behavior
of a few. A high school in Virginia removed the entrance doors from
student restrooms to dissuade students from vaping inside. I can tell you
that kids who are already disinclined to pee or poop at school will
not be using doorless restrooms!

"Stay in there, poop. Restroom restrictions exist at all school levels. A while back, I
spoke to a high school teacher, Shanna Peeples, who, in defiance
You are NOT coming out of her school’s policy, allowed her students free restroom access.
until I get home!" Shanna told me: “I can’t even tell you how much time we wasted
in team meetings, discussing how many passes to give and who
would keep track of it. That made me tired. I wanted to make my
students college-ready and career-ready, not police the bathroom.”
This obsession with monitoring kids’ restroom habits, she continued,
“speaks to how little we trust kids, how little privacy we’re willing to give
them, how little respect.”
Some kids get lucky. They’re simply unaffected by the cultural forces
that conspire against healthy toileting behaviors. Other kids aren’t as
lucky. If a child enters the school system with a history of or tendency
toward constipation, conditions on campus can, at any grade level, tip the
scales just enough to trigger accidents.
If your child is struggling with restroom-related issues at school, read The
M.O.P. Parent's Guide to Advocating for Your Child at School, in Section 10.
The guide offers strategies for gaining the cooperation and compassion of
educators and school personnel. You are your child's best advocate!

section 3 : What's Driving Childhood Constipation | 55

PART B:
Putting M.O.P.
Into Practice

SECTION 4: The M.O.P. Process From Start to Finish

SECTION 5: Alternative Variations of [Link].
SECTION 6: A Guide to M.O.P. Supplies
SECTION 7: Adjuncts to [Link].
SECTION 8: Tracking Your Child’s Progress
SECTION 9: Your Family, Your Doctor, and M.O.P.
SECTION 10: An Anthology of Guides

section 3 : What's Driving Childhood Constipation | 57

Section 4

The M.O.P. Process

From Start to Finish
Years ago, there was just M.O.P. Now, there are a half-dozen versions
of the protocol. In this section, I spell out the “original recipe,” a.k.a.
Standard M.O.P., and discuss when you might want to switch to, or
even start with, one of the variations. I also explain how to administer an
enema to a child and how children can administer enemas to themselves,
for those who are mature enough and prefer the control and privacy.
In addition, I address common questions, such as: What if my child can
only hold the enema for 2 minutes? Should I worry about mucus in my
child’s poop? What if my child says the enema hurts? This section starts
by addressing the single most common question I’m asked: How long
will it take accidents to stop?

59
section 4 : THe M.O.P. Process from start to finish | 59
What to Expect From M.O.P.
The first question I get from parents is: How long will it take for the accidents to stop?
The short answer: anywhere from a few weeks to a year, depending on your child’s
symptoms, age, and pooping habits. There’s also the wildcard factor: dumb luck. For
reasons I can’t explain, some kids make progress far more slowly or quickly than I’d
expect. In general, children with encopresis only — no wetting at all — get the fastest results. Some
stop having poop accidents within a week, though they’re at high risk for a recurrence if they don’t
complete the entire protocol. On the other end of the spectrum, kids who begin with encopresis plus
daytime and nighttime wetting may need six months to a
year to become accident-free day and night, though the
daytime accidents should resolve early on.
It takes about three months I wish I could promise faster results! However, I feel it’s
important to set realistic expectations. In general, it takes
for a stretched, empty
about three months for a stretched, empty rectum to retract
rectum to retract to normal to normal size and regain its tone and sensation. But the
size and regain its tone operative word is “empty.” Accidents typically don’t resolve
unless the rectum is 1.) cleared of impacted stool and 2.)
and sensation. kept clear every day for months. Those can be some high
hurdles! When families start M.O.P., they assume enemas
are so powerful, like a dynamite blast, that the child’s rectum
will be emptied out within a day or two. Thirty days of
enemas seems nuts! But reality can be sobering. Some children are so stubbornly clogged with stool and
have so completely lost the urge to poop that a month of enemas achieves little or nothing.
Heck, a kid can administer enemas every day for a year and get nowhere if the enema isn’t doing the
job. That’s why it’s important to track your child’s symptoms
and adjust the regimen after any 30-day period without
progress. Finding the enema/laxative recipe that works
for your child can take a lot of experimentation.
Though I strongly advise families to temper
their expectations, many parents expect faster “Be emotionally
progress than is realistic and then become prepared for M.O.P. to take
frustrated. They’ll say, “I’m at a loss. What am I
doing wrong?” Usually, the answer is: nothing longer than you expect.
— other than expecting too much.
I thought if we can put a man on
In some ways, overcoming accidents is like
learning to read: a process that happens the moon, we can get impacted
in fits and starts and that each child
stool out of my child and move
experiences differently. Expect uneven
progress and setbacks — two steps forward, on. My biggest surprise has
one step back. Sometimes wetting accidents
even increase at first, because the volume of
been that for my son, this is a
enema solution may itself stretch the rectum, long process.”
placing additional pressure on the bladder. This
situation resolves once the clean-out process
gets going. (If it doesn't, try a smaller enema.)

60 | M.O.P. Anthology — 5th Edition

Obviously, the end goal is for all accidents to stop, day and night. But before this happens, your child will
likely experience more subtle signs of progress. For example:
• fewer stomachaches
• less frequent need to pee
• less urgency to pee
• fewer underwear skid marks
• improved ability to sense the urge to poop
• more spontaneous pooping
• lighter (less drenched) pull-ups
• bedwetting closer to the morning
Though I can’t predict how long it will take for your child to overcome accidents, I can offer general
observations based on my experience. The following observations assume you’re implementing M.O.P. as
described. Skipping scheduled enemas will reduce your child’s odds of success, though it’s no big deal if an
enema or laxative is missed once in a while.

Symptoms Don’t Resolve All at Once

Three things are almost always true:
1.) Encopresis resolves faster than enuresis.
If your child has multiple
2.) The combination of daytime wetting and symptoms, expect them to
nighttime wetting takes longer to resolve resolve in this order:
than bedwetting alone. 3.) Kids with all three
symptoms — encopresis, daytime wetting, and
nighttime wetting — are in for the longest
haul. If your child has multiple symptoms, Poop accidents diminish
expect one symptom to resolve at a time, in
the order below. If you see improvement in two then
symptoms at once, that’s a bonus!
Encopresis: Poop accidents often stop within Daytime pee accidents diminish
a week or two on M.O.P., and in most cases
stop within a month. That’s because children then
with encopresis are so monumentally clogged
that even modest reductions in constipation Overnight accidents diminish
are sufficient to make a difference. If your
child’s poop accidents have not resolved or then
dramatically decreased within one month on
the standard M.O.P. regimen, I advise adding
a stimulant laxative to trigger a second daily
bowel movement or switching to Multi-M.O.P. (two or three docusate sodium mini-enemas per day).
In the rare case that encopresis does not resolve or improve dramatically within three or four months on
M.O.P.x or Multi-M.O.P., I suggest consulting a GI motility specialist. Sometimes, a portion of a child’s
colon ceases to function and may need to be removed surgically, a scenario described in “Outlier Cases and
Medical Conditions to Rule Out” in Section 2. In general, if your child has enuresis in addition to encopresis,
don’t expect improvement in wetting until the poop accidents stop. At that point, you’re essentially starting
from scratch with the wetting.

section 4 : THe M.O.P. Process from start to finish | 61

Daytime pee accidents: My research shows 85% of children with daytime pee accidents (but no
encopresis) will stop daytime wetting within 90 days on Standard M.O.P. If a child has nighttime
accidents in addition to daytime pee accidents, it will almost certainly take several additional months for
the bedwetting to cease. Children with daytime-only wetting typically get faster results than children
who wet only at night.
Bedwetting: In my practice, about 95% of bedwetting-only
patients — no encopresis or daytime wetting, no skid marks,
frequency or urgency — see noticeable progress in the first
No matter what your child’s
month on M.O.P. and most get dry in about three months,
the amount of time it takes the rectum, once cleared, to age, the sooner you start
shrink back to size. But again, children who are starting with treatment, the better. It is
symptoms besides bedwetting are going to have a longer
never too late to resolve
road. Many parents, primarily focused on the wet sheets, are
unaware of the additional symptoms their children have, so enuresis and encopresis.
they may expect a faster route to dryness than is realistic.
Also, keep in mind that this three-month timeline assumes
the type of enema used is effectively clearing out the
rectum. Often it takes a few weeks to figure out the best enema for a particular child.
I’ve had plenty of patients whose bedwetting takes six months to one year to completely resolve, but
looking back, I now believe most of these children would have gotten dry faster on the new Multi-
M.O.P. regimen — if only I had thought of it sooner! Some patients benefit from taking bladder
medication while on M.O.P. or, less commonly, need Botox injections into the bladder, a highly
successful surgical procedure. I discuss both treatments in Section 7. It is my goal to get kids dry
permanently, and I’m in favor of any sound treatments that help achieve that goal.

Younger Children Tend to Overcome Accidents More Quickly

A 5-year-old will almost always overcome bedwetting more quickly than a 15-year-old. That’s because the
rectum has been stretched for less time, which means their bladder nerves have been aggravated for less
time. Also, in younger kids, the tendency to delay pooping may not be as deeply ingrained. However, there
are exceptions. When a teenager has never been treated for constipation, that kid may respond really
well to enemas and stop wetting within a few months. On the other hand, a 5-year-old who has been
constipated since infancy and has been on Miralax for years may have an inherently more challenging case
and need more time on enemas than the teenager. No matter what your child’s age, the sooner you start
treatment, the better. It is never too late to resolve enuresis and encopresis.

When to Consider Alternative Versions of M.O.P.

For most kids, Standard M.O.P. works well. Chances are, even if your child is still having
accidents after 30 days, you’ll be trending in the right direction. However, it’s also
possible your child won’t have made progress. What then?
First, assess whether your child has seen any improvements, which is not necessarily the same thing as
having accident-free days or nights. If you notice subtle signs of progress — fewer stomachaches, less
urgency to pee, and so on — stay the course. If your child was wetting nightly and then has a month with
eight dry nights, that is progress. Maybe it’s not the progress you’d hoped for, but it’s progress nonetheless.
Many parents are quick to change the regimen (and to ask me what they’re doing “wrong”) because their
child hasn’t achieved consecutive dry nights. You have to give the protocol a chance to work.

62 | M.O.P. Anthology — 5th Edition

On the other hand, if your child is at a total standstill, an adjustment is in order. This can be something
as simple as switching from phosphate enemas to liquid glycerin suppositories, or vice versa. Or, you
may need to up your game by trying one of the alternative regimens. I urge you to read Section 5 before
starting Standard M.O.P. so you’re aware of the alternatives and the reasons to choose a particular
version. You may even decide one of the variations is a better fit for your child from the get-go.

The Four Phases of Standard M.O.P.

The regimen Dr. O’Regan used with his son and his patients was simple: one month
of nightly enemas, one month of enemas every other night, followed by one month of
enemas twice a week. Done! His son got dry on this regimen, as did most of the children
in his studies. However, if you look at his research, you can see that the kids who did not achieve
dryness within the 90-day regimen were almost always
those with enuresis. In one study, for example, 21 of 22 girls
with encopresis stopped having poop accidents, and 44 of
Some families prematurely 47 girls with UTIs stopped having infections, but the results
jump to the next phase were somewhat less dramatic for enuresis: 22 of 32 girls
became dry overnight. The results are still super impressive
when a child stops having — far better than you’d see for Miralax, bedwetting drugs,
accidents. This is a recipe or a bedwetting alarm. But the point is that enuresis is a
tougher nut to crack, and some kids need more time, a more
for a recurrence!
aggressive regimen, or both.
Some years ago, in pursuit of better results for my
challenging enuresis patients, I began tinkering with Dr.
O’Regan’s regimen, hence the moniker “Modified” O’Regan Protocol. The purpose of my modifications
was to keep the rectum clear longer (so it has more time to heal and stop aggravating the bladder nerves)
and to make pooping less painful (so kids can more easily overcome the tendency to delay pooping).
Standard M.O.P. involves the following two key modifications to Dr. O'Regan's regimen:
I recommend continuing daily enemas until the
child is completely accident-free — not just for
30 days. Thirty days is an arbitrary number that Five M.O.P. Rules of Thumb
happens to work well for most kids. But if a child
is not dry within that time frame, tapering from
daily enemas will likely reverse progress. There is 1. Administer the scheduled enema even if
no reason to stop the daily enemas (your child will the child poops right beforehand.
not become “dependent”) and very good reason to
continue until your child is reliably accident-free,
2. Adjust the regimen after any 30-day period
without progress.
daytime and nighttime.
I recommend a daily osmotic laxative in addition to 3. Don’t start tapering until all accidents
enemas. Whereas enemas do a powerful clean-out cease, daytime and nighttime.
job, osmotic laxatives keep stool mushy, so pooping
is less painful. Painful pooping is what prompted 4. Complete all four phases to minimize your
most of my patients to become constipated in child’s risk of a recurrence.
the first place, so I’m in favor of anything we can
do to make pooping easier. In some cases, I also
5. Resume daily enemas if accidents recur, and
then taper more slowly.
recommend a daily stimulant laxative instead of, or
in addition to, an osmotic.

section 4 : THe M.O.P. Process from start to finish | 63

In addition, I advise pooping with a footstool, as explained in Section 6, and I recommend “potty
sits,” attempts to poop after breakfast and dinner. However, if your child isn’t amenable to potty sits, don’t
force the issue! When a child’s rectum lacks tone and sensation, a potty sit may be futile, so try not to
perceive your child as “refusing” to use the toilet. Drop the issue for now.
My best advice when starting M.O.P.: Complete all phases of the regimen. Some families prematurely
jump to the next phase when a child stops having accidents. This is a recipe for a recurrence! Even kids who
diligently follow the protocol can experience a recurrence, especially when shifting from one phase to the
next. In a child with a history of constipation, the rectum can fill back up so quickly! So, don’t be in a hurry.
In fact, you may want to delay tapering for a few weeks beyond the minimum 7 days of dryness and then
taper at a slower pace. See the Slow Taper section for ideas. Many families taper much more slowly on the
second go-around, often waiting for 30 days accident-free. That’s not a bad idea for the first go-around, too.
Key point: Do not shift to Phase 2 until ALL accidents — daytime and nighttime, pee and poop — have
resolved. Some families halt enemas when daytime accidents resolve but the child is still wetting the bed.
They’ll say, “Well, the bedwetting wasn’t really bothering us, so we don’t feel the need to keep going.” If
your child is still wetting the bed, continued treatment is warranted.
The four phases of Standard M.O.P. are summarized in the Standard M.O.P. Cheat Sheet later in this
section. Below, I discuss each phase in detail.

Phase 1: Daily Enema + Daily Osmotic Laxative

For treating enuresis: Daily enema + daily osmotic laxative
For treating encopresis: Daily enema only. Do not introduce an osmotic laxative
for at least two weeks.
Phase 1 Summary
During Phase 1, your child will have one enema or liquid glycerin suppository (LGS) per day while
taking a daily osmotic laxative. This phase lasts until your child has remained accident-free for at least
7 consecutive days and nights after having completed at least 30 consecutive days of enemas.
Important Note: The reason I recommend children with encopresis delay the introduction of the osmotic
laxative is that these laxatives can worsen poop leakage. Some kids with encopresis do well on enemas
alone, without ever introducing an osmotic laxative. Others start the osmotic after a few weeks because
the child’s stool is too firm without it.

Phase 1 in Detail
During Phase 1, your child will have a daily enema of any type (phosphate, LGS, docusate sodium,
Microlax), along with a daily osmotic laxative (PEG 3350, lactulose, magnesium hydroxide, or magnesium
citrate). The enema and osmotic laxative options are described in Section 6. Don’t progress to Phase
2 until your child has had at least 30 consecutive days of enemas and is reliably accident-free, day
and night. I define “reliably accident-free” as having no accidents at all for at least 7 days and nights.
However, 7 is not a magic number! It’s an educated guess. Waiting longer may well reduce the risk
accidents will recur. Some families delay tapering until the child has gone 30 days without an accident.
Importantly, the osmotic laxative helps kids achieve a daily “spontaneous poop” (SP) — in other words, a
bowel movement that happens other than after the enema. Yes, one of the key goals during Phase 1 of
M.O.P. is for your child to poop twice a day: once after the enema and one other time. Wait, what? If a
kid is having an enema daily, how could she possibly have anything left to poop? Well, kids with enuresis
and/or encopresis are ultra clogged, harboring enough poop for (at least) two bowel movements a day.
So, if they’re only pooping after the enema, they’re not making a dent in the pile-up. They’re basically

64 | M.O.P. Anthology — 5th Edition

 Cheat Sheet

The 4 Phases of Standard M.O.P.

PHASE 1: Daily enema + daily osmotic laxative
Modification for encopresis (with or without enuresis):
Do not begin daily osmotic laxative until at least week 3.
One enema daily for at least 30 days. Taper only when the child
has completed 30 days of enemas and remains accident-free
for at least 7 consecutive days and nights. If the child makes
no progress after 30 days, switch to a different enema type or
different M.O.P. variation,

PHASE 2: Enema every other day + daily osmotic laxative

Enema every other day for at least 30 days. If the child has
an accident, day or night, return to Phase 1 and follow the Slow Taper plan.
OPTIONAL: Add a stimulant laxative on the no-enema days.

PHASE 3: Enema twice a week + daily osmotic laxative

Enema twice a week for 30 days. If accidents recur, return to Phase 1 and follow the Slow Taper.
OPTIONAL: Add a stimulant laxative as needed.

PHASE 4: Daily osmotic laxative for 6 months, then taper for 6 weeks
After 6 months on a daily osmotic, taper to half a dose daily for 2 weeks, then half a dose every other
day for 2 weeks, then half a dose twice a week for 2 weeks. Then stop, assuming the child remains
accident-free and poops near daily.

Important Guidance
M.O.P.
Cautions
• Don’t taper until all accidents cease, daytime 1) Never perform enemas on a child
and nighttime. with kidney disease. If your child
has another chronic disease, consult
• Enemas can be phosphate (Fleet), liquid your doctor before doing enemas.
glycerin (store-bought or homemade), 2) If any treatment does not sit well
docusate sodium (Enemeez), or Microlax. with you or triggers pain in your
child, don’t do it!
• Have the child poop with feet on a footstool. 3) Use the right enema for your
child’s age group, as described
• After any 30-day period without progress, in packaging guidelines.
adjust the regimen.
• Administer the scheduled enema even if the
child spontaneously poops right before.

Text Copyright © 2020 Steve J. Hodges and Suzanne Schlosberg

Illustration Copyright © 2020 Cristina Acosta Design: [Link]

section 4 : THe M.O.P. Process from start to finish | 65

just maintaining the status quo. After all, their body is still
generating new poop every day. Kids need to shovel out the
fresh stool in addition to digging out the crusty old stuff.
To help children achieve spontaneous poops and develop the
habit of pooping daily, I recommend kids sit on the toilet for
at least 5 minutes, ideally after breakfast and dinner, when the
body is most primed to poop. “Potty sits” will be more successful
if children poop with their feet planted on a footstool. It’s OK
if nothing comes out. Your child is working on developing the
habit. However, don’t force a reluctant child to do potty sits.
Spontaneous pooping will happen in time. And yes, a bowel
movement counts as “spontaneous” if it happens during a timed Pooping Posture
potty sit, though it’s even better if your child feels the urge and This position places the rectum in a
initiates the trip to the toilet. vertical position, giving your child the
benefit of gravity, and stretches the
The reason many kids don’t have spontaneous poops at first is
abdominal cavity, giving the colon
that their stretched rectums have lost sensation. These kids just more room to pump stool to
don’t feel the urge to poop, despite having loads of stool stuffed the rectum for emptying.
in there. When children start pooping spontaneously, that’s a sign
the rectum is shrinking back to size and regaining sensation. It
often means accidents will diminish soon, even if total dryness is
a ways off. Parents in our support group often post with excitement about their child's first SP. One member
wrote: "Out of nowhere, my son stopped what he was doing and said, 'Mom, I need to go potty right now.' This
is monumental."
As you decide how to approach M.O.P., keep the spontaneous poop in mind. If, after 30 days of
Standard M.O.P., your child is showing no signs of spontaneous pooping and not seeing other signs
of progress, either, I suggest adding a senna-based stimulant laxative. Stimulant laxatives such as Ex-Lax
essentially force a bowel movement and help children connect the urge to poop with the act of pooping.
Key point: Always administer the scheduled enema, even if the child poops right beforehand. Parents
often assume they should skip the night’s enema if the child
pooped an hour or even 10 minutes earlier. Celebrate the
poop, but don’t skip the enema! There’s always more poop
“Out of nowhere in there! And if little or no poop comes out after the
enema, don’t sweat it.
he stopped what he
Though most families find it easiest to do enemas
was doing and said, ‘Mom, before bed, rather than squeeze in the routine
before school, the time of day doesn’t matter. If
I need to go potty right now.’ a morning enema is easier for your child, that’s
This is monumental. I was so fine. Just try to do the enema at roughly the same
time each day. If your child is apprehensive about
afraid he’d never poop on his enemas, our Enema Rescue Guide, in Section 10,
has loads of ideas.
own again. The relief I feel in
Once your child has remained accident-free for
knowing he is healing is at least 7 consecutive days and nights after having
completed at least 30 days of enemas, you’re ready to
indescribable!”
start tapering. What if you can’t seem to get past Phase
1? If your child’s progress is at a standstill, shift to one of
the M.O.P. variations described in Section 5.

66 | M.O.P. Anthology — 5th Edition

Phase 2: Enema Every Other Day + Daily Osmotic Laxative
Phase 2 Summary
During Phase 2, your child will have an enema or liquid glycerin suppository (LGS) every other night
while continuing to take an osmotic laxative daily.

Phase 2 in Detail
Once your child has completed at least 30 consecutive days of enemas and has achieved at least
7 consecutive days and nights accident-free, you are ready to start tapering. Be aware that Phase 2
is a common point of relapse. If your child has an accident, this does not mean the child has become
“dependent” on enemas. It means the child is prone to constipation and the rectum needs more time
to heal.
Continue with the daily osmotic laxative throughout Phase 2, adjusting the dose if necessary to maintain
mushy (but not runny) poop. During this phase, your child should poop on non-enema days. If this isn’t
happening spontaneously, I suggest introducing a stimulant laxative on those days, increasing the osmotic
laxative, or continuing with daily enemas a bit longer. Some children are able to stay accident-free during
Phase 2 without spontaneously pooping on non-enema days, but often their luck runs out in Phase 3 and
accidents recur. Pooping on non-enema days during Phase 2 is important.
If at any time during Phase 2 your child has an accident, I recommend starting Phase 1 again and then
following the Slow Taper protocol, described below. It can be hugely disappointing to restart daily
enemas again just when your child has “graduated,” but restarting and tapering more gradually is
the best way to prevent another recurrence. Do you really need to restart daily enemas after just one
accident? Well, I would never tell a family they “must” do anything, and if you want to wait and see if the
accident is a fluke, by all means, continue with Phase 2. But if your child has a second accident, I strongly
recommend restarting daily enemas.

Phase 3: Enema Twice a Week + Daily Osmotic Laxative

Phase 3 Summary
During Phase 3, your child will have an enema twice a week and continue with a daily osmotic laxative.

Phase 3 in Detail
Once your child has maintained dryness throughout Phase 2, taper to enemas twice a week. Maintain the
daily osmotic laxative. If your child isn’t pooping on non-enema days, I suggest introducing a stimulant
laxative on those days.
The shift to Phase 3 is another common point of relapse, which comes as a surprise and disappointment
to many families. If you’ve gotten this far, you might assume you’re home free, but sometimes it just
doesn’t work out that way. Again, if your child has an accident, I advise returning to Phase 1. Throughout
Phase 3, kids should be pooping daily on their own. If your child isn’t, continue with a stimulant laxative as
often as you see fit. You may want to use enemas periodically, to help prevent a recurrence.

Phase 4: Daily Osmotic Laxative for 6 Months, Then Taper

Phase 4 Summary
During Phase 4, your child will take an osmotic laxative daily for 6 months and then gradually wean off
the laxative.

section 4 : THe M.O.P. Process from start to finish | 67

Phase 4 in Detail
In Phase 4, you are done with enemas. Yay!! But remember that accidents can always come back. In my
experience, continuing with a daily osmotic laxative for at least 6 months will greatly reduce the odds
of a recurrence. Of course, laxatives are not a lifetime solution. The ultimate goal is for kids to poop every
day without help from enemas or laxatives. So, I suggest a gradual taper off osmotic laxatives.
After 6 months on Phase 4, start a 6-week taper:
• Weeks 1 and 2: half a dose every day
• Weeks 3 and 4: half a dose every other day
• Weeks 5 and 6: half a dose twice a week

The Slow Taper: An Alternative Plan for

Weaning off Enemas
For over a decade, I have recommended the enema tapering plan Dr. O’Regan used with his son and his
patients. His step-down regimen — dropping from daily to every other day to twice a week — has served
most of my patients well. I call it the Standard Taper, since it is standard in my medical practice.
However, clearly there is a subset of patients for whom this tapering plan is too drastic. Some parents
report that accidents recur when their children shift from Phase 1 to Phase 2 or from Phase 2 to Phase 3.
Of course, a recurrence is demoralizing to both the child and parents after all the hard work to comply
with M.O.P. Over the years, parents in our support group have posted about more gradual tapering
regimens they used successfully. I have learned from these folks and am hereby introducing the Slow
Taper. It's not a single option; it’s a continuum. Your family can choose a variation or invent your own. In
addition to tapering more slowly, you may want to delay tapering until your child has gone two to four
weeks accident-free rather than the minimum 7 days.

The Slow Taper Continuum

• The 2:1 Taper. After completing Phase 1, your child shifts to two days of enemas and one day off. Your
child might do this for a month, then drop to every other day for a month, then twice a week for a
month. So, you're adding one month to M.O.P., perhaps a small price to pay for permanent dryness.
• The 3:1 Taper. From the daily phase, shift to three days of enemas and one day off. You could do this
for two to four weeks before starting the 2:1 taper.
• The Slowest Taper Ever. Some families have turned to this ultra-conservative taper after faster
weaning regimens resulted in a recurrence, and they swear by this approach. After achieving dryness,
the child drops one weekly enema each month. For example: 6 enemas a week for one month,
followed by 5 weekly enemas a week for a month, followed by 4 enemas a week for a month. Yes, this
plan sounds excruciatingly long! But I’m just throwing it out there.

When to Consider a Slow Taper

When a child tapers off enemas, you can’t predict what will happen. At this point, the rectum should be
healed, and the child should feel the urge to poop every day. Whether the child will act on this urge is the
big unknown. Some kids will, out of habit, override the urge and fill back up. I suggest a slow taper in the
following cases:
• A child has previously experienced recurrence on the Standard Taper. As one mom told me, “I’d rather
keep doing enemas than deal with the disappointment of relapse.”

68 | M.O.P. Anthology — 5th Edition

 • A child took an exceptionally long time to become accident-free on M.O.P. For example, a child who
began the regimen with only one symptom and needed to stay in Phase 1 for more than three months.
Or, a child who began with both daytime and nighttime accidents and needed to stay in Phase 1 for
more than six months. These aren’t hard-and-fast rules. You can define “a really long time” as you wish.
• A child who becomes accident-free without having an SP on most days. This kid might do just fine on
the Standard Taper, but we do know that children who don’t reliably have spontaneous poops are more
likely to have a recurrence. For children in this category, I recommend adding a daily stimulant laxative
such as Ex-Lax prior to tapering and maintaining the stimulant laxative, at least on non-enema days,
until the child has entirely weaned from enemas and possibly afterward. This advice assumes that
increasing the dose of osmotic laxative did not result in a daily SP.

How to Administer (or Self-Administer)

an Enema
Depending on your child’s age and
personal preference, you can administer One Mom's M.O.P. Story
the enema or the child can self-administer.
I have patients as young as 5 or 6 who “My son’s behavior and demeanor
insert the tip themselves, with their are so much better.”
parent present, as they prefer the sense When my son was diagnosed with encopresis at
of control. Many kids prefer to do the 5, I found M.O.P., but his pediatrician was against
entire job themselves, in private, from enemas, so I took her suggestion of Miralax clean-
outs. Fast forward 2 1/2 years. The poor guy had
lubricating the tip to inserting the enema. three poop accidents at his 6th birthday party at a
Other children prefer to have a parent do park. Yet I kept up with Miralax. Just before covid
the insertion. happened, he was having daily accidents at school.
You won’t know until you ask your child! His doctor blamed it on stress and had me adjust the
Sometimes, circumstances will nudge you in an Miralax dose.
unexpected direction. The mom of a 9-year-old I went back to M.O.P. His accidents stopped as soon
who does the insertion herself posted: “The self- as we started enemas, and we are now tapering.
administering started because my husband and I After every enema, he would let out a huge sigh of
were going on vacation, and our daughter didn’t relief, telling us how it felt so good. After the third
feel comfortable with her grandmother doing the
day, he was chanting an enema song and telling his
grandparents all about it. A few weeks into it, he was
enema. She said doing it herself was much easier
begging me for an enema when he did not go poop.
than expected. After the vacation, we encouraged
her to continue doing it herself. I think she enjoys My son’s behavior and demeanor are so much better.
the autonomy, and it’s been great for me not being He used to have anger and behavioral problems
stuck in the bathroom for half an hour. When I that we thought were age related, but I am not so
administered, she was hesitant and would stall.
sure now. It is crazy that doctors tell us that it is too
traumatic for these kids.
Now she’s in control, and she feels much better
about it.”
An enema can be inserted on a bed or, for less potential mess, on the floor near the toilet. The following
directions apply to store-bought enemas and homemade LGS and are written as if the parent is
administering the enema. If your child is apprehensive about enemas, the Enema Rescue Guide, in Section
10, should help!
What you need: an enema (bottle or syringe) and lubricant such as Vaseline, K-Y Jelly, Aquaphor, or

section 4 : THe M.O.P. Process from start to finish | 69

 coconut oil. Experiment and see which lubricant your child prefers. Wash
your hands before you remove the enema from the box. Then follow
“When I these steps:
administered the Step 1: Show your child the bottle, tube, lubricated tip, and extra
lubrication.
enemas, my daughter was
Explain what you’re about to do, and if your child worries the tube
hesitant and would stall. will hurt, explain that the extra lubrication will help it slide in more
Now she’s in control, and easily. Point out that the anus is quite stretchy and the tip is smaller
than any BM a constipated child has pooped out.
she feels much better
Step 2: Place a towel on the floor or bed, and instruct your child to
about it.”
lie on their left side, knees bent toward the chest, aiming for the belly
button. Because of the colon’s anatomy, lying on the left side helps the
emptying process and is more comfortable for the child. The Enema Rescue
Guide, in Section 10, describes a few additional positions some children prefer.
Step 3: Rub lubricant on the enema tip, on your child’s anus (or have your child do it), and on the
surrounding skin, to reduce possible irritation from overspray of stool.
Insert the tip straight in the child’s bottom, making sure it gets past the sphincter. You’ll know you’re
in when you pass the point of resistance and when you squeeze and no liquid leaks back. Encourage
your child to take deep breaths, like blowing out birthday candles or blowing up a balloon, to relax the
sphincter. Tensing up can make the process uncomfortable.
Step 4: Squeeze the bottle slowly and steadily until
you have emptied as much as directed by your doctor A teen explains how to
or the package. If you’re using a phosphate enema
(“saline laxative enema”), and your child is under age
self-administer an enema.
12, use the pediatric version or half an adult version.
Children 12+ use a full bottle of the adult version. For • First, I apply lubricant to the tip, so it
liquid glycerin suppositories, children under 6 use 4 doesn’t hurt.
ml (either via store-bought version or homemade) • To give myself the enema, I have found
and those 6+ use an “adult” dose (7.5 ml). If using that lying on your left side takes away a
docusate sodium mini-enemas, use the 283 mg version lot of the discomfort.
for children 12+ and the 100 mg version
• I place a towel on my bed, and when all
for younger children.
the liquid has gone in, I lie on my bed
Enema bottles have a one-way valve, so you can until I feel the urge to poop.
release and squeeze again to make sure you’ve
• While I’m waiting, I watch YouTube,
emptied all the liquid. In some children who are
Netflix, or TikTok on my computer or
extremely clogged, inserting the enema liquid
phone, to distract me from boredom and
stretches the rectum to the point of pain; if this
any discomfort.
happens, stop and encourage your child to poop.
The discomfort should diminish with each day, as the • I usually hold the liquid in for 10 to 20
rectum empties. minutes, and then I use the toilet, with
my legs up on a stool.
Step 5: When nearly all the solution has been flushed
into your child’s rectum, remove the tube. Enemas
contain a bit more liquid than is needed. Your child can sit on the toilet or stay seated or lying down until
the urge to poop kicks in, ideally in 5 to 10 minutes. If the child can only hold for a minute or two, don’t
worry or pressure the child to hold longer. Once pooping starts, the child should aim to sit on the toilet
another 5 to 10 minutes or until the child feels emptied.

70 | M.O.P. Anthology — 5th Edition

Troubleshooting M.O.P.: Answers to Common
First-Timer Questions
Most children who start M.O.P. have never had an enema before, and their parents are
unfamiliar with the process. You may have lots of questions! Below, I answer seven
common questions posted by members of our support group. In some cases, I’ve
included comments from other parents, so you can see the range of experiences.
1. Question: What does output of old poop look like? How do I know if we are “chipping away” at the
old hard blockage or just washing out current stuff? I’ve been expecting giant poops after enemas and
it’s not happening — just brown, green, or yellow enema water.
Dr. Hodges: In general, I wouldn’t measure progress by what comes out. What really matters are changes
in symptoms. Still, you ideally want more than just liquid coming out, so if that’s all you’re getting, have
your child try a different type of enema.

2. Question: Any tips for holding the enema longer? My son can
only hold 2-3 minutes!
Dr. Hodges: Ideally, kids should hold for 5 to 10 minutes, but
don’t make it a stressful thing or insist they hold longer than is
comfortable. When the rectum is chock-full, holding more than a
minute or two may just be impossible. Most kids eventually can
increase their hold time.
Parent: For what it’s worth, neither of my kids hold longer than 2 or
3 minutes. Never have. And we are seeing success — 8 nights dry
in a row right now with my 11-year-old.
Parent: Prior to the enema, our son empties his bladder and, if
possible, his bowels. We find that makes more room to hold the
enema comfortably.
Parent: Netflix and YouTube are our friends. In the beginning, I
would tell my daughter, “This was the time you made it to last A tablet or phone can help
time. Let’s see if we can do 30 more seconds this time.” distract your child while waiting
Parent: An iPad with YouTube playing song videos is our main for the enema to kick in or help
strategy. I say, “Try to hold it for one more song.” your child sit longer on the toilet.

Parent: When I take the enema tip out, I put a small wad of toilet
tissue between her buttocks and tell her to clench to hold it there. That helps her hold it.

3. Question: Should I be concerned that my daughter has mucus in her poop? Sometimes mucus leaks
into her pull-up after the enema.
Dr. Hodges: Mucus is caused by irritation to the colon and is a common reaction to enemas. But as long as
your child doesn’t feel pain and you see no blood, I wouldn’t worry about it.
Parent: My son had mucus for a while when he was on daily enemas. It went away on its own after a
couple of weeks.
Parent: My kids have mucus sometimes, but it was mostly the first couple of weeks. I freaked the first
time it looked like one of my kids pooped out a small jellyfish.
Parent: Mucus is common for us. When it got bloody, we switched to alternating LGS with phosphate
enemas, which helped a lot.

section 4 : THe M.O.P. Process from start to finish | 71

4. Question: Should I be alarmed about bright red blood in stool? I didn’t
see any in the toilet, but it was on the wipe. We recently switched from
phosphate enemas to liquid glycerin suppositories. Our 5-year-old’s
poop is always mushy, so what could the problem be?
"I freaked the first
Dr. Hodges: Bright red blood on wiping is typically from a
hemorrhoid or fissure (tear) that forms from straining, which can time it looked like one
happen even if a child’s poop is mushy. Try more lube on the tip. If of my kids pooped out
your child feels pain with the bleeding, hold off on enemas for a few
days. The scenario to watch out for is bloody mucus with severe
a small jellyfish."
burning, which is a sign of colitis, inflammation of the colon. In that
case, stop enemas and consult your pediatrician.

5. Question: If the enema tip caused my daughter pain with her first
enema, what should I do? The box says to get immediate medical care, but my
daughter seems fine now.
Dr. Hodges: If pain is caused by placing the tube in the anus or due to the fluid insertion and if it is
resolved quickly, you don’t need to do anything else. If you see severe bleeding or the pain persists,
then, yes, seek medical care.
Parent: You want an enormous amount of petroleum jelly on that sucker! The default amount on the
enema tip is not even close to being sufficient, as we had to find out through trial and error!
Parent: The first time can be difficult. You and your daughter should feel proud for completing your first
enema. You might try a different brand with a different tip.
Parent: We’ve found that Aquaphor works best on the tip. It is thicker than petroleum jelly and helps the
tip go in more smoothly.
Parent: Make sure she’s in the correct position before you start: left side, knees up to chest, aiming for
her belly button. I wear vinyl gloves and make sure I’m probing the right spot with a finger before I put in
the nozzle tip. Also, I narrate the whole process: “Lotion, finger, nozzle, enema fluid (as I squeeze out the
fluid). How are you doing?” At the first sign of discomfort, like if he tenses up, I stop and consult him and
wait for him to breathe deeply, like he’s blowing out a candle. Then I continue if he gives me permission.
It’s important that he knows I won’t proceed without his OK.
Parent: Enemas hurt my daughter when she has any sort of rash down there
(caused by sitting in soiled underwear). So, that may also be a contributing
factor. We switched entirely over to bag enemas, which have a much
slower flow rate than the squirt bottles. I think she hated the squirty "The first time
feeling.
can be difficult.
Parent: Enemas would give my daughter a sharp sting if she had a
small tear from a large, hard bowel movement. Other times she’d feel You and your daughter
pain if I tried to insert a tip at not quite the right place. But it heals should feel proud for
very quickly, max two days. Most likely your daughter was tense,
completing your first
and that makes it more difficult to find the right insertion spot and
angle. My daughter prefers K-Y Jelly because it’s very slippery, whereas enema."
petroleum is sticky and the tip doesn’t go in as easily. We’ve found
coconut oil also works well, but it does drip right off.

[Link]: Any tips for easing nausea after an enema? After her first enema,
my daughter was nauseous for an hour and then threw up.

72 | M.O.P. Anthology — 5th Edition

 Dr. Hodges: Nausea and vomiting are not uncommon among children
who are extremely backed up. The GI tract is all connected
neurologically and anatomically, so the enema can worsen the
"You want an fullness in a very full colon and transmit reflex emptying of the
enormous amount of stomach. Try reducing the amount of liquid for now. As she
gets empty, she should be able to tolerate the full amount.
petroleum jelly on that
Parent: When we did the full enema, our daughter threw up,
sucker! The default amount so next time we used half the enema solution, which was a
on the enema tip is not lot better.
Parent: My son experienced nausea when he was very backed
even close to being
up. In my experience, it’s not likely to happen two days in a
sufficient." row; things will have shifted in there. For cramps or nausea,
we place a hot water bottle on my son’s tummy or a rice pillow
warmed up in the microwave. It will get easier.
Parent: My son gets nausea whenever we change formulas, like when
we went to large-volume and when we added glycerin. Each time he has a
one- or two-day adjustment with nausea.

7. Question: We’re starting M.O.P. tomorrow. What should I expect from the
first enema? Will it be a mess? Will it be scary?
Parent: Enemas don’t usually make a mess! For the first week, I made my "We haven’t
daughter a surprise treat bag filled with little toys, snacks, and stickers
and told her she could reach into the bag for one thing after each found enemas to
enema. She loves having choices instead of being told what to do. So, be messy. It’s the
I asked if she’d like to take the cap off the enema, what show she’d like
to watch on YouTube, or what book she’d like to read.
Miralax clean-outs
Parent: Make sure she’s in a comfortable position. We keep a bed mat, that are messy."
pillow, and blanket in the bathroom.
Parent: You cannot have too much lubrication! And tell your kid everything
you’re doing before you do it. Check in to make sure he is comfortable as you
squeeze out the solution. We always put a towel on the bed. Sometimes enema fluid starts to come out
before he realizes it. I wouldn’t expect it to be very messy, but we have had some mess on occasion.
Parent: We haven’t found enemas to be messy. It’s the Miralax clean-outs that are messy. That was one
reason we switched to enemas.

After M.O.P.: Pooping Happily Ever After

Maintenance after M.O.P. is important! Many families are so excited when accidents stop
that they move on with life and forget about the whole constipation thing. But then,
stealthily, the rectum fills back up and the cycle repeats. I often hear from parents who say, “I
thought we were out of the woods, and then out of nowhere, she started having accidents again.” Usually,
the accidents didn’t actually come “out of nowhere.” The signs of constipation likely returned but were
subtle and the child didn’t notice or say anything. Meanwhile, the parents, understandably, were no longer
monitoring the child’s every poop and were none the wiser.
I definitely don’t want parents to hover over their kids in the bathroom for years or interrogate them
about their pooping habits. But I do advise checking in with your child periodically and teaching your

section 4 : THe M.O.P. Process from start to finish | 73

child to recognize the signs constipation may be creeping back — for example if the child’s stools are
bigger and harder or the child isn’t pooping as often. Often, an alert kid will say, “Hey, Mom, can you buy
me a pack of Ex-Lax?” I advise keeping laxatives and enemas on hand, just in case. If accidents do recur,
despite everyone’s best efforts, be prepared to resume enemas. Yes, starting M.O.P. again is a drag, but
take comfort in the fact that you know what’s causing the problem, and you know how to fix it. Acting
immediately is a much better solution than waiting around to see how bad things might get. If M.O.P.
worked the first time, it will work again.
But let’s hope you never have to utter the word enema again! Here’s what your child can do, post-M.O.P.,
to minimize the odds of a recurrence:

Poop on a schedule. It’s important for kids to perceive pooping as part of their daily routine, like
1. brushing their teeth. Of course, eventually they need to get in the habit of going right when the
urge hits, but at first, a schedule will help. After breakfast and after dinner are two great times
to poop, as the urge is generally strongest after eating. Many families find that the “poop on a
schedule” rule benefits everyone. One mom posted: “Our whole family tries after every meal now.
You never know if more will come! I’ve been
surprised at how much more often all of us
are going.”

Pee on a schedule. Holding pee contributes

2. to enuresis by causing the bladder wall to
thicken and go haywire. As kids recover from
chronic constipation, it’s important for them to
pee often. Kids who’ve been on M.O.P. should
use the toilet right before bed, first thing in the
morning, and about every two hours throughout
the day. A vibrating potty watch helps a lot,
especially at school. Many kids don’t want to Jane’s belly stopped aching
“waste” recess or lunch period by using the and her humor came back.
“Your fly’s down!” she’d joke
bathroom, or they may forget to go because or some other wisecrack.
they’ve been habitually holding their pee. Of
course, they may also be dealing with restrictive Jane swam and did yoga,
school bathroom policies. If your child's teachers and jumped lots of rope.
aren't amenable, consult The M.O.P. Parent's She ate beans and zucchini
and ripe cantaloupe.
Guide to Advocating for Your Child at School.

Poop with a stool — for life. Your child will

3. probably always be prone to constipation, so
pooping in the squatting position should be a
lifelong habit. Set an example by pooping with
a footstool yourself. All of us, regardless of age,
should be pooping in a squatting position.

Eat real food. In other words, items your

4. great-grandparents would have recognized as
food, as opposed to the packaged, chemical-
She made a habit of using
laden “products” that often pass for food in the bathroom at school,
our culture. Improved eating habits make a once her mom asked the teacher
difference in how your child poops and feels, to make flexible rules.
even if dietary changes alone don’t resolve This is an excerpt from Jane and the Giant Poop.

74 | M.O.P. Anthology — 5th Edition

 constipation. There’s no shortage of excellent websites to help
families improve their eating habits. Two of the best are Real
Mom Nutrition and 100 Days of Real Food. “Our whole
5. Drink plenty of fluids. Stopping life to sip water isn’t a family tries after
habit for many kids, but it should be. Drinking fluids
every meal now. You
through the day will keep your child’s bladder on a
constant filling/emptying cycle. Encourage your child to never know if more will
drink a few ounces every few hours rather than guzzle come! I’ve been surprised
a whole bottle at once. Rapid filling can cause bladder
overactivity. Let your child choose a fun water bottle to at how much more often
keep in the classroom and another one to carry around all of us are going.”
outside of school.

Stay active. Many kids fall way short of the recommended 60

6. minutes of physical activity each day. Yet exercise is important to
keeping your child’s insides humming along. Help your kids find physical activities they enjoy.

section 4 : THe M.O.P. Process from start to finish | 75

Section 5

Alternative Variations
of M.O.P.
In this section, I review five variations of M.O.P. The first four
— M.O.P.+, M.O.P.x, Double M.O.P., and Multi-M.O.P.
— are alternatives to Standard M.O.P. Each has its pros and
cons, which I cover in detail. The fifth variation, Pre-M.O.P., is
for toilet-trained kids who don’t have accidents but who suffer
from the effects of chronic constipation, such as abdominal
pain, rectal prolapse, or rectal bleeding. If your child has
enuresis and/or encopresis, I suggest reviewing all the M.O.P.
variations and assessing what sounds like a good fit before you
decide which variation to start with or try next.

77
Choosing a M.O.P. Variation
For several years, and in previous editions of the Anthology, I have recommended
starting with Standard M.O.P. The regimen works well for most kids and can be
implemented at very low cost (if you make your own LGS), and the products are readily
available worldwide. I continue to start most of my patients on the original regimen, and
based on their 30-day results, we either continue or try an alternative.
However, recently I have urged some of my patients, such as stressed-out older kids, to head straight for
the more aggressive variations, such as M.O.P.x or Multi-M.O.P. One obstacle is that the docusate
sodium mini-enemas needed for Multi-M.O.P. are not available in many countries and are more
expensive than other types of enemas, so when Multi-M.O.P. isn’t an option, I recommend M.O.P.x.
There are several other scenarios that warrant starting with a version other than Standard M.O.P., as I
summarize below and later explain in detail.
I know all this terminology is confusing for newcomers! The chart titled Cheat Sheet of M.O.P. Variations
recaps the different options, so you can compare and contrast them at a glance. Here, I offer general
guidance on choosing a version. Be sure to read the sections that further describe the differences,
nuances, and rationale behind each.

Reasons to Try Different Variations

Following are various scenarios that might lead you to choose a version other than Standard M.O.P.
• If your child feels distressed about the
accidents and is highly motivated to “do
whatever it takes”: From M.O.P. to M.O.P.+
Try Multi-M.O.P. But if Multi-M.O.P. to Multi-M.O.P.:
is not an option, because you can’t access
docusate sodium enemas or because they’re One 8-Year-Old’s Story
too expensive, try M.O.P.x. After a month on M.O.P. we moved to M.O.P.+
because my son continued to have poop accidents.
• If your child has a strong tendency to Encopresis resolved entirely on M.O.P.+, and our
delay pooping: longest accident-free streak was 16 days. However,
Try M.O.P.x. pee accidents returned, and spontaneous poops
• If you’re aiming to minimize expenses:
were becoming more rare. I worried he was getting
backed up again. We started Multi-M.O.P. to get a
Try M.O.P.x with homemade LGS reliable twice-a-day poop, to finally get ahead of
or M.O.P.+. (If your child has enuresis, things instead of just maintaining.
M.O.P.x is the better option.)
He does his mini-enemas in the morning after
• If your child has impacted stool: breakfast and at night after dinner, before bath.
Try Double M.O.P. He does them himself and is really good at it. He
watches YouTube on my phone while he sits. He feels
• If your child has pooping difficulties but totally fine about twice a day and has never minded
strongly dislikes stimulant laxatives: enemas because he knows they will help him not
Try Multi-M.O.P.
have accidents at school. He also likes that these are
small volume and more discrete than M.O.P.+. He
• If your child does not produce sufficient has been on 2x/day 100 mg docusate sodium mini-
output with small-volume enemas or enemas for almost a month, and we are seeing clear
dislikes the “squirt” feeling: improvements.
Try M.O.P.+.

78 | M.O.P. Anthology — 5th Edition

Cheat Sheet of Variations

After any 30-day period without progress, adjust the regimen.

— Small enema + osmotic laxative

Standard Enema options: Laxative options:
• phosphate (Fleet) • PEG 3350 (Miralax)
• liquid glycerin suppository • lactulose
(store-bought or homemade) • magnesium hydroxide
• docusate sodium (Enemeez) • magnesium citrate
• sodium citrate (Microlax)

— Small enema + stimulant laxative

Enema options: +
• any store-bought enema
• LGS (homemade or store-bought)

— Large-volume enema + osmotic laxative

Enema solution progression: ...add
First, try ...add phosphate
saline + glycerin. Castile soap. enema
Then... Then... contents.

Double — Overnight oil enema + morning large-volume enema

Oil-retention enemas can be done daily, weekly, or periodically.

Oil options: mineral oil olive oil

Multi- — Docusate sodium mini-enema 3x/day (or 2x)

+

Age 12+: Use 283 mg version.

Under 12: Use 100 mg version.
+

Add osmotic laxative when tapering to every other day.

© 2023 Copyright Steve Hodges, M.D., and Suzanne Schlosberg.

Do no reproduce or disseminate without written permission.
M.O.P.+: The Large-Volume Approach
M.O.P.+ is the same regimen as M.O.P. — the four phases are identical — except you
replace small enemas with large-volume enemas. You buy a reusable enema kit and fill the bag
yourself with a combination of saline solution plus liquid stimulants, such as glycerin and/or Castile soap.
Large-volume enemas hold far more solution (up to 600 cc) than store-bought enemas (about 130 cc).
The larger volume stimulates the rectum more aggressively to flush out crusty stool and tends to work
very well for encopresis in particular. For some kids, bigger is better! However, for some children with
enuresis, the extra volume makes accidents worse. Daily large-volume enemas are commonly used at the
country’s most prominent hospitals that treat encopresis. That’s where I got the idea. I wish all the anti-
enema physicians knew how common this treatment is. Below I discuss the pros and cons of M.O.P.+.

Advantages of M.O.P.+
Besides the extra volume, a reusable enema kit has some distinct advantages over store-bought enemas.
For example:
• You control the volume and stimulant dose. With
a store-bought enema or LGS, you use what’s in
the bottle. But with M.O.P.+, you can tinker with
the volume in the bag (from, say, 250 cc to 600
cc) and the amount of stimulant you use, whether
it’s glycerin, Castile soap, baby shampoo, or some
combination. The flexibility can be quite helpful
if your child’s poop output doesn’t seem to be
sufficient or your child can barely hold the enema.
• You control the flow rate. The higher you hang the
enema bag, the faster the flow; the lower the bag,
the slower the flow. Some kids find large-volume Reusable enema bag kits are available online.
enemas more comfortable than store-bought
enemas, because they empty more gradually than the “squirt” that comes out of pre-made enemas.
• You save money. A reusable enema kit can be used for months, minimizing expenses and trash. Many
families go straight to M.O.P.+ for these reasons. (You can also save money by making your own
liquid glycerin suppositories, as explained in Section 6.)
• You have easy access worldwide. In many countries, store-bought enemas are simply not available in
pharmacies or online, except if you want to pay shipping fees from the United States. But it’s easy to
buy reusable enema kits online, along with liquid glycerin or Castile soap.

Disadvantages of M.O.P.+
• The extra volume may cause more wetting. The top-notch hospitals that favor large-volume enemas
typically focus on treating encopresis, not enuresis. For some children with enuresis, the extra volume
proves counterproductive, placing excess pressure on the bladder nerves. Parents will say, “Suddenly,
her pull-ups aren’t just wet; they’re soaked!” Sometimes, this scenario is only temporary, but other
times it's not. If your child’s enuresis has worsened after a week of M.O.P.+ or has not improved after
30 days, try M.O.P.x or Multi-M.O.P. instead.
• Some children feel nauseous when they start large-volume enemas.
A few even throw up. This happens for the same reason wetting symptoms can worsen: The colon is,
temporarily, stretched even further. The GI tract is all connected, so the stretching down below sends
waves upward, causing a more generalized bloating of the bowel. The nausea should subside quickly.

80 | M.O.P. Anthology — 5th Edition

Large-volume enemas take more work. You have to mix the
solution, fill the bag yourself, and wash the hose with soap and
warm water after each use. However, many parents report all this “Large-volume
becomes routine. enemas sound
Tips for M.O.P.+ intimidating, but
M.O.P.+ isn’t a cut-and-dried regimen. You have to keep adjusting they are so easy and
the formula until you find what works for your child. But this just become your new
tinkering can pay off big time. Many parents avoid M.O.P.+ because
they perceive it as too much trouble, only to wish they had tried the normal. Our daughter
regimen sooner. As one mom posted: “We were nervous to try the prefers them.”
large-volume enema with my 8-year-old, but it isn’t as scary as I thought
it would be, and my daughter prefers them. There is a huge difference in
what comes out afterward. I wish we hadn’t put it off for so long."
“My 5-year-old
M.O.P.+ Supply List
tolerates the bag
Note: You don’t need both glycerin and Castile soap to start with.
I recommend starting with glycerin. enema with Castile soap
Lubricant for the nozzle tip and/or your child’s bottom. Options much more than smaller
include K-Y Jelly, Vaseline, Aquaphor, and coconut oil. enemas. She found the Fleet
Enema bag and accessories. Kits include an enema bag, tubing, phosphate enema 'burning.'
clamp, nozzles, hook, and tip. The hook holds the bag, the bag She doesn’t mind glycerin
holds the fluid, the long tubing sends the fluid down, and the
nozzle enters the child’s bottom. For smaller children, use a child- but gets no output.”
sized tip. Search “flex tip enema junior nozzle.” This video1 shows how
to assemble the parts of an enema kit.
Saline solution. You can buy saline solution online or at a pharmacy, or mix it
yourself by adding 1 1/2 teaspoons table salt to 1000 ml tap water. Store extra solution
at room temperature for later use. Some folks buy a gallon of bottled water and add the
salt (5 2/3 tsp) to the bottle, allowing for easy storage. Others mix the solution every
few days so they don’t have to bother with it daily. It’s fine to use room-temperature
water, though some children find warmer water (up to 100 degrees) more comfortable.
• Ages 4 to 7: Start with 300 cc.
• Ages 8+: Start with 600 cc.
Liquid stimulant. Adding a stimulant to saline solution is more effective than saline alone. I suggest
starting with a low dose of glycerin and, if that isn’t effective, increase the glycerin dose and/or add
Castile soap or the contents of a phosphate enema. Expect to do plenty of tinkering. Note
that ml and cc are interchangeable measurements. Stimulant options:
Glycerin: Add 10 ml to 30 ml of glycerin — a thick, clear, sugar-based liquid — to the
enema volume you’re using. (5 cc is a teaspoon; 15 cc is a tablespoon.) A higher dose may
be more effective but may also feel more uncomfortable to your child.
Liquid Castile soap or baby shampoo: Add 10 cc to 30 cc of liquid Castile soap, a plant-
based soap, to the saline solution. Keep or drop the glycerin. Or, you can use the same
amount of baby shampoo, such as Johnson’s No More Tears. Yes, baby shampoo!

1 [Link]

section 5 : Alternative Variations of M.O.P. | 81

 Phosphate enemas: Still no progress? Add (to the glycerin and/or soap) one half
pediatric phosphate enema if your child is age 3, a full pediatric phosphate enema for
kids ages 4 to 10, and an adult phosphate enema for kids 11+.

5 Steps to Administering a Large-Volume Enema

Below I offer step-by-step instructions. If you prefer a video, try search terms such as “administration of
high volume enema” or “how to give a large-volume enema to your child at home.” A number of children’s
hospitals have produced helpful videos. Older children can self-
administer large-volume enemas.
This process is not a whole lot different from administering a “I hang the bag
store-bought enema but may take some practice for both
parent and child. I recommend administering the enema on on the towel rod, and
the floor near the toilet. You’ll need to hang the enema bag my 9-year-old goes into
about 2 feet above the floor by affixing a hook to the wall the bathroom and closes the
or using a hook hanging from a doorknob or towel rack.
door. She lies down on her
» Step 1: Lubricate the tip of the tube and your
child’s anus, or have the child do both on their own.
side and inserts the enema
Remind your child that while this may feel awkward or tube. She waits for it to flow
uncomfortable at first, kids who’ve done it report that it through, and then sits on
starts to feel routine after a few days.
the toilet.”
» Step 2: Place a towel on the floor, and instruct your child to
lie on their left side, knees bent.
» Step 3: Gently insert the nozzle into the anus as deeply as
possible. Many kids prefer to do the insertion on their own.
“Some days my 8 y.o
Encourage your child to take slow, deep breaths to help
relax the sphincter. Tensing up can make the process can hold 350 ml. Other
uncomfortable. days, I have to stop at
» Step 4: Attach the hose to the enema bag, hang the bag 300. For us, holding longer
about 2 feet above the floor, and begin the enema. If
the child complains of cramps, slow the flow by lowering
leads to better output. Figure
the enema bag. It should take just a few minutes for the out the most fluid your kid
colon to fill. can hold for at least 5
» Step 5: When all the solution has entered the minutes.”
colon, remove the hose. The child should aim
to retain the fluid for at least 5 minutes
(if possible), ideally for 10 minutes, and “M.O.P.+ requires
then sit on the toilet for about 10
more equipment and
minutes. Clean the nozzle with soap
and water or rubbing alcohol after slightly more prep time, but
each use. once you get the hang of it,
it’s not a significant change
in routine. My son finds the
large-volume enemas
more comfortable.”

82 | M.O.P. Anthology — 5th Edition

M.O.P.x: Adding a Stimulant Laxative
M.O.P.x has two components: a daily small enema (store-
bought or homemade) plus a daily senna-based stimulant
laxative such as Ex-Lax. Most kids on M.O.P.x don't take an
osmotic laxative. However, in some cases, parents feel both types “At 6, our daughter
of laxatives are needed because their child’s poop is too firm
was having 8 to 10 pee
without the osmotic.
accidents per day. The first
The purpose of replacing an osmotic with a stimulant laxative
is to ensure the child has a daily spontaneous poop. Daily month on M.O.P., we saw small
SPs will speed up the emptying and healing processes and improvements. Then we switched
help the child develop the habit of pooping every day. Many to M.O.P.x. Six months later,
children have lost so much rectal tone and sensation that the she’s dry day and night and is
osmotic laxative used in Standard M.O.P. doesn’t suffice.
weaning off enemas.”
I often recommend M.O.P.x as a starting point for teens and
tweens and for children who have overcome daytime pee accidents
on M.O.P.+ but can’t get over the hump with bedwetting. In general,
it’s a good regimen for children with a deeply ingrained tendency to
override the urge to poop.

Advantages of M.O.P.x
• The child has more spontaneous poops. Even a child with extraordinary powers to hold poop will have
no choice but to poop if given a stimulant laxative in a high enough dose.
• The child begins to connect the urge to poop with the act of pooping. After an enema, children must
poop right away; they only wait a few minutes for the urge and don’t really have to “listen to their body.”
By contrast, a stimulant laxative doesn’t kick in for 5 to 8 hours, so the child must stop what they’re
doing and take the initiative to poop. This is good practice for the post-M.O.P. period (a.k.a. the rest of
their life!) when the child will have to poop on their own, without the help of laxatives or enemas.
• The small enema used in M.O.P.x prevents rectal stretching. For some kids with enuresis, large-volume
enemas are counterproductive because the extra volume stretches the rectum (if only briefly) and
may inhibit the healing of aggravated nerves.

Disadvantages of M.O.P.x
• Stimulant laxatives can cause more nausea and discomfort than some kids can tolerate. With senna-
based laxatives, some amount of cramping comes with the territory. But some kids just feel too sick,
in which case Multi-M.O.P. is a better option for ensuring an SP.
• Stimulant laxatives are difficult to time and disruptive to some kids’ schedules. Ex-Lax typically has
to be taken in the morning so the child is awake when the urge strikes. But this means the child
will need to poop at school or after school, and that doesn’t work for some children. If the stimulant
laxative is taken after school, the bowel movement it triggers may come close to the enema. Ideally,
you want the SP and the enema to be several hours apart.

Enema Options for M.O.P.x

• Store-bought. Phosphate enema (Fleet or generic), liquid glycerin suppository, docusate sodium mini-
enema (Enemeez), or Microlax enema (common outside the United States).
• Homemade liquid glycerin suppository. See Section 6 for instructions.

section 5 : Alternative Variations of M.O.P. | 83

Double M.O.P.: Overnight Oil Enemas for
Impacted Stool
Doctors tend to think new is better — new technology, new drugs, new procedures. But
sometimes, low-tech, old-school remedies prove superior. Exhibit A is M.O.P. itself, based
on research from the 1980s. Exhibit B is the use of overnight oil enemas for stubborn
constipation, a 19th-century remedy that was validated in 2021 by a Japanese study.
I call this regimen Double M.O.P. because it involves two enemas in one day: one oil enema and one
stimulant enema. Before bed, the child inserts an enema of olive oil or mineral oil. The oil does not
stimulate a bowel movement but rather remains there overnight, softening and dislodging crusty old stool.
In the morning, a large-volume enema stimulates a bowel movement and washes out the sludge. You can
do Double M.O.P. on weekends, periodically, for a week straight — whatever you feel is helpful — and
then return to the M.O.P. version you were doing.
I often recommend oil enemas when an x-ray shows a solid rectal mass after more than a month on
Standard M.O.P. However, many kids don’t need an x-ray to tell them they’ve got poop stuck in there. As
one mom posted: “Every night after the enema, my son, age 6, would say he could still feel a big poop but
that it wouldn’t come out. He kept asking if we could do another enema to make it come out. With the
mineral oil, he was able to get out some really hard looking chunks!”
I’d heard about oil enemas back in medical school but never thought about them until a mom in Iceland
posted about the remedy in our support group. Her 7-year-old’s encopresis had resolved on M.O.P. but
his enuresis persisted. Bewildered, the boy’s doctor asked a veteran nurse how stubborn constipation was
treated back in the day. The nurse’s response: olive oil enemas. Within a few weeks, the boy’s accidents
diminished, and an x-ray showed great improvement.
Soon, others in our support group tried it with their kids, and I began recommending oil enemas to
certain patients. A few years later, in 2021, a study from a children’s hospital in Kobe, Japan, validated
this method.2 Impacted stool can cause severe abdominal pain and sends tens of thousands of kids to
the emergency room each year. In the United States, these kids are usually
given a high dose of Miralax, but at this Japanese hospital, children with
fecal impaction were instructed to do olive oil enemas at home. For
“Fleet enemas the study, doctors reviewed records of 118 severely constipated
weren’t getting patients. The study included children with “functional
constipation” — otherwise healthy kids with a garden-variety
enough of the old stuff out. clogged rectum — as well as children with anatomical or
Mineral oil makes the hard neurological conditions that make pooping difficult. Among
poop slippery enough that my both groups, olive oil enemas were deemed useful in about
77% of cases. The study concluded that olive oil enemas are
daughter can push some out. “a safe and effective remedy for chronic constipation” and
A morning enema produces that when followed by glycerin enemas are “useful for fecal
hard pieces followed by disimpaction.”
fresh, soft poop.” This is exactly what two German physicians, Dr. W. Fleiner and
Dr. Adolph Kussmaul, the pioneers of oil enemas, had concluded
130 years earlier! An 1892 medical journal, describing these doctors’
observations, called olive oil enemas “a ready and safe method of

2 A. Yokoi and N. Kamata, “The usefulness of olive oil enema in children with severe chronic constipation,” Journal of Pediatric
Surgery, Volume 56, Issue 7, July 2021, Pages 1141-1144, [Link]

84 | M.O.P. Anthology — 5th Edition

relieving even the most obstinate cases of spasmodic constipation.”3 In a 1904 article, a British physician,
Dr. George Herschell, called these enemas “without question most
valuable in obstinate cases of constipation.”
I agree! The effectiveness of Double M.O.P. became particularly
clear to me when schools closed during the covid-19 pandemic.
Many families used this time to ramp up their kids’ treatment in ways
that would have been inconvenient when kids were in school all day.
Families who had dabbled in Double M.O.P. on weekends began
doing it daily, with great results. As the mom of an 8-year-old posted:
“We are on week six, and for the first time in my son’s life, he’s had no
poo accidents for one month. He also went three weeks without any
pee accidents during the day.”

How to Implement Double M.O.P.

• Use 50 cc to 100 cc of mineral oil or olive oil. You can use an
enema syringe or enema bulb, reuse a store-bought enema bottle, This apparatus for self-
or buy a pre-packaged mineral oil enema. administering olive oil
enemas was devised by
Luckily for your child, you’re living in the 21st century. Back in the
George Herschell, M.D., a
19th, Dr. Herschell had no access to such ready-made products, so
19th-century English doctor.
he developed an apparatus — featuring a glass funnel, 27 inches
of rubber tube, and a nozzle — that patients could use to self-
administer oil enemas. He deemed his device so safe that “even when roughly or unskillfully used it is
impossible to damage the mucous membrane of the rectum.”
• Inject the oil right before bed, after your child has used the toilet for the last time. If the olive oil
prompts your child to use the bathroom once more, that’s fine. The lubricant still helps. However, you’ll
get better results if the oil sits overnight.
• Use a large-volume enema in the morning. Small-volume enemas typically don’t contain enough liquid
to wash away the oil, although some families do use them.
• Expect the oil to leak overnight and the next day. Your child may want to wear pull-ups following an
oil enema.
• Administer oil enemas whenever you can fit them in. Dr. Fleiner, one of
the German oil-enema pioneers, recommended patients repeat olive oil “Mineral oil
injections for two or three consecutive days, followed by periodic oil enemas seem to
enemas as needed. Dr. Herschell advocated overnight oil enemas for be helping us. I feel
two or three weeks, followed by injections on alternate nights and then like I am chipping
periodically. I’ve had patients try both approaches and many schedules away at a cement
in between. If you can manage only on weekends, that’s fine. Any extra block with a
lubrication seems to enhance the clean-out process, even if it’s not a garden hose!”
total solution.
• If you do Double M.O.P. once a week or less often, you needn’t shift all
your regular enemas to morning. You can still do enemas at night, if that’s most
convenient for your family. But on the night of the oil enema, skip the regular enema. Instead, do it the
next morning and then again 36 hours later, to get back to your regular evening schedule.

3 Maryland Medical Journal: A Journal of Medicine and Surgery, Volume 28, 1892 [Link]
AKQRAAAAYAAJ&pg=PA350&lpg=PA350&dq= Kussmaul+and+Fleiner+German+physicians&source=bl&ots=
b4H1Hjq9c6&sig=ACfU3U0_oohTWHqzWA9B19LHyTpV-b2 LQ&hl=en&sa=X&ved= 2ahUKEwikge6lrpH2AhXcITQIHW
_eBUEQ6AF6BAgVEAM#v=onepage&q=Kussmaul%20and%20Fleiner%20German%20physicians&f=false

section 5 : Alternative Variations of M.O.P. | 85

Multi-M.O.P.: The Full-Court Press
While M.O.P.x — a daily small enema plus a daily stimulant laxative — is usually quite
effective for the tougher cases, I recently stumbled upon a regimen that seems to work
even better: three docusate sodium mini-enemas per day. I call it Multi-M.O.P.
AYKM? (As my kids have informed me, that means “Are you kidding me?”) Am I really suggesting
some kids administer three enemas per day? Yep. But only docusate sodium mini-enemas, not other
formulations, as I will explain shortly. With Multi-M.O.P., children ages 12+ use the 283 mg version
of docusate sodium mini-enemas, sold under the brand name Enemeez. Children under 12 use the 100
mg version, sold as EnemeezKids (previously DocusolKids). These enemas have three ingredients, but
docusate sodium, a sodium salt, is the key ingredient.
Kids on this regimen take no stimulant laxatives, a big relief to
those who experience significant nausea or cramping with Ex- Am I really
Lax. Another bonus: (most) children on Multi-M.O.P. don’t take
osmotic laxatives for the first two phases. But the biggest benefit suggesting some
is how effective this regimen is proving to be. kids administer three
Now, I don't toss around the term breakthrough often, but I believe enemas per day?
it applies here. Over and over, in my clinical practice and in our
Yep.
private support group, I have seen Multi-M.O.P. succeed in cases
where other M.O.P. variations have not. Nothing in my career has
made me happier than these kids' successes.
In my clinic, I’ve had patients cancel follow-up appointments because their wetting had stopped, and
we had nothing left to discuss. Several parents in our support group have reported that Multi-M.O.P.
was the only regimen that halted accidents in their children, and they have posted x-rays showing their
child’s rectum dramatically less clogged than before. One mom posted that after 30 days on Multi-M.O.P.,
her 12-year-old daughter was on a streak of nine dry nights, after never having a dry night in her life. "Her
confidence is soaring," this mom wrote. This is a girl who’d taken Miralax for five years, who had shed
tears over missed camps and sleepovers, whose self-esteem, according to her mom had "hit rock bottom."
Her constipation was so seemingly intractable that several months of other M.O.P. variations had not
made a dent.
If you’re wondering how kids deal with multiple enemas per day, the answer seems to be for the most
part, quite well. The mom of a 7-year-old posted: “My son is more compliant with Multi-M.O.P. than
he has been with any other protocol. He is a kid who I have to ask many,
many times to do basically anything, but when it comes to the enema,
he's pulled down his pants and popped his butt into the air before
I've even gotten the supplies together!” This mom says her son is
"My son is more motivated because he's seeing results and because he prefers
enemas to Ex-Lax. This boy is the youngest I know of who has
compliant with tried the regimen; most are teens and tweens who've tried
everything else and are willing to do just about anything to get
Multi-M.O.P. than he
dry. The 12-year-old girl I mentioned above gives herself enemas
has been with any during her lunch break at school in the student restroom. Her
mom reported: “She does it sitting up, so it’s not as great as
other protocol." when she’s laying down at home, but she gets output. It takes
her 10 minutes, start to finish. She does not seem to mind. She is
a determined girl.” In this section, you’ll also hear from a determined
14-year-old boy who stealthily administers his enemas on sleepovers.

86 | M.O.P. Anthology — 5th Edition

In my experience, physicians underestimate both the
capability of kids to manage an enema regimen and
the difficulty of emptying the rectum in chronically I believe this regimen
constipated children. When the mom of the 12-year-
old girl told their pediatrician about Multi-M.O.P., succeeds because, for super-
the doctor “worried about her self-administering clogged kids, evacuating the
the enemas and her mental capacity to handle that.”
rectum three times a day is
The doctor said, “Keep up the Miralax and see you in
another three months!” simply more effective than
Why does Multi-M.O.P. work so well? It’s not doing so once a day.
because docusate sodium has magic powers, though
these enemas clearly work well. (Docusate sodium
draws water into the bowel, plumping up stool; the
increased stool mass, in turn, stimulates nerve endings in the bowel lining, triggering the urge to poop.)
I believe this regimen succeeds because, for super-clogged kids, evacuating the rectum three times a day
is simply more effective than doing so once a day. Enemas are more effective and reliable than stimulant
laxatives for triggering a complete evacuation, so a modified Multi-M.O.P. regimen — two enemas per
day rather than three — may be more effective than M.O.P.x. However, so far, it appears that the children
getting the best results are those administering three docusate sodium mini-enemas per day.
Is Multi-M.O.P. a guaranteed fast track to dryness? No. A handful of parents in our support group have
reported that their children's symptoms did not improve after 30 days on Multi-M.O.P., the point at
which they filled out the survey. For children who show no improvement on this regimen after six weeks,
I strongly recommend an x-ray. Based on the results, bladder medication, bladder Botox, or a motility
evaluation may be warranted.

The Origins of Multi-M.O.P.

Until recently, I did not realize that docusate sodium mini-enemas could be used multiple times a day.
I’ve always emphasized that enemas should be limited to once a day, except with Double M.O.P.
(an overnight oil enema followed by a morning large-volume enema to wash out the remnants from
impacted stool). The once-a-day rule stemmed from a simple fact: It’s not safe to administer more than
one phosphate enema per day. As I explain in Section 4, excessive phosphate could cause an electrolyte
imbalance. Phosphate (Fleet) enemas have long been the standard with M.O.P., and for years I based my
recommendations on the assumption that most families would be using phosphate enemas. I didn’t think
of investigating whether other enema solutions might be safe for use multiple times a day. I also didn’t
consider that families might be receptive to multiple enemas per day. After all, doctors and parents alike
tend to become aghast at the mere mention of a single daily enema.
So, for multiple reasons, I never explored the possibility of
a regimen such as Multi-M.O.P. However, the idea began
percolating as more parents in our private support group posted
Honestly, it didn’t x-rays of their children’s stubbornly clogged rectums. These folks
even occur to me that had diligently implemented M.O.P.x and/or M.O.P.+ for many
an otherwise healthy months, and yet accidents persisted. Understandably distraught,
parents would post: “After all these months and all these enemas,
child might benefit how can my child possibly still be constipated? What else can
from more than one we do?” On occasion, the same scenario would play out in my
clinical practice.
enema per day.
Now, I cannot explain why any particular child is unable to get
empty on a daily enema plus a daily stimulant laxative. It’s likely a

section 5 : Alternative Variations of M.O.P. | 87

combination of genetics and a deeply ingrained tendency to override the urge to poop. Regardless, I know
that 1.) this scenario occurs, 2.) emptying the rectum is the ticket to dryness, and 3.) enemas evacuate
the rectum better than anything else. Logically, then, multiple enemas would work better than one. So, I
began to investigate: Could multiple daily enemas be administered safely?

Multi-M.O.P. Safety
I began reading up on the different enema solutions and consulting experts in chemistry. When I looked
more closely at docusate sodium mini-enemas, I realized I’d missed something obvious: The adolescent/
adult version of these enemas already was approved for use up to three times daily. It says so right on the
box, under Directions:
Enemeez 283 mg Docusate Sodium Mini Enema: Adults and children 12 years of age and older (with
adult supervision) one to three units daily.
This does not mean the manufacturers of Enemeez
One Multi-M.O.P. Caution
endorse using their product three times a day for
resolving enuresis or encopresis in children ages Docusate sodium enemas should not be
12+. They do not. The company makes no mention of used in conjunction with overnight oil
enuresis or encopresis in its literature and generally enemas (Double M.O.P.). Docusate sodium
markets to patients with neurogenic bowel, the loss of reduces surface tension in the bowel,
normal bowel function caused by a spinal cord injury or allowing for increased absorption of oil,
nerve disease. Compared to kids without neurological and therefore “may increase harmful side-
impairment, these folks may need extra stimulation effects of mineral oil,” according to Quest,
to produce a bowel movement. According to the manufacturer of Enemeez. These side-
manufacturer: “If a patient doesn't produce a bowel effects include nausea, vomiting, diarrhea,
movement in 30 minutes, then [Enemeez mini-enemas] and abdominal cramps. No data exists
can be repeated up to 3 times.” Of course, that is not pertaining to docusate sodium and olive
how I am using Enemeez enemas with my enuresis oil, but out of caution, I advise against this
patients. My patients have no problem pooping after combination, too. At any rate, this scenario
enemas. Whereas patients with neurogenic bowel is unlikely to come up. Double-M.O.P. calls
may need two or three tries to achieve one bowel for overnight oil enemas to be used in
movement, my patients on Multi-M.O.P. are using conjunction with large-volume enemas, not
multiple daily enemas to trigger multiple daily bowel mini-enemas.
movements. But the point is: Either way, it’s safe
for kids age 12+ to rectally administer three 283 mg
docusate sodium mini-enemas in one day.
Is it a good idea? Well, to comply with U.S. government rules, the Enemeez box states that these enemas,
when purchased over the counter, should be used “only for occasional constipation, unless directed by a
doctor.” That’s basically what all enema labels say and, in my opinion, this caution reflects unsupported
fears about enemas and a misunderstanding about what it takes to treat chronic constipation in children.
Obviously, the entire premise of M.O.P. is that enemas are the best tool for resolving enuresis and
encopresis. At any rate, as a doctor, I am permitted to prescribe “off label” use of products to my patients.
Having researched docusate sodium extensively, I feel comfortable recommending 283 mg docusate
sodium mini-enemas for use up to three times a day in children ages 12+. I also believe it is safe for kids
under 12 to use the 100 mg version three times a day. The pediatric pharmacy at the hospital where I
work, and chemistry experts I trust, assure me that rectal administration of 300 mg of docusate sodium
per day is safe for children under 12. If your doctor is interested in reviewing the data, refer the physician
to Lexicomp, a reference that advises clinicians on the safety of drugs, especially patients with complex
conditions. Also, I am happy to discuss Multi-M.O.P. with any provider.

88 | M.O.P. Anthology — 5th Edition

 Multi- Cheat Sheet

Age 12+: Use 283 mg docusate sodium mini-enema.

Under 12: Use 100 mg docusate sodium mini-enema.

The 5 Phases of MULTI-M.O.P.

3 docusate sodium mini-enemas daily for at least 30 days and
Phase 1: 7 days/nights accident-free. No osmotic or stimulant laxatives.
MULTI-M.O.P. is
2 docusate sodium mini-enemas per day for 30 days. recommended for
Phase 2: No osmotic or stimulant laxatives. children who:

1 docusate sodium mini-enema or other small enema every • Cannot achieve

Phase 3: an empty rectum
other day for 30 days. Introduce daily osmotic laxative.
with other M.O.P.
1 docusate sodium mini-enema or other small enema twice a variations.
Phase 4: week for 30 days. Continue daily osmotic laxative.
• Prefer enemas to
stimulant laxatives.
Phase 5: Maintain daily osmotic laxative for 6 months before tapering.
• Feel highly motivated
to resolve enuresis
and/or encopresis.
MULTI-M.O.P. Guidance:
• If your child can’t fit in three docusate sodium mini-enemas daily on • Have experienced
school days, aim for two on weekdays and three on weekends. a recurrence of
• Be patient! You may not see improvement for 4 to 6 weeks. accidents after
success on other
• If accidents recur, return to the previous phase.
M.O.P. variations.
• Doctors interested in maximum daily doses of docusate sodium
administered rectally should consult Lexicomp.
• Do not use docusate sodium enemas in conjunction with oil enemas,
as this may increase the risk of nausea or cramping.

Important Note: Multi-M.O.P. is an off-label use of docusate sodium mini-enemas and is not endorsed
by the manufacturers of Enemeez.

© 2023 Copyright Steve Hodges, M.D., and Suzanne Schlosberg.

Do no reproduce or disseminate without written permission.

section 5 : Alternative Variations of M.O.P. | 89

Do docusate sodium mini-enemas pose any safety risk? In theory, excess amounts of docusate sodium
could cause diarrhea, leading to dehydration. But to me, that’s a far-fetched scenario. There are no FDA
complaints against docusate sodium mini-enemas or reported severe side-effects. Stomach cramps and
nausea are listed as possible side-effects, but those are
the same side-effects that apply to any other enema
or laxative product. The fact that the dose of docusate
The fact that the dose sodium mini-enemas does not need to be reduced for
of docusate sodium children with kidney or liver impairment further suggests
these enemas are plenty safe.
mini-enemas does not
Notably, the small size of these enemas ensures against
need to be reduced for excess rectal stretching, a problem that sometimes arises
children with kidney or with large-volume enemas. Plus, these tiny enemas are
less intimidating to some kids than Fleet-sized and large-
liver impairment further
volume enemas.
suggests these enemas
In my (admittedly) limited experience, docusate sodium
are plenty safe. mini-enemas seem to be quite gentle. However, there
are exceptions. A couple of parents in our support
group reported their children experienced a burning
sensation from docusate sodium mini-enemas, and these kids switched to M.O.P.x with liquid glycerin
suppositories. My rule with an enema or laxative is: If it hurts your child, don't use it. My corollary is: If you,
as a parent, are uncomfortable with any recommendation, don’t follow it.
I have been asked: Given the expense of Multi-M.O.P., can we use LGS instead? I can't offer a
definitive answer. Glycerin is not an electrolyte and therefore does not pose the same safety concerns as
phosphate. In theory, multiple LGS per day should be safe, and some families have reported doing it with
success. Still, the manufacturer of Pedia-Lax liquid glycerin suppositories, CB Fleet, advises against using
LGS twice a day. A CB Fleet representative told me via email: “Glycerin can be irritating to the mucosa
and (even) one liquid glycerin suppository can cause burning.” This has not been my experience. In fact,
my patients find liquid glycerin quite gentle, and very rarely report discomfort.
Bottom line: I have no personal experience with a regimen involving two LGS per day (or mixing and
matching LGS and docusate sodium in one day). I generally advise families interested in Multi-M.O.P.
to stick with docusate sodium mini-enemas for Phases 1 and 2, but I don’t have a
good reason to caution against using LGS twice a day. In Phase 3, when the
child tapers to one enema per day, certainly any enema is fine. Note that “My kid
unlike LGS, docusate sodium mini-enemas involve multiple ingredients
and cannot be made at home. loves not
taking laxatives —
When to Consider Multi-M.O.P.
Think of Multi-M.O.P. as a full-frontal attack on enuresis and
no more cramping
encopresis. Which kids might want to launch this sort of blitz? and runs to the
In my experience:
bathroom at
• Children who cannot get empty with M.O.P.x.
school.”
As I've mentioned, some kids maintain a significant stool burden in the
rectum despite a daily enema plus a high dose of a senna-based stimulant
laxative. These children either can’t achieve a daily spontaneous poop, because
they're overriding the urge or don't feel it, or because they don’t fully evacuate. An x-ray can confirm
whether the rectum contains a stool build-up (though I realize that in many countries it’s impossible
to get an x-ray).

90 | M.O.P. Anthology — 5th Edition

 • Children who prefer enemas to stimulant laxatives.
Yes, these kids exist! In fact, "my kid prefers enemas to laxatives" is the number one reason families
choose Multi-M.O.P., according to early results from a survey I am conducting in our private support
group. Senna-based laxatives work quite well for most kids, but some children can’t tolerate the high
dose of Ex-Lax needed to stimulate a bowel movement. The cramping and/or nausea are just too
much. Also, stimulant laxatives are unpredictable: The bowel movement might come 5 hours later or 8
hours later or at some unknown time when the child is at soccer practice. Timing Ex-Lax can be tricky,
and to some kids, inserting an enema and pooping 10 minutes later is far easier and produces a lot less
anxiety than waiting for Ex-Lax to kick in.
• Tweens and teens who are highly motivated for the accidents to stop.
Having accidents in middle school or high school is downright miserable, and many children will
do anything for dry sheets, even if it means waking up early to administer an enema before school,
administering an enema at lunch period, and giving themselves a third enema before bed. After years
and years of wet sheets and/or soiled underwear and missed sleepovers and summer camps, the
prospect of an accident-free life makes Multi-M.O.P. seem totally worthwhile.
• Children who do well on other M.O.P. variations but backslide upon tapering.
Some children who succeed on Standard M.O.P. start having accidents a few months or even weeks
later. They fill right back up because their rectum hasn’t fully regained tone and sensation. Tapering off
enemas more gradually may prevent this scenario, allowing the rectum more time to heal. That’s why I’ve
introduced the Slow Taper regimen, described in Section 4. However, some kids who have experienced the
frustration of a relapse want to tackle the constipation more aggressively, and Multi-M.O.P. fits the bill.

Common Questions About Multi-M.O.P.

Given that Multi-M.O.P. is new, I’m not a fountain of knowledge about this regimen. Here are common
questions I’ve received, along with the best answers I can currently offer:
Question: How quickly can I expect my child’s accidents to stop on Multi-M.O.P.?
Answer: I do urge folks to be patient. The mom of an 8-year-old with encopresis and enuresis posted
that after 10 days, Multi-M.O.P. was "going horribly" and her son felt hopeless. Three months later,
she posted that they had begun Phase 3. The father of a 12-year-old boy said his son almost gave up on
Multi-M.O.P. after a month without progress but then saw “sudden improvement.” Still, it’s been a slog
for this child. His dad posted: Our son was dry around 2/3 of the time the first two months and more than
80% of the time the third month, which is more success than we’ve seen in years. This regimen has been
both easier and more effective than others we have tried in the past.”
Question: Will three Enemeez per day get my child dry more quickly than two?
Answer: In my experience, yes. But again, I haven’t had enough patients on both versions to draw a
conclusion. I know it’s easier to fit in two enemas per day than three, so do the best you can. Your child
could aim for three docusate sodium mini-enemas per day on weekends and two a day on weekdays.
Question: Should we really avoid osmotics on Multi-M.O.P., even if my child has hard poops?
Answer: Very few kids on Multi-M.O.P. need osmotic laxatives for the first two phases (and stimulant
laxatives are replaced by the extra enemas). These kids are pooping so much that stool does not have a
chance to sit idle and dry out. However, a few parents have reported their children did need an osmotic to
keep poop soft, and that’s fine.
Question: Could doing an enema three times a day cause sphincter damage?
Answer: No. The tips of docusate sodium mini-enemas are tiny. And plenty of kids poop multiple times a
day on their own; they just don’t fully evacuate, which is the problem. I see no reason for concern.

section 5 : Alternative Variations of M.O.P. | 91

 One Teenager’s Multi-M.O.P. Story
The Mom’s Perspective
My 14-year-old wasn’t seeing enough dry nights desmopressin. Once
on M.O.P., so he agreed to do one docusate a week, we’d "At
sodium mini-enema before school and one experiment sleepovers,
before bed. The whole process takes less than and skip he hid the trash in
10 minutes each time. I made sure he never desmopressin
missed his twice-a-day enemas by counting them
his toiletry bag. I’d
to see if he
in the trash. At sleepovers, he hid the trash in his still needed it. text him with our
toiletry bag. I’d text him with our code word to Finally, he didn’t. code word to make
make sure he did it. After a month sure he did it."
He definitely preferred Multi-M.O.P. to M.O.P.x. of twice-a-day
Doing an extra enema is much more manageable mini-enemas with
and predictable than Ex-Lax and has no side- no desmopressin and no
effects. accidents, he has weaned to one Enemeez at
night before bed. So far, still dry. I found you
During Multi-M.O.P. I kept him on desmopressin have to be patient and trust the process. It takes
to keep his morale up. It took us 13 weeks on months, but don’t give up!
the twice-a-day program before we could drop

The Teen’s Perspective

This teenager’s mom interviewed her son for With the two-a-day program, I always knew when
me. Here are his answers: I was going to poop.

Q: When your mom first told you about the Q: How did you
"I
manage Multi-M.O.P.
twice-a-day plan, what was your reaction? preferred two
on sleepovers?
A: I felt a mix of "No way" and "OK." I felt
A: Going on
mini-enemas a day
like it would be really hard, but I pushed myself over Ex-Lax because
sleepovers was not I had much more
because I wanted to be cured. Seeing the x-ray
a big deal. No one
of my insides and understanding the treatment control over when
seemed to notice
helped me a lot to keep me going. It ended up I was going to
how much time I was
being much easier than I thought it would be, poop."
in the bathroom. I'd
and after a few weeks of practice, it wasn't even
say I was pooping or do it
a big deal to go on a sleepover or an overnight
when I was going to also take a shower. I had a
school trip in a hotel.
toiletry kit with a zippered pocket where I'd keep
Q: What did you think of two enemas per day the enemas and another pocket with a Ziploc
compared to one enema per day plus Ex-Lax? bag to put in the trash when I was done, so no
one would ask what I had left in the bathroom
A: Even though it's never fun to put something
trash can.
up my butt, I preferred two mini-enemas a day
over Ex-Lax because I had much more control Q: What is your best advice for teens who feel
over when I was going to poop. I hate pooping too discouraged to try enemas twice a day?
at school, and a few times the Ex-Lax would kick
in early, which meant I had to go poop at school.
A: Just do it. It's not a big deal and it cured me.

92 | M.O.P. Anthology — 5th Edition

Pre-M.O.P. for Constipated, Accident-Free Kids
I often hear from parents of children who don’t have accidents but who nonetheless
suffer severe symptoms of chronic constipation. Here’s an example:
My 5 y,o. does not have accidents, but he began rectal bleeding last year. He eats a fantastic diet and
has a bowel movement daily, but his stool is hard, and he complains of abdominal pain. An x-ray revealed
constipation, so our doctor started him on a fiber supplement and 1 cap of Miralax per day. But he still has
bleeding episodes. I’m concerned this may become a long-standing problem. Does this seem like a typical
case of constipation? What do you recommend?
Yes, this is a textbook case of chronic constipation, Pre-M.O.P. in a Nutshell
and yes, left untreated or undertreated, childhood
pooping difficulties may persist into adulthood.
•Daily osmotic laxative
For example, in my opinion, irritable bowel
syndrome (IBS) may be a consequence of childhood •Enema, LGS, or high-dose senna after a child
constipation that was never properly treated. Adults doesn’t poop for 24-48 hours
with IBS often alternate between constipation •Lidocaine gel for kids who strain due to pain
and diarrhea, sometimes in the same day, and they
experience abdominal pain, cramping, and gas.
Can I prove these symptoms stemmed from untreated constipation in childhood? Nope. But in my 15 years
of medical practice, I’ve talked to enough adults diagnosed with IBS about their long history of pooping
troubles to make that connection. Many of these adults are parents of my enuresis/encopresis patients,
and certainly chronic constipation runs in families. I also suspect that some chronic pelvic floor disorders
in adults, such as interstitial cystitis, a condition that causes bladder and pelvic pain, develop after years
of untreated childhood constipation.
I mention all this not to cause worry but to encourage parents to pursue treatment, beyond Miralax, for
children whose pooping difficulties are impacting their daily lives. It’s tempting to dismiss symptoms like
stomachaches, bloating, and painful pooping when a child also eats well and poops daily. But the fact
is, plenty of children who are “regular” and have stellar dietary habits nonetheless struggle with chronic
constipation. I was one of these kids myself. I strained to poop throughout my childhood, and it never
occurred to me that my experience was abnormal.
Some kids literally spend hours a day on the toilet. Some, like the 5-year-old mentioned above, strain
so hard to poop that their stools emerge bloody, due to a small tear, or fissure, in the lining of the anus.
Other kids experience rectal prolapse: the rectal lining pushes down through the anus and outside the
child’s body. It’s an alarming sight for parents. Other kids end up in the ER with impacted stool, even
though they’ve never had an accident.
Most of these kids have taken Miralax, either consistently or off and on, to no avail. Eventually, their
symptoms get so bad that their parents search online for
answers, find M.O.P., and ask: “My child is constipated but
doesn’t have accidents. Should we try M.O.P.?”
It’s tempting to dismiss For some kids, yes. Children who are severely clogged and
symptoms like stomachaches, particularly adept at overriding the urge to poop may need
some variation of M.O.P. However, for most accident-free
bloating, and painful pooping
kids, daily enemas aren’t needed. Instead, I favor the Pre-
when a child also eats well M.O.P. approach: an enema or liquid glycerin suppository on
and poops daily. any day the child does not poop or appear to fully evacuate,
in combination with a daily osmotic laxative.
I originally conceived of Pre-M.O.P. as a regimen to

section 5 : Alternative Variations of M.O.P. | 93

resolve chronic constipation and prevent enuresis/encopresis
in babies and toddlers — young children who have not yet
reached toilet-training age but who are already experiencing The conventional treatment
painful pooping and who habitually delay pooping. The — Miralax, fiber supplements,
regimen is spelled out in The Pre-M.O.P. Plan: How to Resolve
Constipation in Babies and Toddlers and Overcome Potty- probiotics, occasional
Training Struggles. Ex-Lax — ignores the
However, that book is aimed at parents of babies, not 5-year- fact that chronic constipation
olds with rectal bleeding or 8-year-olds who spend two
is . . . chronic!
hours a day struggling to poop. Most of the book does not
pertain to parents of toilet-trained children. In addition, my
recommendations for older kids who don’t have accidents
differ slightly from the standard Pre-M.O.P. regimen. In this section, I discuss guidance for treating
accident-free, toilet-trained children who struggle with chronic constipation.

Why Some Severely Constipated Kids Don’t Have Accidents

You may be wondering: If these kids are so clogged up, why don’t they have enuresis or encopresis?
Interestingly, some of these children are actually more constipated than their peers who have accidents.
An x-ray may show a larger stool mass and more rectal stretching. But, by a quirk of genetics, their bladder
nerves may not be as sensitive to the bulging rectum. So, their bladder does not go haywire and contract
without warning. And their rectum does not become so floppy that stool just drops out, as in the case of
children with encopresis.
These kids are lucky they’re not having accidents, but they suffer in other ways, and like children with
enuresis and/or encopresis, they are typically undertreated by physicians. The conventional treatment
— Miralax, fiber supplements, probiotics, occasional Ex-Lax — ignores the fact that chronic constipation
is ... chronic! Constipation is typically considered a harmless, temporary condition, so treatment is usually
short-lived and modest. But let me tell you: Kids don’t have bloody stools, severe stomachaches, or rectal
prolapse episodes if they are not extremely and persistently backed up.

Pre-M.O.P. Guidance for Older Kids

• Use a daily osmotic laxative.
Give your child a daily dose of PEG 3350, lactulose, magnesium hydroxide, or magnesium citrate.
The options are discussed in Section 6. You can give a full dose once a day or half a dose twice a day.
• Administer an enema if the child hasn’t pooped in 24 to 48 hours.
Though osmotic laxatives often aren’t enough for these kids, osmotics are nonetheless important for
keeping poop soft and should remain part of the treatment plan. Painful pooping is likely what set off
the constipation in the first place, so minimizing that pain is key.
Also key: an enema or liquid glycerin suppository before bed if the child has not pooped in the
previous day or hours or does not appear to have fully evacuated. In other words, if the output was
meager. Of course, unless you have x-ray vision, you can’t know whether your child’s rectum has been
emptied. You just have to use your judgment.
In The Pre-M.O.P. Plan, I recommend an enema or suppository if the child hasn’t pooped in 24 hours,
but that’s because my goal is to do everything possible to prevent enuresis or encopresis from
developing. In the case of an older child, we already know the kid is not highly prone to accidents.
That child has skated by! So, I think it’s less urgent for the child to fully evacuate every single day. Still,
since the child’s constipation is a significant problem, I would make sure your child evacuates fully at
least every 48 hours. Daily is better.

94 | M.O.P. Anthology — 5th Edition

 Could you use Ex-Lax instead of enemas? Yes, but make sure your child uses a high enough dose to
stimulate a full-on bowel movement. Many parents avoid this because of the cramping and nausea
that come with the territory. The urge to poop must be strong enough for the child to have no
choice but to respond. Otherwise, you’re back to where you started. For most kids, enemas are more
reliable than stimulant laxatives. With enemas, you can time when the child will poop, whereas timing
stimulant laxatives can be tricky. See Section 6.
What about using a higher dose of an osmotic laxative? You could try, but that can cause poopy leakage
and your child may not feel enough of an urge to poop. Enemas are more effective and reliable.
If a constipated child isn’t having accidents, how do you know when to start tapering the regimen?
You’ll have to go by the child’s pooping habits and symptoms. Is your child comfortably pooping every
day? Are the stomachaches and bloody stools gone? If so, start weaning slowly. Taper your child’s
regimen as you see fit, but my general rule of thumb is: Treat your child for twice as long as you think
you need to! I had my own kids on an osmotic laxative for two years. Parents tend to be fearful of
overtreating constipation, even though “dependence” is not an issue. In reality, folks should worry a lot
more about undertreatment.
If you’re using a stimulant laxative, you can try dropping
the child’s daily dose by one square each week while
Parents tend to be fearful adding an osmotic laxative and see if the child’s pooping
output stays the same. I realize you can’t monitor the
of overtreating constipation,
size and consistency of your child’s each and every
even though “dependence” bowel movement, especially if you have an older child
is not an issue. In reality, who may be pooping at school or doesn’t want you
peering into their toilet bowl. So, I suggest teaching
folks should worry a lot more your child what to look for, using the How’s Your Poop?
about undertreatment. chart in Section 8. Stay vigilant about your child’s
pooping, and don’t hesitate to return to enemas any time
problems resurface.
• Use lidocaine gel to ease pooping pain.
Many kids fight the urge to poop because pooping hurts. These kids fight hard! I’ve discussed the
two key ways to resolve painful pooping: laxatives (to keep poop soft) and enemas (to avoid the
poop pile-up). But there’s a more immediate aid for kids who strain due to pain: applying lidocaine
gel to the child’s anus.
Lidocaine is a combination of anesthetic pain reliever and a corticosteroid. This gel decreases
rectal inflammation, swelling, itching, and pain. I tell kids to put a dab on their anus twice a day,
about 15 minutes before the enema. The numbing lasts about 30 minutes to 3 hours.

section 5 : Alternative Variations of M.O.P. | 95

Section 6

A Guide to M.O.P. Supplies

In this section I cover the most common enema options, both
store-bought and homemade, as well as various osmotic and
stimulant laxatives. My advice: Be open to experimenting. You
can’t predict which products will be most effective or preferable
for your child. Depending on your country of residence, you
may find your options more limited than in the United States,
but no matter where in the world you live, you will be able to
implement M.O.P.

97
section 6 : A Guide to M.O.P. Supplies | 97
Enema Overview: Store-Bought and Homemade
When I first began recommending Dr. O’Regan’s protocol to my patients, I steered
them toward Fleet (phosphate) enemas or the generic equivalent, because Dr. O’Regan
used them and because they’re readily available in the United States, where I practice
medicine. These enemas have been around practically forever — well, since the 1950s — and honestly,
I didn’t give the type of enema much thought. I just knew enemas worked much better than Miralax and
was grateful to offer my patients a more effective way to stop accidents.
Eventually, I realized that for many kids, liquid glycerin
suppositories (LGS) are just as effective and, in some
cases, an even better choice than phosphate enemas. When a mom in the United
More recently, I discovered the benefits of docusate Kingdom tried to purchase
sodium mini-enemas, which can be used up to three
times a day for children 12+ (see the Multi-M.O.P. 25 enemas online from a
variation in Section 5). As our support groups have pharmacy, the large quantity
become more international, I’ve learned that in some
raised a red flag for the
countries, the only available store-bought enema brand
is Microlax, which has yet another key ingredient pharmacist, who would not
(sodium citrate dihydrate) and works well for many. authorize her purchase.
I’ve also learned that some countries restrict the number
of enemas a customer can purchase. When a mom in
the United Kingdom tried to purchase 25 enemas online from a pharmacy, the large quantity raised a
red flag for the pharmacist, who would not authorize her purchase. The pharmacist emailed, “Who is the
medicine intended for? What are the symptoms? Is your GP aware you take this medication?”
The mom posted in our group: “No, my GP doesn’t know I’m doing this. No medical professionals are
supporting us. Beyond frustrated! Day 43 of M.O.P. with 11 y.o. — HUGE progress. Last 10 days accident-
free!!” I suggested she make her own enemas, an increasingly popular option in our support group. DIY
enemas can be made for a fraction of the cost of the ready-made variety and the components are easily
bought online, without interrogation from a pharmacist! In the DIY Enema section, I describe the two
homemade options.

Store-Bought Enema Options

Best-case scenario, you will need 53 enemas: 30 for the first month, 15 the second month,
and 8 for the third month. Your child may well need a lot more, especially if you’re tackling
enuresis. While buying pre-made enemas in bulk saves money, I advise against making a bulk purchase until
your child has tried different brands or varieties. Some children report a strong preference or have much better
stool output with one type or another. You don’t want to get stuck with a truckload of phosphate enemas
if your child prefers LGS, or vice versa. Parents in our support group have tried to unload enemas in bulk,
not an easy sale to make! Here’s a rundown of the store-bought enemas commonly used with M.O.P.

Phosphate Enema, Sold as "Saline Laxative Enema"

Phosphate enemas, commonly referred to as Fleet enemas, come in two sizes: a pediatric version for
children ages 2 to 11 and an adult version for kids 12 and older. Confusingly, these are labeled "Saline
Enema" or "Saline Laxative Enema," even though the active ingredient is phosphate. Any brand of
phosphate enema will suffice, although some children find certain tips more comfortable than others.
(Still, adding lubricant to the tip and to the child’s bottom should alleviate any discomfort.)

98 | M.O.P. Anthology — 5th Edition

Phosphate is an electrolyte, and some physicians warn against these enemas for fear they will cause an
electrolyte imbalance, an unwarranted concern I discuss in Section 1. But if you or your doctor have the
slightest worry, simply try a different type of enema. There’s no shortage of options. Also note that in a
minority of children, phosphate enemas cause a burning sensation, in which case I recommend any of the
other options.

Liquid Glycerin Suppository (LGS)

Liquid glycerin suppositories, known in M.O.P. parlance as LGS, contain a smaller volume than phosphate
enemas and contain nothing but glycerin. (The other store-bought enemas contain a mix of ingredients.)
I wish LGS were labeled “liquid glycerin enema,” as the term “suppository” causes much confusion. Most
folks think of suppositories as bullet-shaped solids, which also are inserted rectally and used to relieve
constipation. With M.O.P. it is important to use liquid glycerin. Solid suppositories are less effective
and less reliable and sometimes get “spit” right out of the child’s bottom. I typically recommend solid
suppositories just for babies doing Pre-M.O.P.
With store-bought LGS, you use the pediatric size (4 ml) for children ages 2 to 5. Children 6 and older use
the “adult” size (7.5 ml). For some children, glycerin stimulates a greater output of stool than phosphate;
for other kids, it's just the opposite. You just can’t predict. If your child experiences burning from
phosphate but can’t get enough output with LGS, try large-volume enemas with glycerin and/or Castile
soap. If your child responds well to store-bought LGS and you want to save money by making your own,
see the DIY section.

Docusate Sodium Mini-Enemas

These enemas come in two sizes: 283 mg for ages 12+ and 100 mg for younger kids. Children tend to find
these enemas gentle and unintimidating due to their small size, although I’ve heard a couple of reports
of burning. Docusate sodium mini-enemas, sold as Enemeez or DocuSol Kids, are a popular choice among
folks with neurological conditions that require them to use enemas every day for life. For our purposes,
the key advantage of docusate sodium mini-enemas is that they are the only type of enema that has
been approved in the United States for use three times a day for kids ages 12+. For kids under 12,
I personally believe using the 100 mg version two or three times a day is safe, and I recommend this
“off label” use to my patients, as I explain in the Multi-M.O.P. part of Section 5.
Parents report that docusate sodium mini-enemas cost more than store-bought alternatives, so families I
work with tend to use them only for the first two phases of Multi-M.O.P. Also, some parents report that
while docusate sodium mini-enemas are highly effective, they cannot squeeze out enough of the solution,
so much of this pricey liquid goes to waste. One mom devised a solution others have adopted: She cuts
off the end of the enema and draws up the liquid with a cheap syringe. For her child's comfort, she fits the
syringe with a soft tip, the type used with a reusable enema kit (and described in the DIY portion of this
chapter). But most folks just use the enemas as packaged and report no problems.

Microlax Enemas
I have no personal experience with Microlax enemas, as they are generally not used in the United States.
The main ingredient is sodium citrate, a sodium salt. Microlax is the main enema brand available in many
countries, including Australia and much of Europe, and this type of enema seems to work fairly well.
However, a number of parents have reported their child did not get sufficient output with Microlax enemas,
in which case they purchase Fleet enemas from overseas (not an inexpensive option) or make their own
glycerin enemas using a syringe or bag enema kit (M.O.P.+).

section 6 : A Guide to M.O.P. Supplies | 99

DIY Enemas: Liquid Glycerin and Large-Volume
You have two options for homemade enemas: 1.) large-volume enemas, using a bag
enema kit, and 2.) liquid glycerin suppositories, using a syringe or old enema bottle.
Both are inexpensive and have their benefits.
Large-volume enemas are used with M.O.P.+ and Double M.O.P., variations described in detail in
Section 5. You purchase a bag enema kit online (includes bag plus tubing, clamp, nozzles, and so on)
and fill it with saline solution and a stimulant, such as glycerin or Castile soap. I describe the benefits,
dosages, and details in Section 5. All of the elements are readily available online. Search "bag enema kit,"
and you will find many brands. I don’t have a recommendation, as they’re all pretty similar. Brands of liquid
vegetable glycerin and Castile soap are more or less equivalent, too.
For years, bag enema kits were the only DIY option
I mentioned to patients. It didn’t occur to me to
advise folks to make their own LGS. That was an idea
Parents would ask: If glycerin
generated by parents in our private support group, who
wanted both the cost savings of homemade enemas is the only ingredient in
and the small volume of LGS. Parents would ask: If LGS, and glycerin is readily
glycerin is the only ingredient in LGS, and glycerin
available, why can’t we just
is readily available, why can’t we just make these
ourselves? It was an excellent question! I couldn’t make these ourselves? It was
see any reason these folks shouldn’t make their own, an excellent question!
so many parents began experimenting with ways to
imitate the store-bought liquid glycerin suppositories.
To be clear, you cannot make your own version of
a phosphate (Fleet) enema, a docusate sodium enema, or a Microlax enema. Those products contain a
mix of ingredients and cannot be re-created on a DIY basis. I’m only talking about liquid glycerin here. But
since glycerin is a gentle and a highly effective option for many kids, I endorse this option.
DIY LGS won’t be the solution for every child. Some kids simply respond better to other ingredients.
However, if you’re looking to save money, homemade LGS is worth a try.
You simply mimic the amount of glycerin found in an age-appropriate, store-bought liquid glycerin
suppository. For children ages 2 to 5, that’s 4 ml. For children 6 and older, it’s 7.5 ml. These volumes
account for the fact that not 100% of the liquid will get squeezed into the child’s rectum. For example,
in a 7.5-ml suppository, about 5.4 ml of glycerin enters the rectum, according to Pedia-Lax. You just can’t
squeeze every drop out, and that’s fine.

The Syringe Method

Here are tips from parents who make their own LGS with syringes:
• Look for a syringe with a long enough tip to insert into the child’s anus. Ideally that’s at least 5/8”.
Many parents use a 20 ml syringe. Some prefer 60 ml syringes because the tips are longer.
• You can either wash reusable syringes or purchase one-time-use syringes. “I keep a bottle of Blue
Dawn in the bathroom and wash our hard plastic syringes in hot water,” one mom posted. A mom who
buys single-use syringes in bulk on Amazon wrote: “They end up costing about 30 cents each, which
I’ll take over having to clean one!”
• Placing a silicone or PVC tip onto the syringe tip may allow for easier, more comfortable insertion.
Silicone tips are made for reusable enema bags, but refills are sold separately. Search “enema
attachment replacement tip.” The tips are long, so you’ll need to snip off the last few inches. One mom

100 | M.O.P. Anthology — 5th Edition

 Illustration by Mark Beech

posted: “I cut off the last 2 inches of a PVC replacement tip, which fits
perfectly on a plastic syringe. The tip is soft and small and doesn’t hurt
my kid at all.”
“Syringes
The Bottle-Refill Method work great for
Though the syringe method traveling because the
seems to be the most box of syringes comes
“I bought several popular, some parents with caps. I pre-load
packs of liquid glycerin who’ve tried that
method find it easier
the glycerin into a few
suppositories and saved the
to wash and reuse syringes and pack
tubes. I purchased glycerin
store-bought bottles. them.”
from Amazon and refilled the To avoid measuring the
tubes. I washed and sucked up right amount each time, place
soapy water after each use tape around the bottle as a guide.
and left to air dry. Super (Phosphate enema bottles hold much more volume than you
use with an LGS). The bottom of the tape should line up with
cheap!!!”
liquid contents.
Some parents reuse store-bought LGS instead of Fleet bottles. One
mom explained: “I decant glycerin into a small container so I can suck
it into the bulb. I squeeze the bulb, insert into the glycerin, and release, turn it
upright, and squeeze to get rid of air bubble. Then I repeat until overflowing. The technique took a bit of
trial and error.”

Osmotic Laxatives: Options, Timing, and Dosing

Dr. O’Regan’s patients used nothing more than Fleet phosphate enemas and, overall,
got great results. However, in my experience, adding an osmotic laxative to the enema
regimen can help a lot, especially with enuresis. On the other hand, for children with encopresis,
osmotic laxatives sometimes create a bigger mess, so for these kids I recommend starting with enemas
only and adding an osmotic laxative after about two weeks. By that time, accidents should have stopped
or decreased dramatically, and because the child is less clogged, a mess is less likely. Though some
children do best without any osmotic laxatives, in general, I consider these laxatives an important part of
M.O.P., especially once the child is tapering from, or has completely weaned off, enemas.
Finding the right osmotic laxative and the right dose to keep poop soft — but not too soft — can be
challenging. Here is some guidance for experimenting:
• Your child can take the full dose once a day or half a dose twice a day.
• You can switch osmotic laxatives at any time without tapering.
• Your child can take two different osmotic laxatives.

section 6 : A Guide to M.O.P. Supplies | 101

I don’t have strong feelings about
which type of osmotic laxative to
use, but you or your child might.
“Our magic
Below I discuss the pros and cons
of the four osmotic laxatives mix seems to be “We use a combo
most commonly used with a capful of Miralax of chewable
M.O.P.: PEG 3350, magnesium
hydroxide, lactulose, and in the morning, with magnesium
magnesium citrate. a tablespoon of milk hydroxide tablets
PEG 3350 (Miralax, of magnesia in the and lactulose.”
Movicol, Osmolax, or evening.”
Generic Equivalent)
Pros: A flavorless, odorless powder
sold in large bottles, PEG 3350 is easy to
administer and, for most kids, very effective. You simply mix it in water or other clear liquids. If your child
prefers PEG 3350 mixed in milk, that’s fine. Milk won’t compromise the effectiveness of the laxative,
though the powder doesn’t dissolve as well as in clear liquids. You just have to stir it more, especially if
using almond milk. PEG 3350 is similar to PEG 4000, sold in France and other countries.
Cons: Some kids may resist drinking so much liquid, and for a minority of kids, PEG 3350 just doesn’t work
well. More significantly, questions have been raised over Miralax safety. Neuropsychiatric side-effects, such
as aggression, mood swings, and obsessive-compulsive behaviors, have been reported, although no studies
have found a causal link. I discuss the Miralax controversy in the sidebar, “Is Miralax Toxic for Children?”
Bottom line: If you have concerns about Miralax or your child responds poorly, find an alternative!
Dosing tips: Start with 1/2 cap or a full cap (17 mg) and adjust as needed.

Magnesium Hydroxide (Milk of Magnesia, Pedia-Lax Chewable Tablets)

Pros: Magnesium hydroxide can be taken in many forms. Milk of magnesia liquid and caplets are generally
inexpensive. More expensive but more palatable to most kids are Pedia-Lax Chewable Tablets in
watermelon flavor.
Cons: If your child requires a lot of laxative to maintain mushy poop, Pedia-Lax chews may be too costly.
Yet most kids don’t like the taste of liquid milk of magnesia, which one kid dubbed “milk of magnausea.”
To save money, some parents alternate the chewable tablets with liquid milk of magnesia.
Dosing tips: If you’re using liquid milk of magnesia, try 1 to 2 tablespoons for children 11 and under and
2 to 4 tablespoons for children 12 and older, followed by a glass of water. With chewable tablets, start
with 1 to 3 per day for ages 6 and under. Older children can take up to 6 tablets.

Lactulose
Pros: A manufactured sugar that contains two naturally occurring sugars, galactose and fructose, lactulose
comes in a sweet syrup that’s easy to take. It’s also available as a powder (Kristalose). Some kids prefer
drinking a couple of teaspoons of lactulose to downing a whole glass of water mixed with powder. And
some get better results with lactulose than with PEG 3350.
Cons: In the United States, lactulose requires a prescription, although it’s sold over the counter in much of
the world. Its side-effects — diarrhea, nausea, gas — are the same as those associated with Miralax, though
some children seem to have more gas or discomfort with lactulose than with PEG 3350. Also, some kids
tire of the sweet taste of lactulose.
Dosing tips: Start with 5 to 10 ml/day. Maximum recommended dose is 30 ml/day.

102 | M.O.P. Anthology — 5th Edition

Magnesium Citrate
Pros: Magnesium citrate is popular among parents who are not
comfortable with PEG 3350 and seems to be effective for many “Though Miralax
children. The powder version is the most popular, but magnesium is supposed to be
citrate is also available in liquid, gummy, or tablet form. Keep
‘tasteless,’ my son could
in mind that some products are not intended as a laxative
but rather as a “relaxation supplement,” so the recommended taste it, no matter what
dose might be a lot lower than what your child needs for help beverage we mixed it in.
pooping. He prefers lactulose and
Cons: Many kids dislike the sour taste, and to get an effective sometimes mixes it with
dose, they need to take a lot more of this stuff than the
chocolate milk.”
alternatives. For both reasons, many kids find magnesium citrate
a chore to take. Parents are always looking for ways to disguise the
flavor, like adding Stur (a liquid made from fruit and stevia leaf extracts),
mixing it with peanut butter, or pouring the contents of a capsule into
chocolate milk.
Dosing tips: Dosages to treat chronic constipation are not well-established, so you’ll need to experiment.
When using the powder version, kids generally start with 1 to 2 teaspoons and increase up to 4 teaspoons
if needed. The following dosing is for the liquid version of magnesium citrate, the concentration of which
is 1.745 grams per fluid ounce/30 ml.
• Ages 12+: 6.5 to 10 fluid ounces
• Ages 6 to 11: 3 to 7 fluid ounces
• Ages 2 to 5: 2 to 3 fluid ounces

Is Miralax Toxic for Children?

PEG 3350 is a fraught topic. Many physicians consider it 100% safe, while many
outraged parents report that their children were harmed by it. What do I think?
I don't think PEG 3350 causes problems in the vast majority of children, but perhaps does negatively
affect some kids, and no parent who is uncomfortable with PEG 3350 should feel compelled to give it to
their children.
More than 100 published articles have studied PEG 3350 in children, and none
have linked it to severe or harmful side-effects, psychiatric or otherwise. These
studies indicate PEG 3350 does not enter the child’s bloodstream, has no
effect on the body’s balance of electrolytes, and just washes out the colon.
However, in 2009, the Drug Safety Oversight Board of the United States Food
and Drug Administration published a summary of PEG side-effects reported
by parents to the FDA’s Adverse Event Reporting System.1 Reported side-
effects included seizures, tics, lethargy, rage, anxiety, aggression, tremors, and
obsessive-compulsive behaviors. A small fraction of my patients and members
of our private support groups have reported symptoms such as these, too. Just
because no studies, to date, have found a direct association between PEG
Illustration by Mark Beech
3350 and behavioral changes doesn’t mean no such association exists.

1 [Link]

section 6 : A Guide to M.O.P. Supplies | 103

 One Mom’s Miralax Story:
“The sensory experience could have been too overwhelming.”
On Miralax, my son, age 3, was manic-laughing in a been directly caused by the Miralax. He is normally
distressed "please help me" sort of way that was heart not very aware of the sensations going on in his body,
wrenching. It was definitely related to Miralax because but all of a sudden there’s a massive change in the
if he skipped a day, his behavior returned to normal amount of movement in his GI, and he’s not used to it,
(for him — he’s autistic). Because of this, we avoided and the sensory experience could have just been too
Miralax for many years. overwhelming.
However, when he was 9, we tentatively tried it again, But things have changed as he’s older, and he can
and it’s completely different now. No behavior changes tolerate the Miralax. Also, this time he’s on M.O.P., so
at all. things are moving and exiting more, which is much
In retrospect, I believe that although the behavior more comfortable for him than just forced leaking
changes were related to the Miralax, it might not have around a blockage.

Why might PEG 3350 cause psychiatric symptoms in children? The answer, so far, is unknown. It’s unclear
whether the reported neurobehavioral effects are caused by PEG 3350 itself, contaminants in certain
brands, or something else entirely. For example, see the box on this page from a mom whose autistic son
displayed alarming symptoms after taking Miralax at age 3 but tolerated it well when he was older.
Neurological issues aside, one common argument against PEG 3350 is that it has not been approved
by the FDA for use in children. This is true, and in light of this fact, giving PEG 3350 to a child sounds
irresponsible. My own wife was distraught, for this reason, when I gave Miralax to our children. But I
don’t make much of the fact that Miralax isn’t FDA-approved for kids. Nearly 80% of hospitalized children
receive medications that are not approved for children.2 Once the FDA approves a drug for any indicated
use, physicians may legally prescribe the drug for patients in other age groups.
That’s called off-label use, and it’s common practice. PEG 3350 was approved by the FDA for adults in
1999, is available over the counter, and is already taken by children all over the world every day. So, the
manufacturer has no incentive to fund the complex, lengthy, and expensive process required to petition
for the drug’s approval in children. The fact that PEG 3350 is not FDA-approved for children does not
mean it is unsafe for children. Only a small number of drugs have been formally tested in children. Because
PEG 3350 is actually one of them and because thousands of my patients have taken this drug without
incident, I’m inclined to think it’s safe for the relatively short duration of M.O.P.
I certainly welcome all research into the possible neurological side-effects of Miralax in children. In
general, I treat Miralax like any medicine or food: If it causes problems for your child, steer clear.
Alternative osmotic laxatives work well and pose no safety concerns in recommended doses. I never insist
parents give their children Miralax. I think it’s fine if you want to use it. And it’s fine if you don’t.

Stimulant Laxatives: Options, Timing, and Dosing

In my clinical practice, I use stimulant laxatives a lot more than I did earlier in my career.
Ex-Lax and other senna-based laxatives have proven immensely helpful for children
on M.O.P. who have difficulty pooping spontaneously (that is, in addition to after the
enema). As I explain elsewhere, the goal on M.O.P. in the early phases is for kids to poop twice a day.
Otherwise, it’s hard to get ahead of chronic constipation. For many children, keeping poop soft with an
2 Children’s Hospital of Philadelphia. (2007, March 7). “Most Children in U.S. Hospitals Receive Medicines Off-label.”
ScienceDaily. Retrieved from [Link]/releases/2007/03/[Link]

104 | M.O.P. Anthology — 5th Edition

osmotic laxative isn’t enough to achieve a daily SP.
These kids are so accustomed to overriding the One Dad's M.O.P.x Story:
urge to poop that they need the direct stimulation
that senna produces. For many children, stimulant “Really commit to the daily Ex-Lax.”
laxatives make all the difference. “My 9-year-old daughter is now pooping on her
own daily and has been accident-free for several
Ex-Lax not only causes more poop to be
months. We’re off enemas, and she takes just
evacuated but also helps kids consciously act on enough Miralax to keep things soft. I give credit to
the urge to poop. Enemas, on the other hand, daily LGS + daily Ex-Lax.
force a bowel movement pretty much right away,
You’ve got to find the Ex-Lax dose that will reliably
so the child isn’t challenged to recognize the
produce a BM and make ‘em take it every single
urge and find a toilet in a timely manner. Pooping
day. She didn’t like the taste of the chocolate,
once a day after an enema and once a day with a
so we switched to the pills. She complained of
stimulant laxative is a win-win for lots of children. cramping, so we went down to one pill, but lo
Note that children who are particularly clogged and behold — no poop. So, we went back up to
may be more prone to nausea on stimulant two pills. Eventually, the cramping went away
laxatives. You may want to hold off the senna until (or just stopped bothering her), but the pills
your child is more cleaned out. were still producing. It took time, consistency,
Some kids use stimulant laxatives in the beginning experimentation, and commitment, but the process
worked for us.”
of M.O.P. and then, once they have more
frequent SPs, switch to an osmotic laxative.
Other kids don’t start on stimulant laxatives until
they have started tapering from daily enemas, using Ex-Lax on the off-enema days. Some kids take both
osmotic and stimulant laxatives daily. Stimulant laxatives are especially helpful on vacation, when enemas
may be too difficult to maintain.

Senna Options
Senna-based laxatives come in many forms. Chocolate-flavored squares, sold as Ex-Lax or generic
equivalents, are the most popular. As one mom put it, “My kid loves it and begs for ‘chocolate chewies!’”
Another posted: “I think it is genius to put laxative into chocolate.” However, these chocolate squares are
unavailable in many countries, even online. Also, some kids prefer syrup or
gummies, and still others would rather swallow a tablet. Some parents
crush tablets and mix the powder in applesauce.
I suggest asking a local pharmacist for the options available
in your country. A mom in Ireland, whose doctor would not “With Miralax,
support the use of stimulant laxatives, posted: “You’re not
my son kept leaking
supposed to give senna without direction from a doctor,
so I bought Senokot liquid in the pharmacy without saying poop and couldn’t feel it.
who it was for and got the dosage amount off the Internet.” When we changed to Ex-Lax
Sometimes, you have to be resourceful.
plus 1 tsp of fiber, he stopped
Know that stimulant laxatives, while a game changer for
many children, have their downsides. Most notably, these leaking and started feeling
laxatives cause some cramping or discomfort when taken in the urge. Boom!”
the necessary dose. Some kids experience intolerable nausea or
even vomiting. However, when you reduce the dose to the point
where the child feels no discomfort, it probably won’t stimulate a
bowel movement. Some discomfort comes with the territory.

section 6 : A Guide to M.O.P. Supplies | 105

Senna Timing
The perfect time to give a child Ex-Lax can be elusive. The urge to
poop should strike within 5 to 8 hours, but that’s a big range — will
it happen when the child is at home or at band practice? — and can
be hard to plan for. A few timing tips:
• Experiment with stimulant laxatives on weekends rather than
school days. Then, use the information you gathered to set a
school-day schedule, so that the urge kicks in at a time that is
(relatively) convenient.
• Maximize the number of hours between your child’s SP and
enema. If your child does enemas before bed, an ideal schedule
would be to take the stimulant laxative before school and poop Timing stimulant laxatives can
at school, though I know many kids won’t be on board with that! be tricky, so it's a good idea to
Or, if feasible, the child could take the laxative during school experiment on weekends.
(you may need a doctor’s note for younger kids) and poop right Illustration by Mark Beech
after school. Even better: Do an enema before school, followed
by senna in the early afternoon and an SP before bed. I realize that’s not convenient for school days,
but some families use that schedule during school breaks.
• Start by giving stimulant laxatives in the morning, rather than at night. I generally don’t recommend
taking senna before bed. It’s important for the child to be awake when the urge strikes, and hopefully
your child is sleeping more than 5 to 8 hours. Some parents swear by nighttime senna, but others have
reported overnight poop accidents or, more commonly, the child sleeps through the urge and does not
poop in the morning.

Senna Dosing
If your child doesn’t poop within 8 hours, increase the dose. Some
parents will say, “My child poops 15 hours after Ex-Lax,” but if “M.O.P. helped
that’s the case, the bowel movement almost certainly wasn’t us eliminate poop
triggered by the Ex-Lax, and the child needs more. A few
dosing tips: accidents, but our child
never would self-initiate.
• Have your child take the whole dose at once. With
osmotic laxatives, it’s fine to take half in the morning Ex-Lax is helping my
and half at night, but that's not the case with stimulant son feel when he
laxatives.
needs to poop.”
• Don’t be afraid to increase the dose. No parent wants to see
their child uncomfortable, but some cramping may be necessary
for stimulant laxatives to do their job. Many parents dial back the
dosage so much that the child does not feel the urge to poop, rendering
the laxative useless.
• If you can’t find a happy-medium dose, add a fiber supplement to bulk up the poop. For example,
if a dose of 4 chocolate squares doesn’t trigger a bowel movement but 4 1/2 squares results in
explosive diarrhea, try the higher dose while adding fiber.
• Plan for a lot of experimentation. Children who are the same age and have the same constipation
symptoms may need dramatically different doses of stimulant laxatives — for example, anywhere
from 1 Ex-Lax square to 6. I suggest making small adjustments, such as increasing by 1/2 square or
even 1/4 square.

106 | M.O.P. Anthology — 5th Edition

Though you may need to make significant adjustments, following
are common starting points for different forms of senna: “Adding
Chocolate squares (Ex-Lax or generic): Each chocolate square stimulant laxatives —
contains 15 mg of senna. senna pills for my oldest
• Under age 6: Start with 1/2 or 1 square. and Ex-Lax for the younger
two — was the game changer
• Ages 6 to 11: Start with 1 square and increase to
4 squares if needed. for my three kids. Because
it caused bad cramps, we
• Ages 12+: Start with 2 squares and increase up to 6 squares. increased the dose slowly. I’d
Senna tablets: One Ex-Lax tablet contains 25 mg of senna. wait until their bodies got
Unlike the chocolate squares, the tablets are difficult to break used to a dose before
in half, so it’s harder to increase the dose gradually. A child old adding more.”
enough to swallow pills can start with 1 tablet and increase to 3
or 4 tablets if needed.
Senna syrup: One teaspoon (5 ml) contains about 9 mg of senna,
so you might start with 1/2 to 1 teaspoon for younger kids and 2 to 3
teaspoons for older kids.

Pooping With a Footstool

You probably haven’t thought about a toilet stool since
your child was potty training, but children of every age
should use a stool when pooping. (So should adults!) The
stool should be tall enough to place your child in a squat.
Human beings were designed to squat while pooping. Squatting
straightens the rectum, letting poop fall out easily. If you’ve pooped
in the woods, you know what I’m talking about! By contrast, sitting
upright is like trying to poop uphill. With the rectum bent, poop has a
tougher exit route.
Research even shows the squatting position makes pooping more
comfortable and faster. In one study, subjects took 2 minutes and 10
seconds to poop while sitting on a tall toilet, compared to 51 seconds
in a squatting position.3 What’s more, toilets are too tall for children.
With their feet dangling, kids often clench their inner thighs and can’t
relax. Think about it: Do you fully relax your body when you’re sitting on
a barstool without a footrest? No!
In addition, kids on the smaller side should sit on a kid-sized toilet seat,
either a flip-down seat or one that you place on the rim. When kids
sit on an adult-sized toilet, they clench their pelvic floor muscles to
keep from falling in. We can’t see them doing it, and they may not even
know they are doing it, but I assure you, they are!
It's hard to relax the
pooping muscles when
your feet are dangling.
3 Sikirov D. (2003). Comparison of straining during defecation in three positions: From page 21 of
results and implications for human health. Digestive Diseases and Sciences, 48(7), Jane and the Giant Poop.
1201–1205. [Link]

section 6 : A Guide to M.O.P. Supplies | 107

Section 7

Adjuncts to M.O.P.
In my experience, almost all cases of enuresis and/or encopresis can be
resolved with one or another variation of M.O.P. But not every case!
Some children need additional treatment to overcome their accidents for
good. In this section, I discuss an assortment of adjunct therapies, some
more useful than others: oral laxative “clean-outs,” bedwetting alarms,
pelvic floor therapy, bladder medication, and bladder Botox.

109
section 7 : Adjuncts to M.O.P. | 109
Overview of Adjuncts to M.O.P.
Heads up: The therapies included in this section are not created equal! I have grouped
five treatments into one section based on a vague organizing principle: all of them fall
outside of M.O.P. But I don’t want to suggest that I find these treatments similarly valid
or that they are appropriate for all children.
On the “less useful” end, I discuss oral laxative clean-outs,
which help temporarily at best, and bedwetting alarms, which
I find more useful as a gauge of progress on M.O.P. than as The treatments covered in
a remedy for enuresis. In the “more useful” category, I include this section do not directly
pelvic floor therapy and bladder medication. But again, empty the rectum, and in
when I recommend these approaches to families, it’s always
in addition to M.O.P., not as replacements for aggressive my opinion, emptying the
constipation treatment. Among the treatments I cover in rectum is the first and most
this section, bladder Botox is by far the most effective and
important order of business.
reliable for enuresis. I can pretty much guarantee a child will
stop wetting after having Botox injected into their bladder.
However, this is an expensive surgical procedure, not a
treatment I routinely recommend. Keep in mind: The treatments covered in this section do not directly
empty the rectum, and in my opinion, emptying the rectum is the first and most important order of business.

Oral Laxative Clean-Outs

I’ll say it up front: I’m not a fan of oral clean-outs. Often, the
liquid cleanse washes past the impacted mass of stool, so “I’ve come to
the child ends up with diarrhea and constipation. Or, the believe a clean-
treatment just pushes the poop in the colon downstream,
out is like a strict
so the rectum becomes even more clogged. One mom in our
group posted an apt analogy: “I’ve come to believe a clean-out is like diet to lose 5 pounds:
a strict diet to lose 5 pounds: The effects are only temporary. I found The effects are only
that it cleaned my daughter out, but as soon as the cleanse was over,
temporary.”
she started to fill back up.” Another mom, after viewing her daughter’s
x-ray, posted that two months of M.O.P. had barely made a dent in the
stool pile-up. She wrote: “If enemas aren’t even doing the trick, it makes me
realize how inadequate our oral clean-outs were.”
“I think oral
Often, clean-outs may accomplish nothing besides ruining a kid’s
weekend. “Oral clean-outs gave my daughter messy accidents and clean-outs are
painful rashes,” one mom posted. Countless families have told me they’ve helpful, but not as
gone through with oral clean-outs simply to placate their anti-enema a way to avoid
GI doctors. One mom posted that her child had done three fruitless oral
clean-outs in one month. “I was being nice with the GI. I’m not totally M.O.P.”
surprised but had wishful thinking.” She went back to M.O.P. after that.
Still, some families report that occasional clean-outs, in conjunction with
M.O.P., have resulted in breakthroughs after their child stalled out on M.O.P. “Only
when we added in periodic clean-outs to M.O.P. did we see progress,” one mom posted. “I think they’re
helpful, but not as a way to avoid M.O.P.”

110 | M.O.P. Anthology — 5th Edition

My general philosophy is, Hey, whatever works. So, for those who wish to try oral clean-outs, I am
including instructions here. You may want to have your child administer an enema right before an oral
clean-out to unplug things and help empty more effectively. However, don’t administer daily enemas
during the clean-out period. You can use PEG 3350 or magnesium citrate for clean-outs. I suggest starting
on a Friday night, so you have the entire weekend to complete the process. Restart enemas once the
clean-out is done.

PEG 3350 Clean-Out

• Dosing recommendations: Give your child at least the amount of laxative listed for their weight. You
may need to give more. One dose means the cap of PEG 3350 is filled to the line. I recommend mixing
the powder with Gatorade or Pedialyte because they contain electrolytes, which will help prevent
dehydration. Plus, these beverages taste good, so kids may be more motivated to drink the full dose.
– Under 45 pounds: Mix 7 doses of PEG 3350 in 32 ounces of Gatorade, Pedialyte, or other clear,
noncarbonated liquid.
– 45 to 80 pounds: Mix 10 doses in 48 ounces of liquid.
– Over 80 pounds: Mix 14 doses of PEG 3350 in 64 ounces of liquid.
• Have your child drink the entire bottle over 24 hours. The child can eat anything but should drink
only this fluid.
• You’re shooting for watery poop. Your child should pass five or six stools within 24 to 48 hours.

Magnesium Citrate Clean-Out

I have no experience using magnesium citrate for oral clean-outs and cannot vouch for any of the
protocols listed below. I do not prescribe them to my patients. However, some members of our support
groups have used magnesium citrate for clean-outs, in both the liquid and powder forms. The doses used
in these protocols vary greatly, and I have no basis for recommending one over another.
Liquid magnesium citrate clean-out
The cherry flavor seems to be most popular, and some families mix the solution with Gatorade or Sprite.
Here are three different protocols parents have tried:
• Use 1 ounce of magnesium citrate for every 10 pounds the child weighs. Drink the dose in the
evening, followed by the same dose 12 hours later.
• Drink 2 ounces of magnesium citrate every 2 hours until the child (of any age) has ingested
10 to 12 ounces.
• For children ages 6 to 11, drink 3 to 5 ounces at once. Children 12+ drink 5 to 10 ounces at once.
Powder magnesium citrate clean-out
The following clean-out protocol is excerpted, with permission, from the Parents Against Miralax Facebook
group. The protocol is intended for use with either Natural Vitality CALM powder (unflavored) for adults
or pure magnesium citrate. You start in the morning and continue with the dosing every 2 waking hours
until the child’s stool is watery/yellow.
Mix the age-appropriate powder dose with boiling water. Stir the fizz out. Cool, and mix with organic juice.
Recommended doses:
• Ages 2-3: Start with 1 tsp (165 mg of mag citrate). Repeat with 1/2 tsp (80 mg) every 2 hours.
• Ages 3-5: Start with 2 tsp (325 of mag citrate). Repeat with 1 tsp (165 mg) every 2 hours.
• Ages 5+: Start with 1 Tbsp (490 mg of mag citrate). Repeat with 1 Tbsp every 3 hours.

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Bedwetting Alarms
A while back, a mom in our support group described her
7-year-old’s slow progress with bedwetting. After 6 weeks on
M.O.P., the boy had no spontaneous poops and one dry night,
his first ever. Over the next 6 weeks, after switching from magnesium
citrate to Ex-Lax, he started having daily spontaneous poops but still, no
dry nights. The following month, he added periodic overnight oil enemas,
pooped noticeably more, and had two dry nights. A bedwetting alarm can
Now, most families would be discouraged by these results. They might offer insight into your
say: Four months of enemas and just three dry nights? Waste of time! child's progress on M.O.P.
But this mom was not so quick to declare disaster. Instead, she purchased Illustration by Mark Beech
a bedwetting alarm, not because she hoped the alarm was a ticket to
dryness but as a way to evaluate the timing of her son’s accidents. “After 3 nights on the bedwetting
alarm,” she posted, “we’re thrilled to discover that he’s not urinating until about 6 a.m. — right before he
wakes up. So, he’s able to hold it for 8-9 hours. We’ve
made a lot more progress than we realized!”
This is a terrific example of how bedwetting alarms can
Preventing wet sheets isn’t be helpful: as a tool to monitor your child’s progress on
M.O.P. rather than a replacement for enemas.
the same thing as resolving an
A bedwetting alarm includes a urine sensor that can
overactive bladder. Cleaning
either be placed in the child’s underwear or on the
out and healing the rectum is bottom bed sheet. The sensor is attached to an alarm
a better way to permanently that clips to the child’s shirt and rings when the sensor
gets wet. Though it seems counterintuitive to wake the
resolve enuresis. child after the fact, eventually this process primes kids to
wake up before they wet the bed.
Now, in some cases, an alarm on its own can resolve
wet sheets. I’m certainly in favor of dry sheets, and if that works for some families — excellent. However,
preventing wet sheets isn’t the same thing as resolving an overactive bladder. Cleaning out and healing
the rectum is a better way to permanently resolve enuresis. Children with a healthy rectum and stable
bladder don’t need to wake up to pee overnight. They enjoy dry nights and a full night’s sleep.
Alarms are popular because, unlike medication, they can be bought without a prescription and have no
side-effects, other than parental grouchiness from having your sleep interrupted every night for weeks.
But that is no small consideration. Often, the child does not wake up when the alarm sounds, which means
a parent has to wake up the child and turn off the alarm, escort the child to the bathroom, help with a
change of clothes, place the alarm back on, and return to bed. Most families abandon ship before the three
months it takes for the alarm to fully work, if that even happens. In general, I think a family’s time and
energy is better spent on M.O.P. than on trying to resolve enuresis with an alarm.

Bladder Medication
Not long ago my “bedwetting” Google Alert sent me a press release titled, “SSRI Helps
Hard-to-Treat Bedwetting"1 SSRIs are antidepressant drugs, and in this study, the drug
trialed was Prozac. Can Prozac actually help resolve difficult cases of bedwetting?
1 [Link]

112 | M.O.P. Anthology — 5th Edition

Um, no. The press release put a ridiculously positive spin on a Journal of
Urology study that tested Prozac in children with “refractory” bedwetting
— in other words, cases that were resistant to other treatments. How did
these kids fare? After 12 weeks on Prozac, bedwetting stopped in 10.7%
of cases. Another 21% of kids found partial relief. Yet the study’s authors,
from Egypt, concluded Prozac “could be considered as a reasonable
treatment” for difficult cases.2
Nonsense. Prozac will never be a solution to bedwetting, because
bedwetting is caused by chronic constipation, not a brain chemistry
imbalance. Likewise, DDAVP, the most commonly prescribed bedwetting The newer enuresis drugs
drug, will never be a panacea because DDAVP, too, addresses an enuresis have fewer side-effects
“cause” (urine overproduction) that does not exist. than the older drugs and
can help some kids.
By the time patients are referred to me, most have been placed on at
Illustration by Mark Beech
least one medication for bedwetting. If drugs worked well, these kids
wouldn’t have landed in my clinic! Enuresis medications, alone, have
dismal success rates, and yet drugs are considered a “first-line” treatment for enuresis. For decades,
my profession has been on a never-ending search for an
effective bedwetting drug. In fact, the Egyptian scientists
note that they turned to Prozac because DDAVP has a poor
success rate. These authors asserted we must then search
For decades, my profession
“for novel and more efficient therapies.”
has been on a never-ending
But this focus on drugs is misplaced. “Novel” treatments
search for an effective aren’t needed. “Efficient” treatment for enuresis already
bedwetting drug. exists, even for the most difficult cases. When a child is
declared “refractory to treatment,” this signals to me the
child has not been treated appropriately.
The Prozac scientists seem convinced there’s a significant
group of bedwetting children who are not constipated — the “hard-to-treat” cases. In fact, the scientists
deliberately excluded constipated children from their experiment. But the study has a fatal flaw: the
children were never tested for constipation using x-ray or anorectal manometry. The parents were simply
asked about the children’s pooping history. Chances are, the “not constipated” kids in their study were
actually quite clogged. From my perspective, those “hard-
to-treat” enuresis patients weren’t treated properly in the
first place, so they only appeared resistant to treatment.
Giving kids with enuresis Prozac is like throwing darts Rather than scour the
in the dark. Rather than scour the universe for drugs
universe for drugs that might
that might randomly cure a few kids, we should focus on
refining treatments that tackle the condition’s root cause. randomly cure a few kids,
Nonetheless, I do prescribe enuresis drugs to some of my we should focus on refining
patients. Sometimes, it’s as a stop-gap measure, to keep
treatments that tackle the
kids dry for a sleepaway camp or class trip. In other cases,
it’s when kids have made strides in their constipation condition’s root cause.
treatment, and medication can help in the home stretch.
The newer enuresis drugs have fewer side-effects than
the older drugs and can help some kids. I’m in favor of

2 Mohamed Hussiny, Abdelwahab Hashem, et al., The Safety and Efficacy of Fluoxetine for the Treatment of Refractory Primary
Monosymptomatic Nocturnal Enuresis in Children: A Randomized Placebo-Controlled Trial, Journal of Urology, 1 Nov 2022
[Link]

section 7 : Adjuncts to M.O.P. | 113

helping kids! I think there can be a role for medication, especially when all of the following are true:
• The child has been on M.O.P. for several months and has experienced a reduction in nighttime
wetting but can’t quite get over the hump.
• An abdominal x-ray shows the child’s rectum is empty, or nearly so, but the rectum remains stretched.
• The child is feeling really down and could use a psychological boost from additional dry nights.
Would I recommend medication for a 7-year-old who just started on M.O.P.? No. Would I prescribe a
bedwetting drug to a 15-year-old who has been on M.O.P. for 6 months, is still wetting a couple nights
a week despite an improved x-ray, and is feeling distressed and discouraged? Yes. Following is a brief
rundown of the three categories of bedwetting medications. Overall, they’re not much more effective
than a placebo, but it’s hit and miss with an individual child. You can experiment with one or more of
these medications. Sometimes, a combination is helpful.

DDAVP (Desmopressin)
One day in my clinic I saw a teenage patient
who’d never had a dry night despite two years on Desmopressin can give
desmopressin. His mom asked, “Do you think he
should stay on the medication?” kids a psychological boost,
Only about 30% of patients who take DDAVP achieve and I’m all for that. But I
dryness for 14 days straight, and even among those do make sure my patients
kids, 60% to 70% have a recurrence of accidents understand the drug’s limits.
when they stop taking the drug. So overall, fewer
than 20% of kids achieve any kind of “sustained”
dryness. I am amazed at my profession’s enthusiasm
for such an ineffective drug. In one article, a team of urologists advised that since desmopressin is
effective only on the night it’s taken, “it must be taken on a daily basis.” In other words: If the drug isn’t
working, keep taking it!
DDAVP mimics antidiuretic hormone (ADH), the hormone that regulates fluid levels. Taken as a pill or
nasal spray, the drug essentially fools the kidneys into producing less urine at night. But since children
with enuresis don’t have abnormal hormone levels, there’s no real rationale for taking this drug indefinitely.
Though desmopressin is generally safe, the idea of altering the hormones that control urine output in
children doesn’t sit well with me. If a child is producing plenty of urine at night and is otherwise healthy,
there is probably a good reason the child’s body is producing that pee. We all need to get rid of fluid to
maintain our body’s fluid and electrolyte balance, so why mess with that? Especially since desmopressin
doesn’t tackle constipation.
Desmopressin can give kids a psychological boost, and I’m all for that. But I do make sure my patients
understand the drug’s limits. One mom reported that her teenage son chose to stop the drug because he
wasn’t satisfied with the “fake dry.” He felt he could only gauge progress on his enema/laxative program
without drug-aided dryness. Other kids prefer to keep taking DDAVP while on M.O.P. and then skip a
few nights every once in a while to see how their bladder is doing on its own. Both are valid choices.
Desmopressin, by the way, is taken only for bedwetting, not daytime wetting.

Anticholinergics
Anticholinergics are designed to calm bladder overactivity by blocking the signal from the colon to the
bladder and can be used to control both overnight and daytime wetting. I have found these drugs more
effective in children with daytime-only enuresis than with nighttime-only wetting or both presentations,
but I will prescribe them for both.

114 | M.O.P. Anthology — 5th Edition

First-generation anticholinergics, such as Oxybutynin, work fairly well, but one of the common side-
effects of this drug is ... constipation! So, you can see why I am hesitant to prescribe it. Other side-effects
include dry mouth, facial flushing, and blurry vision.
The easiest way to test this medication is to purchase the Oxytrol patch over the counter. These patches
are made for adults with overactive bladders. If your child is the size of an adult, use a whole patch. For
smaller children, cut the patch in half. You apply the patch to an area of clean, dry skin on the child’s
abdomen, hips, or bottom. Or, a doctor can prescribe Oxybutynin in a liquid, gel, or pill form. I prefer the
newer anticholinergics, such as Toviaz and Vesicare, which have fewer side-effects. But they only come in
pill form and are expensive.

Beta-Agonists
Like anticholinergics, beta-agonists such as mirabegron are designed to calm the bladder, though they
work somewhat differently. And beta-agonists, too, can be used for both daytime and nighttime enuresis.
As with anticholinergics, I’m apt to prescribe beta-agonists sooner for children with daytime-only wetting.
Beta-agonists are sold in pill form only and are expensive. In the United States, insurance companies won’t
cover these drugs until a child has failed on both desmopressin and anticholinergics.
An in-depth discussion of bladder medications is beyond the scope of this book, but I do want families
to be aware of them. I feel strongly that resolving the constipation that underlies enuresis is critical.
I understand the appeal of medication: Writing a prescription is easy for a doctor and can reassure
distressed parents something is being done. But bedwetting is not a condition, like type 1 diabetes, that
needs to be controlled with daily medication, and my goal is to minimize the amount of time a child
would take these drugs.

Pelvic Floor Therapy

If you’ve ever torn a hamstring tendon or blown out a
knee, you know physical therapy (PT) is an important
part of the recovery process. If you have a child
with sensory processing disorders or developmental
struggles, you may have visited an occupational
therapist (OT). PTs and OTs use biofeedback to evaluate
a child’s ability to relax and contract their pelvic floor
muscles at the appropriate time. But did you know Pelvic floor therapists use a tool
physical and occupational therapy can also help children called “surface biofeedback” to
who have toileting difficulties? evaluate a child’s ability to relax
In many children with chronic constipation, the muscles that control and contract their pelvic floor
peeing and pooping, known as the “pelvic floor” muscles, don’t work muscles at the appropriate time.
as they’re supposed to. The specialists trained to help children regain coordination in these muscles are
called pediatric pelvic floor therapists (PPFT). These experts have much to offer children who are working
to overcome chronic constipation.
Pelvic floor therapists treat children with a variety of symptoms, including daytime and/or nighttime
pee accidents, poop accidents, recurrent UTIs, urinary urgency and frequency, urinary retention, and
vesicoureteral reflux, a condition I mention in Section 2. Both physical and occupational therapists can
work with these kids if they have had specific training in pelvic floor therapy for children.
How exactly does pelvic floor PT or OT fit in with M.O.P.? Well, fully evacuating the rectum requires five
things: 1.) a powerful colon and rectal contraction, 2.) soft poop, 3.) relaxed pooping muscles, 4.) normal

section 7 : Adjuncts to M.O.P. | 115

function of the ribcage and breathing muscles, and 5.) good
core (abdominal muscle) control. M.O.P. helps with the first “At 9, my
two. Pelvic floor therapy targets the other three. daughter did PT
Below, I have invited Dawn Sandalcidi PT, RCMT, BCB- for 4 months, as we were
PMD, a trailblazer in the field of pediatric pelvic floor transitioning from enemas to
disorders, to explain how pelvic floor therapy can help
laxatives alone. With electrodes
children on M.O.P. “Our goal is to give children a
sense of control and confidence while they work placed near the anus, we could see that
toward resolving their conditions,” says Dawn, who when she thought she was relaxing, she
lectures internationally and hosts our Zoom course was actually tightening. She practiced
for health professionals. To find a qualified pelvic the same exercises at home and learned
floor therapist for your child, go to [Link] to use her pelvic muscles correctly.
[Link]/find-a-provider or get She has been accident-free for over
a referral from your pediatrician, pediatric urologist,
a year, and physical therapy
pediatric GI, or the PT/OT department at a local
children’s hospital. was the last piece we
needed.”
Among children with chronic constipation, what
Q: exactly goes wrong with the toileting muscles?
Instead of relaxing their pelvic muscles when they poop, or “opening the poop door,” many
A: children tense up and close the door, an understandable response given their history of large,
painful bowel movements. Some kids keep their pelvic floor muscles tightened all day. Other
children not only contract these muscles when they should be relaxed but also relax these muscles
when they should be contracted. Eventually, all the holding inhibits the natural reflex to pee or
poop, and kids may not even feel the urge. (A stretched rectum also compromises the child’s
ability to sense the urge.) What’s more, tired and weak pelvic floor muscles make pee and poop
leaks more likely to happen with activities such as running or jumping.

Q: How do pediatric pelvic floor therapists pinpoint where the trouble lies?

PTs and OTs use a tool called “surface biofeedback” to evaluate a child’s ability to relax and
A: contract their pelvic floor muscles at the appropriate times. The therapist places small sensors
(“stickers”) on either side of the child’s anus and teaches the child how to feel the muscles and
how to squeeze or relax. Viewing a computer screen with customized images — hot air balloons,
butterflies, and spaceships that move up and down when the muscle works correctly — children
and parents are able to see how much these muscles are squeezing and relaxing. Biofeedback also
helps children understand what it feels like to contract and relax the pelvic floor muscles, so they
can do exercises at home.

Q: After the evaluation, what does pediatric pelvic floor therapy involve?

Treatment typically involves 8 to 12 visits over several months. Therapists customize treatment
A: based on the initial evaluation and any treatment plan the doctor has prescribed. Visits include
exercises and games to help the child’s pelvic floor muscles work correctly and in harmony with
each other. Therapists remain in contact with the doctor throughout treatment.

What other services do pediatric pelvic floor therapists offer children, besides helping them retrain
Q: their toileting muscles?

116 | M.O.P. Anthology — 5th Edition

 We educate families on several fronts, including:
A:
• Proper toilet posture and breathing for complete bowel and bladder emptying
• Sensory training to respond appropriately to the urges to pee and poop
• Strategies for the school setting and dealing with social challenges related to leakage
• Setting a toileting schedule
• Proper hygiene techniques
• Exercises to do at home
“The therapist
How do you deal with kids who are embarrassed said my daughter’s
Q: to come for pelvic floor therapy?
pooping muscles were
Therapists who enter this field are adept at
A: developing a rapport with kids and helping them
constantly tensed. Belly
feel comfortable. We respect children’s privacy breathing helps make her
and fears and aim to meet them where they more aware of those muscles
are. Parents are often surprised that their kids and take back active
actually want to come back to therapy!
control of them.”

Bladder Botox
Injecting Botox into a child’s bladder wall is the very definition of a “quick fix” for
enuresis. The procedure takes 15 minutes and often halts accidents within a week. Kids
stay dry for months, for years — sometimes forever. And yet, I consider this procedure a last resort, not
a first-line treatment. Why? For starters, it’s expensive, and insurance won’t cover the surgery until all
other remedies have been exhausted. But the cost isn’t the main reason I reserve bladder Botox for a small
number of cases.
It’s clear to me that emptying a child’s rectum is the ticket
to resolving enuresis for good. Calming an overactive
bladder requires shrinking the enlarged rectum that’s
triggering the overactivity. To me, that’s obvious. If bowel
emptying didn’t matter, bladder medications alone would
have a strong track record. But they fare poorly, because
if you don’t treat the underlying constipation, there’s
just too much force on the bladder nerves. Bladder meds
have the best chance of working when a child is also
maintaining an aggressive bowel-emptying program. I have
many patients on M.O.P. who also take medication. Even
though the meds achieve a “fake dry,” in the words of one
mom, dry is dry, and for a teenager, that means everything.
These kids keep plugging away at M.O.P., and at some
point, they are able to drop the medication and remain dry.
The “fake dry” becomes real.
But that plan doesn’t work out for every single kid, and
some teens, understandably, just don't want to wait any Bladder Botox is the very definition
longer. So, for these cases, I have increasingly turned to of a "quick fix" for enuresis.
injecting Botox into the bladder. Yes, this is the same

section 7 : Adjuncts to M.O.P. | 117

drug, botulinum neurotoxin, that cosmetic dermatologists use to temporarily minimize frown lines and
crow’s feet. Botox also is used to control migraines, neck spasms, and excessive sweating, among other
conditions. The drug temporarily weakens or paralyzes certain muscles by blocking the nerve signals that
cause these muscles to contract.
For enuresis patients, we insert a scope into the bladder and inject Botox into multiple locations, to
evenly disperse the drug. The child is under general anesthesia, and the aftermath is pain-free. The most
common side effect is blood in the urine for a few days after surgery, but that’s not dangerous. One fear
among parents is that after the Botox injection, their child won’t be able to pee at all. They imagine a
frozen bladder like a celebrity’s frozen forehead! But I’ve never had that happen. Experienced surgeons
know how much Botox to use. Besides, you are injecting Botox into a bladder that is already overactive.
In my bladder Botox patients with spina bifida (kids who will always have trouble pooping), I typically
repeat the procedure annually, whereas my patients without neurological impairment usually don’t need
a second surgery. By the time the Botox has worn off, between three months and one year, the child’s
bladder has recovered, thanks to M.O.P. However, the maximum recommended Botox dose isn't enough
for some kids, in which case I need to repeat the procedure, and the second procedure does the trick.
How well does Botox work? In my clinic, we analyzed all our Botox cases over a 10-year period, excluding
children with neurological impairment. The group of 50 patients included 23 girls and 27 boys, average
age 11. Nine months after surgery, 94% were either completely dry (29 kids) or having fewer accidents (18
kids).3 Among the children whose enuresis had improved but not resolved at the 9-month mark, several
had achieved total dryness after surgery but resumed having accidents when the Botox wore off. Those
are cases where a second Botox surgery usually halts enuresis permanently.
On the rare occasions that Botox doesn't last,
it’s always for the same reason: the child remains
constipated, as demonstrated via x-ray. The
enlarged rectum continues to place so much My experience with bladder Botox
force on the bladder nerves that even this provides additional evidence that
powerful, nerve-blocking drug can’t counteract
it for long. My enuresis patients who fare best enuresis is caused by constipation,
with Botox are those who’ve worked hard to not deep sleep, an underdeveloped
empty their rectum and have gotten close to bladder, anxiety, or urine
dryness but need help to finish the job. This
pattern reinforces my opinion that an aggressive overproduction. If those conditions
bowel-emptying regimen is the key to resolving caused wetting, Botox would not
enuresis. Getting to the root of the problem
stop accidents. But it does.
remains more effective than covering it up.
Interestingly, some of my patients report they are
able to poop more easily after a Botox injection.
I suspect these patients had developed an especially strong tendency to override the urge to poop, and
once they didn’t have to worry about accidents, they became more relaxed about pooping. I don’t know —
that’s just a guess. But I’ve heard it enough times to believe it’s worth mentioning.
My experience with bladder Botox provides additional evidence that enuresis is caused by constipation,
not deep sleep, an underdeveloped bladder, anxiety, or urine overproduction. If those conditions caused
wetting, Botox would not stop accidents. But it does.

3 Overholt, T. et al., OnabotulinumA toxin injections were effective and safe for symptom improvement in children with
refractory nocturnal enuresis. Presented at the Society of Women in Urology National Annual Meeting in Scottsdale, Arizona,
January 2023.

118 | M.O.P. Anthology — 5th Edition

Section 8

Tracking Your
Child’s Progress
It is important to evaluate your child’s progress on M.O.P. every
30 days. This way, you know when to stay the course and when to
adjust the regimen. Taking a minute each day to note the basics
can save you months in the long run! This section includes tips
and charts to help you and your child create an accurate picture
of what’s happening on M.O.P.

30-Day
Tracker
hart
DAY/DATE: _____

Tracking C
___________

____
DAY/DATE: _____

WEEK ______
Enema:  _____________________ ___________
DAY/DATE: _____
Enema: ______ poop shape here.

Weekly
___________
Osmo: ______
Stim: _______
_______________ DAY/DATE: _____ Draw your own
Enema: ______
____________
___________
Osmo: ______ _______________ Enema/L DAY/DATE: _____
SP: ________
 __________ SP: ______ Stim: _______ Osmo: ______ Stim: ______ Minutes held: GS:  Type: ______ ____________
__

___________
____________
______
__
____

_______
__________

NOTES:_____
__

 _____________________Y
__________

Enema:
____
________

__  __________  _______________
____________
__________

_
__________

Previous Night: Dry

__________

 Wet 
________

SP: ________
____________

Osmo: ______ MONDA

__________
__________

 __________ Osmo. lax.:  ________________

__________
____

SP £ ________

Previous Night: Dry

__________


__________

Stim: _______
______

Wet 
____

Daytime Accidents:
____

 __________ Daytime Acciden

____________
__________
__________

1
Previous Night: Dry
______

Stim. lax.:  _____

____

 Wet  SP: ________

__________
______

_____
__

 __________ Daytime Acciden  ______

____

_____

2
Notes: __________ ts:
SP £ ________

______________ __ ____
SP:  _____ ST POO P:
SP £ ________

ts:  __________
1Wet 
____________
____
____________

3
Notes: __________ ______________ Previous Night: Dry
______________
SP £ ________

____________
____
____________

____________

Notes: __________ Overnig

4
SP £ ________

ht: Dry  Wet

____________
____________
____________

______________ 
____________

DAY/DATE: _____ Daytime Accidents:

____________

 __________
____________

____________

5
____________

Daytime Accidents:
____________

___________
____________

 _____
____________

DAY/
____________

DATE: __________ ______ Notes: __________ poop shape here.

____________

 _____________________
____________

Enema:
£

______ DAY/ ______________ Draw your own

SP
____

2ND POOP:
Enema: ______ DATE: __________
____________

____________
SP

______
MORE NOTES:

Osmo: ______ Stim: _______ _______________ Enema/L DAY/DATE: _____

____________
MORE NOTES:

GS:  Type: ______ ___________

Osmo: ______ _______ DAY/ ____________
MORE NOTES:

 _____________________ Enema/LDATE
____

SP: ________
 __________ SP: ______ Stim: _______ Minutes held:  _______________
: _______________
NOTES:_____
____
____________

Enema:
MORE NOTES:

_
____ ________
____________

GS:  Type: ______ TUESDAY

___ ________
MORE NOTES:

____ ________

__  __________ Osmo. lax.:  _____

____
____________

Osmo: ______
___ ________

_______
MORE NOTES:

Previous Night: Dry

 Wet 
____

Stim: _______ Minutes held:

____ ________
____

___________
____
____
___ ________
MORE NOTES:

_______ ____

 _______________
____ ________

Previous Night: Dry

____

Stim.
 __________ Daytime Acciden  Wet 
____

Daytime Accidents: lax.:  _________________ SP: ________

____ ________

 __________ Osmo. lax.:  _______________

____

6
____

ST POOP:
____ ________

1
____

SP:  _____
____

ts:  __________

7
Notes: __________ ______________ Previous Night: Dry _
 Wet  Stim. lax.:  _____
____

______________ ____________

8
Overnig
____________
____

Notes: __________ ht: Dry  Wet

____

______________  SP:  _____

____

Daytime Accidents:
____
_______ ____

 __________ Overnig
9
Daytime Accidents: ______________
poop shape here.
____________

DAY/DATE: _____  _____

10
______ Notes: __________ ht: Dry  Wet Draw your own
____________

____

___________ ______________  2ND POOP:

____________

DAY/
____________
____________
____

____
___________

DATE: __________
dry £ wet £
____________

Enema:  _____________________ Daytime Acciden

____________
____________
____

______ DAY/
___________

ts:  __________
dry £ wet £
____________

DATE: __________
____________
esis: ________
____________
____________

Enema: ______ _
dry £ wet £

____

Osmo: ______ ______ DAY/

NOTES:_____
____________

_______________
____________

DATE: __________
is: ____________
£

Stim: _______ Enema: ______

____________

______ NESDAY
____________

Osmo: ______ _______________ Enema/L DAY/DATE: _____ WED

____________

wet

SP: ________
 __________ SP: ______ Stim: _______ Osmo: ______ Stim: ______ Minutes held:
____________

GS:  Type: ______

dry £ wet £

__________
presis: ________

_
wet

_______
dry £ wet £

 __________ SP: ______ _  _______________  _____________________

Enema:
presis: ________

__
£

Previous Night: Dry

esis: ________

 Wet  ST POOP:
presis: ________
dry £

__  __________ Osmo. lax.:  _____

ACCIDENTS: a.m.
enuresis: ____

 ______ Stim: ______1

ime enuresis:

Previous Night: Dry Osmo:

dry

____

 __________ Daytime Acciden  Wet  ___________

ACCIDENTS: a.m.
enuresis: ____

Daytime Accidents:

11
ime enuresis:

Notes: ________

Previous Night: Dry _

ACCIDENTS: a.m.

 Wet  Stim. lax.:

ime enuresis:

SP: ________
Daytime enur

 _________________

12
Notes: ________
____

ts:  __________  __________

ACCIDENTS: a.m.

Notes: __________
Notes: ________

______________
____
Encopresis: ____
ACCIDENTS: a.m.

Daytime Accidents: SP:  _____

13
 __________ Overnig poop shape here.
Notes: ________

Notes: __________ ______________

Encopresis: ____

Previous Night: Dry

ACCIDENTS: a.m.

______________  Wet  ND POOP: Draw your own

Notes: ________

14
____

____ Encopres
ACCIDENTS: a.m.

Notes: __________ ht: Dry  Wet

 _____ 2 ____________
____ Notes:

DAY/DATE: _____ ______________ 

____________
Daytime Accidents:

15
s:

Enco

___________ Daytime Accidents:

____________
enur

DAY/  _____ _____

Note

DATE: __________ ______

NOTES:_____
Dayt

 _____________________
is:

Enema: ______ DAY/ Notes: __________

________ Enco
ime

______________
Dayt

DATE: __________
Enema: ______ THURSDAY
________ Enco
ime
Encopres

______
Dayt

Osmo: ______ _______________ Enema/L DAY/DATE: _____

ime

Stim: _______
Dayt

GS:  Type: ______ ___________

____

Osmo: ______ DAY/

___

_______
Dayt

SP: ________
 __________ SP: ______ Stim: _______ Minutes held:  _______________  _____________________ Enema/LDATE : _______________
____________

Enema:
___
Dayt

_
____________

P:
___

 ______ Stim: _______ Minutes held: Type: _____________ 1 POO

GS: ST
____
____________

 __________ Osmo. lax.:  ________________

____________
________

__
___

Previous Night: Dry Osmo:

____________

 Wet 
____________
____________

: ____________
___

 _______________
____________
____________

Previous Night: Dry

o £ Stim. £
____________

Stim.
 __________ Daytime Acciden  Wet 
___

lax.:  __________ SP: ________

____________

Daytime Accidents:
________

16
____________

 __________ Osmo. lax.:  ________________

o £ Stim. £
____________

_______
___________

____________

poop shape here.

Stim. £

SP:  _____

17
ts:  __________ Draw your own
____________

Notes: __________ ______________ Previous Night: Dry

Stim. £

______________  Wet  Stim. lax.:  _____ ND POOP:

dose: ________

____________
18
____________ 2
.£

Notes: __________ Overnig ht: Dry  Wet

dose: ________

. type/dose: ____

______________  ____________
.£

Daytime Accidents: SP:  _____

____________

19 ____________
 __________ Overnig ______________
o £ Stim. £

Daytime Accidents:
S: Osmo £ Stim

NOTES:_____
____

DAY/DATE: _____  _____

20
S: Osmo £ Stim

______ Notes: __________

____

ht: Dry  Wet

TIVES: Osmo £

___________
____
o. type/dose:

______________ 
LAXATIVES: Osm

DAY/ FRIDAY
____________

DATE: __________
TIVES: Osmo £
. type/dose: ____

o. type/dose:

 _____________________
LAXATIVES: Osm

Enema: ______ DAY/ Daytime Accidents:

____________

____
. type/dose: ____

 ___________
dose
o. type/dose:

DATE: __________
____

Enema: ______
____________

____
. type/dose: ____

o. type/dose:

____

______ DAY/
Osmo:  ______ Stim: _______ _______________ DATE: __________
o. type/dose:

Enema: ______
1ST POOP:
______
 ________  __________ Osmo: ______ Stim: _______ Osmo: ______
DAY/DATE: _____
o. type/dose:

____

_______________ Enema/L
type/

SP: GS:  Type: ______ ___________

:

____

_ Stim. type/
Osm
dose

_______
s:

 __________ SP: ______ Stim: _______ Minutes held:  _______________

_ Stim. type/

SP: ________ Enema: _____________________

____ Notes:

____ Note
_____ Stim

Previous Night: Dry

Osm

 Wet 
____ Notes:

.
TIVE

_____ Stim

__  __________ Osmo. lax.:  _____

_______ Osm

Osmo: ______ poop shape here.

o. type/
S:

____ Notes:

Previous Night: Dry

LAXA
TIVE

 __________ Daytime Acciden  Wet  ___________ Stim: _______ Draw your own
_______ Osm

21
Daytime Accidents:
____ Notes:

2ND POOP:
LAXA
TIVE

Previous Night: Dry

____________
_______ Osm

 Wet  Stim.
____ Notes:

lax.:  _________________ SP: ________

22
LAXA

_____ Stim

ts:  __________  __________ ____________

_______ Osm
––––––––––––

Notes: __________
____ Notes:

LAXA

____________
_____ Stim

______________
___
_______ Osm

23
SP:  _____
__

Daytime Accidents:
 __________ Overnig
__ LAXA

NOTES:_____
Notes: __________ ______________
_____ Stim

Previous Night: Dry

_______ Osm

__

______________  Wet 
24
____

SATURDAY
__

Notes: __________ ht: Dry  Wet

____
____________


____

____________

DAY/DATE: _____ ______________

25
__

Daytime Accidents:
 __________
____________

____

____________

____________

___________ Daytime Accidents:

______

DAY/  _____
____________

____________
____

DATE: __________
Min. held: ____

______
______

Enema:  _____________________ Notes: __________

____________

______ DAY/
____________

______________
Min. held: ____

DATE: __________
1ST POOP:
____________
____

Enema: ______
Min. held: ____

______
____________

 ______ Stim: _______ _______________ Enema/L DAY/DATE: _____

____________

Osmo:
held: ________

____

Min. held: ____

GS:  Type: ______

____________

___________
____________

____________

Min. held: ____

Osmo: ______ _______ DAY/DATE: _____

____________

SP: ________
 __________ SP: ______ Stim: _______ Minutes held:  _______________
____________

 _____________________ Enema/LGS:
____
Min. held: ____

Enema: ___________
____________

____

poop shape here.

 ______ Stim: _______ Minutes held: Type: _____________
____________

__  __________ Osmo. lax.:  _____

____

Draw your own

Notes: ________

Previous Night: Dry Osmo:

 Wet  ___________
2ND POOP:
____

____

Notes: ________

____

Previous Night: Dry Stim. lax.:  _____  _______________ ____________

____

 __________ Daytime Acciden  Wet  ____________

Week of: –––––––––

Notes: ________

Oil £ ________

SP: ________

26
Daytime Accidents: ____________  __________ Osmo. lax.:  ________________ ____________
Type/dose:__
____
Notes: ________

ENEMA/LGS:

NOTES:_____
27
SP:  _____
e:__
Notes: ________

____

ENEMA/LGS:

ts:  __________
____

Notes: __________ ______________ Previous Night: Dry

Type/dose:__

______________  Wet  Stim.

Oil £ ________
Notes: ________

lax.:
ENEMA/LGS:

28
_____
Overnig ____________ SUNDAY
Type/dose:__
Min.

Notes: __________ ht: Dry  Wet

Notes: ________

Oil £ ________

ENEMA/LGS:

Oil £ ____

______________ 
/dos
Type/dose:__

SP:  _____

29
Daytime Accidents:
Oil £ ________

ENEMA/LGS:

 __________ Overnig
Oil £ ____

Daytime Accidents: ______________

Type/dose:__

Oil £
ENEMA/LGS:

124 | M.O  _____

30
Type/dose:__

.P. Antholog ______ Notes: __________ ht: Dry  Wet

GS:


Type

1ST POOP:
y — 5th Edition ______________
Daytime Accidents:
ENEMA/L

SUNDAY  _____ ______

SATURDAY
FRIDAY
THURSDAY
2ND POOP:
WEDNESDAY
TUESDAY
MONDAY

section 8 : Tracking Your Child’s Progress | 119 119

How Monitoring M.O.P. Saves Time
I don’t want to overwhelm you by suggesting you take copious daily notes. You needn’t
become a full-time M.O.P. data analyst! However, some basic tracking, along with
monthly assessments, will alert your family to patterns that can, in turn, inform your
next steps.
I’ve had parents tell me, “We did M.O.P. for 6 months, and it didn’t work.” Whoa! If your child has made
no progress after 30 days, make a change. One mom noted, “I should have started using the tracking
immediately so I could see we needed to be more aggressive sooner. I could have cut out at least 3
months of phosphate enemas. The calendar helps me analyze more objectively how things are going.”
Your notes can spotlight subtle signs of improvement that might otherwise have gone unnoticed and that
might keep you and your child motivated. “When I feel like giving up,” one mom posted, “I look at the notes
I wrote a few months back about tummy pain that’s gone or the increasing
# of dry nights, or that my daughter can feel she’s empty after a BM
— all signs that she’s healing." Another mom reported her son had
experienced a number of discouraging setbacks, but when she "We had been
analyzed the data, she said, “It turned out the downslide wasn’t doing M.O.P. for
as bad as I initially thought it was.” over 6 months, and I
Tracking will let you know when it’s time to move from one was almost to the point of
phase to the next, so you don’t taper too soon. Keeping notes
also will remind your family to complete the treatment each giving up. I didn’t realize
day. “It seems like it would be easy to remember whether you how much progress
gave your child an enema or when you switched to a new
he was gaining until
type of solution, but it’s not!” one mom posted. An occasional
missed enema won’t matter, but skipping enemas more often may I updated the
compromise your results. graph."
You can track your child’s progress using any of our paper
tracking calendars (and download additional pages at [Link]
[Link]/downloads). Or, you can create your own spreadsheet or find a suitable app.
Some parents use our calendars to collect the raw data and transfer the data to spreadsheets to more
visually analyze the trends. Here are a couple of the clever charts and graphs parents have posted in our
private support group. Don’t worry: You don’t have to go to such lengths. I’m showing you these just to
give you an idea of what other folks have found useful.

In January, this child was pooping spontaneously 61% of days and had 61% dry nights. By August,
the child was having an SP on 94% of days and was dry 90% of nights.

Jan Feb Mar Apr May June July Aug

Spont. Poop 61% 79% 84% 67% 71% 93% 90% 94%
Night Dry 61% 76% 77% 80% 94% 83% 84% 90%
BM Leaks 6% 3% 3% 0% 0% 0% 0% 0%
Damp 3% 0% 3% 0% 0% 0% 0% 0%
Fully Wet 6% 3% 0% 0% 0% 0% 0% 0%

120 | M.O.P. Anthology — 5th Edition

Over 8 months, this child showed significant improvement in daytime dryness and spontaneous
poops but minimal improvement overnight, typical for children with both encopresis and enuresis.

100%
Dry all Day
Spontaneous Poop
80% Wet AM

60%

40%

20% Dry AM

Poop Accident
Pee Accident
0%
January February March April May June July August

End of March: Covid hit, school ended. 3/23: Switched to adult enema, stopped Miralax, started Ex-Lax.

M.O.P. Tracking Tips

Here you'll find four tracking sheets: a 30-day calendar, a weekly calendar, a Multi-M.O.P.
calendar, and a simplified Teen Tracker (which works for all variations except Multi-M.O.P.).
The weekly calendar will suit those who want to make extensive notes and/or prefer a
Monday-through-Sunday format.
Here’s some guidance on filling in the all-purpose 30-day calendar. After you read this, the other calendars
will be self-explanatory.
Enema: Check off whether your child had an enema, and, if relevant, indicate the type and dose. For
example: "LGS," "1/2 adult Fleet," or "LV 30 ml gl" (large-volume enema with 30 ml of glycerin). You might
also want to note how many minutes your
child held the enema.
Osmotic Laxative: Use the “Osmo. Lax.” You’ll quickly devise your own notation system.
box to check off whether your child For example, one mom tracks the dampness of her child’s
took an osmotic laxative, and use the pull-ups on a scale from “dry” to “soaked." She wrote: “To
blank space to note the type and dose. me, it's significant if he soaks through to his pants versus
Many kids take two different types. You just having a little dampness. Less volume is a huge win
may need to experiment until you find and sign of progress, and we need encouragement.”
the sweet spot: poop that’s mushy but She suggests boxes ...
not runny.
Dry Damp Wet Soaked
Stimulant Laxative: If your child is using
a senna-based laxative, use this space to £ £ £ £
note the type and dose. You might also ... or a scale like this:
record the time of day your child took the
Night
laxative, to assess how long it takes for
Dry Wet
the urge to kick in.

section 8 : Tracking Your Child’s Progress | 121

Spontaneous Poop (SP): Note whether your child had an SP (or maybe two!), and note the time of day if
it's helpful.
Previous Night: If your child has nocturnal enuresis, use these boxes to record whether your child was dry
or wet overnight. Remember, if your child has daytime accidents, you are unlikely to see any improvement
in bedwetting until daytime accidents have resolved.
Daytime Accidents: Note the number and type of accidents. Some folks use a symbol or code, such as E
(for encopresis) and W (for wet).
Notes: Use these lines to note anything else that seems relevant, such as:
• Presence/absence of skid marks
• Belly pain or bloating “I think tracking
• Ability to sense the urge to poop is half the process
of M.O.P. You can get
• Pee frequency or urgency
an accurate picture of
• Dampness of morning pull-up
whether your child is
Some parents note what time of night they changed wet sheets (if
making progress.”
their child wakes up to tell them or they’re using an alarm). If your
child used to wet the bed at midnight and now regularly does so at 5
a.m. that’s progress.

Involving Your Child in the Tracking Process

Unless you're with your child all day long, you'll need their help to monitor their
progress. Some kids are more willing than others to report when they pooped, what it
looked like, whether they had an accident, and so on. When I was a kid, I wouldn’t have
been too thrilled to reveal these things to my parents, so I give children a lot of credit
for participating in the tracking process.
Assisting you with recording the details can help kids feel invested in M.O.P. One mom in our support
group posted: “We track on the M.O.P. calendar when at home, and when my daughter is at school, she
texts me the info to add to the chart later, so we don’t forget. The texting might seem excessive, but it
did get her VERY motivated to do enemas and track poops.”
Make sure your child is familiar with the How’s Your Poop? chart, which illustrates the various poop
shapes. While some kids are embarrassed by the prospect of describing their poops to Mom or Dad,
others get a kick out of it. One mom posted: "We talk and joke about poop freely in this house, and no
one is stressed anymore!”
Another mom posted that her 7-year-old daughter has become so comfortable discussing her bowel
movements that she does it in public. She wrote: “My daughter reports when she went, how much, and
what it looked like. She even did it at Disney World, in front of people — without fear and being so proud.
She would come out of the bathroom saying, ‘Mom, I had snakes and I had this much!’ And then she’d
show me volume with her hands.”
The mom of a preschooler posted: “My little one is 4, so he isn’t able to track himself yet, but he does like
to examine and describe what his poos are like when he goes! And he likes taking the lids off the enemas
and other small things. I think the more they are involved in every aspect of M.O.P., the better. Certainly
from a respectful parenting background, the more that we are doing M.O.P. WITH children rather than
doing it TO them, the better. It is, after all, a very intimate process.”

122 | M.O.P. Anthology — 5th Edition

 Sample Calendars

Sample #1
This 6-year-old, with daytime and nighttime enuresis, follows STANDARD M.O.P. Though wet at night,
she’s been having fewer daytime accidents and more SPs. On Day 23, she had a small accident and no
SP, so on Day 24, she increased lactulose and took 2 Ex-Lax.

DAY/DATE: __Tues. 8/17

_______________ DAY/DATE: Wed. 8/18
_________________ DAY/DATE: __Thurs. 8/19
_______________ DAY/DATE: __Fri. 8/20
_______________ DAY/DATE: __Sat. 8/21
_______________
Enema: £ √ _____________________
LGS Enema: £ √ _____________________
LGS Enema: £ √ _____________________
LGS Enema: £ √ _____________________
LGS Enema: missed!
£_____________________
Osmo. Lax.£√ __________________
20 ml lac Osmo. Lax.£√ __________________
20 ml lac Osmo. Lax.£√ __________________
20 ml lac Osmo. Lax.£√ __________________
30 ml lac Osmo. Lax. √ __________________
£ 30 ml lac
Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ √ __________________
Stim. Lax. £ 2 Ex-Lax Stim. Lax. £ __________________
√
Previous Night: Dry £ Wet £ √
Previous Night: Dry £ Wet £ √
Previous Night: Dry £ Wet £ √
Previous Night: Dry £ Wet £ √
Previous Night: Dry £ Wet £
0
Daytime: SP_____ Accidents _______ 0
Daytime: SP_____ Accidents_______ W
Daytime: SP_____ Accidents_______ W
Daytime: SP_____ Accidents_______ 0
Daytime: SP_____ Accidents_______

21 22 23 24 25
Notes:__SP and dry day – yay!
_______________________ Notes:_________________________ Notes:_________________________ Notes:__Ex-Lax ➙ SP,
_______________________ Notes:__yay – SP/dry!
_______________________
____________________________ ____________________________ small accident after school
____________________________ lactulose to 30
____________________________ ____________________________

Sample #2
This 15-year-old has been dry at night for weeks and has tapered to Phase 2 of M.O.P.x. Ex-Lax at
school produces an after-school SP. Not a fan of note-taking, he records the basics on the Teen
Tracker. On his no-enema days, he writes NDE!, for “no darned enema!”

Fri. 4/16
DAY/DATE: ______________ Sat. 4/17
DAY/DATE: ______________ Sun. 4/18
DAY/DATE: ______________ Mon. 4/19
DAY/DATE: ______________ Tues. 4/20
DAY/DATE: ______________

Enema £√ Laxative £
√ Enema £ Laxative £√ Enema £√ Laxative £
√ Enema £ Laxative £√ Enema £√ Laxative £
√
Overnight: Wet £ Dry £√ Overnight: Wet £ Dry £√ Overnight: Wet £ Dry £√ Overnight: Wet £ Dry £√ Overnight: Wet £ Dry £√
MONTHLY TOTALS:
MULTI-M.O.P. Tracker
√ Accidents £ £ Daytime: SP £
Daytime: SP £ √ Accidents £ £ Daytime: SP £
√ Accidents £ £ Daytime: SP £
√ Accidents £ £ Daytime: SP £ √ Accidents £ £
Accident-free days _____
NDE!
Notes:_________________ Notes:_________________ NDE!
Notes:_________________ Notes:_________________ Notes:_________________
Accident-free nights _____
16
____________________________
17
____________________________
18
____________________________
19
____________________________
20
____________________________

Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________
Sample
DS Mini-Enema #3
DS Mini-Enema
      DS Mini-Enema    DS Mini-Enema    DS Mini-Enema   
Overnight:
This 10-year-old Overnight: Dry  Wet
Dry  Wet  with encopresis Overnight:
(noenuresis) has Dry started Overnight: Dry She
 Wet  Multi-M.O.P. Overnight: Dry  Wet 
 Wetself-administers

Daytime Accidents:
docusate sodium
   Daytime Accidents:
mini-enemas  aday Daytime
twice Accidents:days
on school   and
 Daytime Accidents:
three times    on Daytime
a day Accidents:   
weekends.
On Day
Notes: 8, she had a small
_________________ accident, and onNotes:
Notes: _________________ Day_________________
10, she had a skid
Notes:mark. Her mom records
_________________ the
Notes: _________________
details on the Multi-M.O.P.
______________________
1 calendar.
______________________
2 3
______________________ ______________________ ______________________
4 5
Sat. 10/6
Day/Date: _____________ Sun. 10/7
Day/Date: _____________ Mon. 10/8 Day/Date: _____________
Day/Date: _____________ Tues. 10/9 Wed. 10/10
Day/Date: _____________
√
DS Mini-Enema  √
√ √
DS Mini-Enema  √
√ √ 
DS Mini-Enema  √  √ 
DS Mini-Enema  √  √ 
DS Mini-Enema  √ 
√ Wet 
Overnight: Dry  √ Wet 
Overnight: Dry  √ Wet 
Overnight: Dry  √ Wet 
Overnight: Dry  √ Wet 
Overnight: Dry 
Daytime Accidents:    Daytime Accidents:    √
Daytime Accidents:  Daytime Accidents:    √
Daytime Accidents: 
barely pooped after Notes: _________________
Notes: _________________ decent output 3x tiny accident
Notes: _________________ Notes: _________________ skid
Notes: _________________

3rd enema. no accidents!! no

______________________
6accidents!
______________________
7 8
______________________ ______________________ ______________________
9 10
Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________
DS Mini-Enema    DS Mini-Enema    DS Mini-Enema
section DS Mini-EnemaYour
  8 : Tracking DS Mini-Enema
  Child’s Progress   | 123
Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet 
Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:   
 30-Day Tracker
DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________
Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________
Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax. £ __________________
Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________
Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £
Daytime: SP_____ Accidents _______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______
Notes:_________________________
____________________________

DAY/DATE: _________________
1 2
Notes:_________________________
____________________________

DAY/DATE: _________________
____________________________

DAY/DATE: _________________
3
Notes:_________________________
____________________________

DAY/DATE: _________________
4
Notes:_________________________
____________________________

DAY/DATE: _________________
5
Notes:_________________________

Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________
Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax. £ __________________
Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________
Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £
Daytime: SP_____ Accidents _______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______

6 7 8 9 10
Notes:_________________________ Notes:_________________________ Notes:_________________________ Notes:_________________________ Notes:_________________________
____________________________ ____________________________ ____________________________ ____________________________ ____________________________

DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________
Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________
Osmo. Lax. £ __________________ Osmo. Lax. £ __________________ Osmo. Lax. £ __________________ Osmo. Lax. £ __________________ Osmo. Lax. £ __________________
Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________
Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £
Daytime: SP_____ Accidents _______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______

11 12 13 14 15
Notes:_________________________ Notes:_________________________ Notes:_________________________ Notes:_________________________ Notes:_________________________
____________________________ ____________________________ ____________________________ ____________________________ ____________________________

DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________
Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________
Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax. £ __________________
Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________
Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £
Daytime: SP_____ Accidents _______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______

16
Notes:_________________________
____________________________

DAY/DATE: _________________
17
Notes:_________________________
____________________________

DAY/DATE: _________________
18
Notes:_________________________
____________________________

DAY/DATE: _________________
19
Notes:_________________________
____________________________

DAY/DATE: _________________
20
Notes:_________________________
____________________________

DAY/DATE: _________________
Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________
Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax.£ __________________ Osmo. Lax. £ __________________
Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________
Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £
Daytime: SP_____ Accidents _______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______

21 22 23 24 25
Notes:_________________________ Notes:_________________________ Notes:_________________________ Notes:_________________________ Notes:_________________________
____________________________ ____________________________ ____________________________ ____________________________ ____________________________

DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________ DAY/DATE: _________________
Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________ Enema: £_____________________
Osmo. Lax. £ __________________ Osmo. Lax. £ __________________ Osmo. Lax. £ __________________ Osmo. Lax. £ __________________ Osmo. Lax. £ __________________
Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________ Stim. Lax. £ __________________
Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £ Previous Night: Dry £ Wet £
Daytime: SP_____ Accidents _______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______ Daytime: SP_____ Accidents_______

26
Notes:_________________________
____________________________

124 | M.O.P. Anthology — 5th Edition

27
Notes:_________________________
____________________________
28
Notes:_________________________
____________________________
29
Notes:_________________________
____________________________
30
Notes:_________________________
____________________________
 Week of: –––––––––––––––––––––
ENEMA/LGS: Min. held:___________ LAXATIVES: Osmo £ Stim. £ ACCIDENTS: a.m. dry £ wet £ MORE NOTES: SP £ _____________
Type/dose:______________________ Osmo. type/dose:________________ Daytime enuresis:________________ ______________________________
Oil £ __________________________ Stim. type/dose:_________________ Encopresis:_____________________ ______________________________

MONDAY
Notes:_________________________ Notes:_________________________ Notes:_________________________ ______________________________

ENEMA/LGS: Min. held:___________ LAXATIVES: Osmo £ Stim. £ ACCIDENTS: a.m. dry £ wet £ MORE NOTES: SP £ _____________
Type/dose:______________________ Osmo. type/dose:________________ Daytime enuresis:________________ ______________________________
Oil £ __________________________ Stim. type/dose:_________________ Encopresis:_____________________ ______________________________

TUESDAY
Notes:_________________________ Notes:_________________________ Notes:_________________________ ______________________________
Weekly

ENEMA/LGS: Min. held:___________ LAXATIVES: Osmo £ Stim. £ ACCIDENTS: a.m. dry £ wet £ MORE NOTES: SP £ _____________
Type/dose:______________________ Osmo. type/dose:________________ Daytime enuresis:________________ ______________________________
Oil £ __________________________ Stim. type/dose:_________________ Encopresis:_____________________ ______________________________
Notes:_________________________ Notes:_________________________ Notes:_________________________ ______________________________

WEDNESDAY
ENEMA/LGS: Min. held:___________ LAXATIVES: Osmo £ Stim. £ ACCIDENTS: a.m. dry £ wet £ MORE NOTES: SP £ _____________
Type/dose:______________________ Osmo. type/dose:________________ Daytime enuresis:________________ ______________________________
Oil £ __________________________ Stim. type/dose:_________________ Encopresis:_____________________ ______________________________

THURSDAY
Notes:_________________________ Notes:_________________________ Notes:_________________________ ______________________________

ENEMA/LGS: Min. held:___________ LAXATIVES: Osmo £ Stim. £ ACCIDENTS: a.m. dry £ wet £ MORE NOTES: SP £ _____________
Type/dose:______________________ Osmo. type/dose:________________ Daytime enuresis:________________ ______________________________
Oil £ __________________________ Stim. type/dose:_________________ Encopresis:_____________________ ______________________________

FRIDAY
Notes:_________________________ Notes:_________________________ Notes:_________________________ ______________________________

ENEMA/LGS: Min. held:___________ LAXATIVES: Osmo £ Stim. £ ACCIDENTS: a.m. dry £ wet £ MORE NOTES: SP £ _____________
Type/dose:______________________ Osmo. type/dose:________________ Daytime enuresis:________________ ______________________________
Oil £ __________________________ Stim. type/dose:_________________ Encopresis:_____________________ ______________________________

SATURDAY
Notes:_________________________ Notes:_________________________ Notes:_________________________ ______________________________
Tracking Chart

ENEMA/LGS: Min. held:___________ LAXATIVES: Osmo £ Stim. £ ACCIDENTS: a.m. dry £ wet £ MORE NOTES: SP £ _____________
Type/dose:______________________ Osmo. type/dose:________________ Daytime enuresis:________________ ______________________________
Oil £ __________________________ Stim. type/dose:_________________ Encopresis:_____________________ ______________________________

SUNDAY
Notes:_________________________ Notes:_________________________ Notes:_________________________ ______________________________

section 8 : Tracking Your Child’s Progress | 125

 MONTHLY TOTALS:
MULTI-M.O.P. Tracker Accident-free days _____
Accident-free nights _____

Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________
DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema   
Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet 
Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:   
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

______________________
1 ______________________
2 ______________________
3 ______________________
4 ______________________
5
Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________
DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema   
Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet 
Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:   
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

______________________
6 ______________________
7 ______________________
8 ______________________
9 10
______________________

Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________
DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema   
Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet 
Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:   
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

______________________
11 12
______________________
13
______________________
14
______________________
15
______________________

Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________
DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema   
Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet 
Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:   
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

16
______________________
17
______________________
18
______________________
19
______________________
20
______________________

Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________
DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema   
Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet 
Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:   
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

21
______________________
22
______________________
23
______________________
24
______________________
25
______________________

Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________ Day/Date: _____________
DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema    DS Mini-Enema   
Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet  Overnight: Dry  Wet 
Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:    Daytime Accidents:   
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

26
______________________
27
______________________
28
______________________
29
______________________
30
______________________

126 | M.O.P. Anthology — 5th Edition

Teen M.O.P. Tracker MONTHLY TOTALS:
Dry nights ________ Wet nights ________

DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________

Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £
Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £
Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

1
____________________________
2
____________________________
3
____________________________
4
____________________________
5
____________________________

DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________

Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £
Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £
Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

6
____________________________
7
____________________________
8
____________________________
9
____________________________
10
____________________________

DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________

Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £
Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £
Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

11
____________________________
12
____________________________
13
____________________________
14
____________________________
15
____________________________

DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________

Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £
Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £
Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

16
____________________________
17
____________________________
18
____________________________
19
____________________________
20
____________________________

DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________

Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £
Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £
Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

21
____________________________
22
____________________________
23
____________________________
24
____________________________
25
____________________________

DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________ DAY/DATE: ______________

Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £ Enema £ Laxative £
Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £ Overnight: Wet £ Dry £
Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £ Daytime: SP £ Accidents £ £
Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________ Notes: _________________

26
____________________________
27
____________________________
28
____________________________
29
____________________________
30
____________________________

section 8 : Tracking Your Child’s Progress | 127

 Content by Steve Hodges, M.D., and Suzanne Schlosberg
Illustration Copyright © 2016 Cristina Acosta
Design by [Link]

128 | M.O.P. Anthology — 5th Edition

WEEK __________
MONDAY NOTES:_________________________________________ Draw your own poop shape here.

1ST POOP:

2ND POOP:

TUESDAY NOTES:_________________________________________ Draw your own poop shape here.

1ST POOP:

2ND POOP:

WEDNESDAY NOTES:_________________________________________ Draw your own poop shape here.

1ST POOP:

2ND POOP:

THURSDAY NOTES:_________________________________________ Draw your own poop shape here.

1ST POOP:

2ND POOP:

FRIDAY NOTES:_________________________________________ Draw your own poop shape here.

1ST POOP:

2ND POOP:

SATURDAY NOTES:_________________________________________ Draw your own poop shape here.

1ST POOP:

2ND POOP:

SUNDAY NOTES:_________________________________________ Draw your own poop shape here.

1ST POOP:

2ND POOP:

section 8 : Tracking Your Child’s Progress | 129

Section 9

Your Family, Your Doctor,

and M.O.P.
For many folks, M.O.P. represents a big leap. You may worry enemas
will be painful or embarrassing for your child or that M.O.P. will prove
too time-consuming. Your child may share your apprehensions. With this
section, I hope to help your family overcome these concerns and related
family tensions. I think you will find that for all the challenges M.O.P.
poses, the treatment will ultimately make your family’s life easier.

Much of the advice in this section comes from parents who’ve been
in the trenches. I’ve also enlisted
Amanda Arthur-Stanley, Ph.D., Zack, I I think you’re
a psychologist well-versed in don’t think the right, Zoe.
bathtub is going We’d better
M.O.P., to answer questions to unclog itself. take action!
that are out of my purview as a
urologist. For additional insights
on tackling worries about
M.O.P., I direct you to the
Enema Rescue Guide and
The M.O.P. Maestro Guide,
both in Section 10.

131
section 9 : Your Family, Your Doctor, and M.O.P. | 131
Overcoming Apprehension About M.O.P. ---
Yours and Your Child’s
Some families are so exhausted from years of accidents and failed remedies that they
jump into M.O.P. with gusto. I’ve heard from parents who
started their kids on the regimen the same day they heard
about it. Within hours, they’ve downloaded this book
and purchased enemas at the drugstore. “After all the “I have had many
chiropractic and alarms and medication,” one mom wrote, “this children admit to me
was the first program that made sense. Even my son, who’s
with tears in their eyes
14, couldn’t wait to get started.”
that it bothers them to have
I’m guessing these folks are in the minority. More often,
parents and children alike feel apprehensive, especially if accidents, even though they
their physicians oppose the plan. Some families take a year have told their parents
to work up to the idea of enemas, only to get started after the opposite.”
exhausting every other option. That’s fine! What’s important
is feeling committed when you do start, because consistency — Robin Lund, pelvic floor
is important, setbacks are common, and progress is often slower physical therapist
than families expect.
If your child worries that enemas will hurt and/or does not want
to give them a try, read the Enema Rescue Guide: 12 Strategies to Help
Your Child Get Comfortable with M.O.P., found in Section 10. The guide is packed with creative and
practical ideas from parents who’ve been there. If you feel overwhelmed by the logistics of implementing
M.O.P., especially if you have multiple children on the protocol, turn to The M.O.P. Maestro Guide: How
to Orchestrate Your Family's Daily Enema Regimen Without Going Bonkers also in Section 10. This guide
features unvarnished advice from
parents who have implemented
M.O.P. with two, three, even four
children. If you think M.O.P. sounds
daunting with one child, imagine
playing “musical toilets” every night
with 5-year-old triplets!
Though the specific advice differs,
both guides offer the same general
message: All this M.O.P. stuff
soon becomes business as usual.
Administering enemas, dosing
laxatives, setting a daily schedule,
tracking your child’s progress — none
of it is as big a deal as it seems
initially, and the rigamarole is a lot
better than what came before. Here
are a few other notions to keep in
In Emma and the E Club, Emma quickly becomes an enema mind as you gear up:
pro, inspiring her doctor to call her “Her Excellency, the
Exalted Empress of the Enema Empire.” You may actually be more fearful
than your child is. Many parents

132 | M.O.P. Anthology — 5th Edition

project their own fears onto their children. You may not
get the resistance you expect. Children tend to be more
upset about their toileting problems than they let on and
often are quite amenable to trying a new approach. Robin When a child’s accidents
Lund, a South Dakota physical therapist who has worked have gone unresolved for
with many patients on M.O.P., says her patients often
years, the parent-child
hide the true extent of their distress. She told me: “I have
had many children admit to me with tears in their eyes relationship is often frayed.
that it bothers them to have accidents, even though they Resolving the accidents
have told their parents the opposite.”
can go a long way toward
As you explain to your child what’s involved in M.O.P.,
repairing that relationship.
one mom advises, “Don’t make it more anxiety-ridden than
it needs to be. Stay relaxed when you’re educating your
child about their body. Be compassionate and matter of
fact about it. The parent’s emotional tone is a huge part of
whether you’re successful or not.”
Emphasize that you and your child are in this together. Rather than run the show yourself, offer your
child lots of choices. Let them try out different enemas and laxatives. A child may prefer a laxative syrup
or pill rather than a powder mixed with water. Maybe the child prefers to do the enema after school rather
than before bed, or vice versa. “Recognize your child is a partner in this treatment,” one mom advises. “For
M.O.P. to work, you have to address your child’s concerns and engage his cooperation.”
When a child’s accidents have gone unresolved for years, the parent-child relationship is often frayed.
Resolving the accidents can go a long way toward repairing that relationship. One mom in our support
group posted: “I just want to share a note of appreciation my 16 y.o. gave me over the weekend. It was
my birthday, and he made me a card where he mentioned being grateful for all that I do for the family,
including [buying] his enemas! Evidence that we can endure the (sometimes) long journey and have our
relationships heal in the process.”
Don’t expect to be a M.O.P. pro overnight. Cut yourself slack as you learn the ropes. One mom
cautioned: “You will make mistakes — maybe you will give an incorrect dosage, spray enema water all
over the bathroom, misread directions and have to dump out your enema
solution and start over. And there will be nights you just have to skip
everything because mentally and emotionally it’s tough. But if you
persevere, it is worth it.”
“Be compassionate
Set realistic expectations, and emphasize to your child that
and matter of fact. progress may be slow. I’ve said it multiple times in this book,
The parent’s emotional but I will say it again: M.O.P. is not an overnight cure! Your
child may have zero dry nights for a while, but this does not
tone is a huge part necessarily mean your child has not made progress. Fewer
of whether you’re stomachaches, less urgency to pee, more urges to poop — these
are all signs of improvement. In the early months, a dry day or
successful or not.” night may just be icing on the cake. “I wish I had had a clearer
understanding of what progress looked like,” one mom posted.
“I thought it would be more linear than it has been, and I did not
understand that just a few more dry days each month was real progress.”

section 9 : Your Family, Your Doctor, and M.O.P. | 133

Five Important Messages for Your Child
Given the amount of shame and blame our society heaps on children who have
accidents, it is no surprise that many kids feel down about themselves. Scientists publish
papers on “stool toileting refusal,” language that suggests the child is willful, defiant,
intentionally oppositional. Enuresis and encopresis are included in textbooks on “abnormal child
psychology” and “mental disorders.” The DSM-5 defines enuresis and encopresis as “the inappropriate
elimination of urine or feces.” Think about the word inappropriate. What are the synonyms? Incorrect.
Improper. Unseemly. Tactless. Unacceptable.
Below are five messages of my own, to counter what children of all ages
may be hearing from others or feeling internally. You can access a
video in which I make these points directly to kids at [Link]
“As daunting [Link]/facebook-group-video. In addition,
as this treatment all these themes are reinforced in our children's books, especially
is, it has led to a big Bedwetting and Accidents Aren't Your Fault, Emma and the E Club,
improvement for my child. and M.O.P. for Teens and Tweens.
He no longer has to come up
with a story to tell classmates
1. Accidents are not your fault!
There is absolutely nothing you did to cause your accidents.
about why he smells like Your insides have gone a bit haywire, that's all. Accidents are
poop, and I don’t have to like sneezes and hiccups: something that just happens in your
soak and scrub soiled body. The good news is, accidents can be fixed.
underpants.”
2. Tons of kids have accidents.
You might think you’re the only kid who has accidents, but believe
me, you aren’t! Millions of kids around the world have accidents, including
other kids at your school and in your neighborhood. Of course, they don’t talk about it with their
friends, so nobody knows. I’ll bet some of your friends have accidents, but you just don’t know it.

3. Enemas really work. "My 6-year-

I totally get that enemas are not fun, but I promise you,
old recently had
they work better than anything else. It can take a
a relapse. We asked him
while for M.O.P. to start working, so don’t expect the
accidents to stop right away. But if you stick with the what he thought would help,
program, eventually you will be accident-free. and he came up with a whole
plan involving high-volume enemas,
4. It’s important to finish the whole M.O.P. program. potty sits, and drinking more water.
That’s the best way to stop accidents completely and He showed us 1.) how much he has
forever. So, stick with it the best you possibly can. If matured, 2.) how much M.O.P. helps
you stop the program early, accidents are more likely to because even my kid knows it, and
come back. 3.) how empowering it can be
to include your kid in
5. Tell your parents how things are going for you on M.O.P. strategizing."
If something hurts or feels uncomfortable, let them know, so
they can buy a different kind of enema or laxative. Always tell
a parent when you have an accident, and help keep track of your poops
and your treatment. The more your parents know, the more they can help. We all have the same goal,
which is to stop accidents now, so you won’t have to deal with them when you get older.

134 | M.O.P. Anthology — 5th Edition

“Help! My Spouse Thinks M.O.P. is Crazy!”
Physicians may be the most skeptical of M.O.P., but based on the emails I receive and
clinic visits, I’d say fathers are a close second. Dads tend to push hard for Miralax clean-
outs and seem to be more doubtful that enemas are either necessary or safe. I will not
begin to speculate as to why, and certainly plenty of dads are supportive. In fact, recently more fathers
have joined our private support group. Still, I do many video consultations where the main purpose seems
to be persuading the child’s father that M.O.P. is indeed warranted and will not scar their child for life.
What can you do if you want to pursue M.O.P. with your child but are finding opposition from your
spouse or co-parent? I suggest many of the same strategies outlined in the “If Your Doctor Opposes
M.O.P.” section below. Additionally, here is some input from members of our support group:
• “My husband didn’t get on board until he saw the x-ray. It showed our son’s rectum was basically
flattening his bladder. Plus, reading the study about how enemas work better than Miralax appealed
to his rational side.”
• “Within 5 days of an oral clean-out, my daughter started having accidents again. So, my husband no
longer felt justified in refusing to do M.O.P. and agreed to a bottom-up approach.”
• “All it took was my husband seeing progress. He was sick of cleaning out her car seat every time she
emptied her bladder in it! As her daytime accidents have improved, he has been more and more on
board because he can see M.O.P. is working.”
• “I finally had to ask my husband to trust me, and he has backed off and even started helping with
the enemas. It took months of discussion, lots of patience, and finally a few dry nights to get us here.
I keep doling out the info, keep asking him to back me up with the grandparents, keep showing him
the tracker.”
• “I made my husband start doing the Miralax and getting up to change the sheets. He experienced
how much of a pain it is and got on board with M.O.P. real quick.”
• “What turned my husband around was an x-ray. He had blamed the bedwetting on behavior issues
and on my ‘failure’ to properly potty train. Once he saw the x-ray, he couldn’t argue. He could see
this was a medical issue and that our doctor, who kept telling us ‘Don’t worry, he’ll outgrow it,’ was
uninformed. He even admitted to me, ‘I think you might know more about this than the doctor does.’”
• “My hubby was not supportive, and it set us back a couple years. The quicker everyone is on board,
the better. It may take a while and there are lots of variations to try, but definitely get going!”
It’s not just M.O.P. that can strain a relationship; a child’s accidents can
trigger all kinds of tensions. For example, one mom posted: How can we
deal with the strain our son’s accidents have had on our marriage? My
husband is frustrated because he says all we talk about anymore is
poop and pee. I am frustrated because I'm the one administering
“Within 5 days
the meds, encouraging and rewarding and coaxing, attending of an oral clean-out, my
appointments, making treatment decisions, talking with daycare daughter started having
providers, researching, and monitoring the daily status. He leaves accidents again. So, my
for work at 6 a.m. and doesn't get home until 6 p.m. I wish I had
the luxury to “not worry about it so much.” husband no longer felt
This mom’s post generated a lot of empathy and support. Below
justified in refusing to
are comments from other parents that may help folks struggling do M.O.P.”
with the same issues.

section 9 : Your Family, Your Doctor, and M.O.P. | 135

 • “Maybe you need to take a break from some of your
responsibilities. Delegate or let them go for a little bit, to
focus on your other relationships. We've all been there.”
“My husband
• “My husband is supportive, but we’ve had our fair
share of arguing and blaming each other for my is supportive, but
son’s encopresis. I would lie if I said it hasn’t
taken a toll on our relationship. Raising children
we’ve had our fair share
is already challenging, and this issue is definitely of arguing and blaming
next level. It’s also isolating, as we tend to keep
to ourselves for fear of judgment.”
each other for my son’s
• “I ended up consciously deciding not to discuss encopresis. I would lie if I
it anymore with my husband or my mother or
sister. I just give brief updates if they ask. I think
said it hasn’t taken a toll
it was good for me to let go of that topic with on our relationship.”
them.”
• “My husband used to get so angry and triggered by
accidents, despite being told our son could not help it. It
was so stressful for me and my son. I even feel like I changed
the way I perceived my husband. I was resentful for a long time.
Eventually my son's daytime issues resolved, so things
got better.”
• “My husband (in school to be a nurse practitioner) has been critical of this program and agreed with
all the doctors who said our daughter just needed to grow out of it and was not trying hard enough.
So, I continue to do all of it alone. I am hopeful that as he sees her continued progress, he will be
comfortable sharing this program with doctors and patients.”
• “I have tension with my husband over this. Now he is accustomed to the routine, but he does little
to help me. As long as I do all the work and worrying, things are good. There is a loving humor in my
house that I am ‘poop obsessed,’ but I just try to laugh about it.”
• “I am also in charge of absolutely everything. My husband refuses to do the enemas — he says he is
scared to hurt her, as if I wasn't petrified the first time I did it. I think it's just his m.o. to bury his head
in the sand and only get involved if I confront him about it, whereas I am proactive. You are not alone
in the trenches.”

If Your Doctor Opposes M.O.P.

It’s always helpful to work with a healthcare provider when your child is on M.O.P. Every
child’s case is unique, and a doctor or nurse practitioner may have extra insight into
your child’s circumstances. Also, with a doctor on board, you can get baseline and, if necessary,
follow-up x-rays, as well as prescriptions for medications you may want to try. Plus, it just feels better to
be working with, rather than against, your doctor!
But getting a disapproving doctor on board can be challenging. Many doctors are shocked and appalled
by M.O.P., for a host of unfounded reasons, and they are not shy about telling parents how they feel.
Heck, it’s tough for me to persuade my own colleagues that daily enemas are safe and work better than
Miralax. At a medical conference I attended, I talked to hundreds of pediatricians, and while the majority
knew enuresis is caused by constipation, some considered bedwetting primarily a psychological or

136 | M.O.P. Anthology — 5th Edition

behavioral problem. Only a few used x-rays to diagnose constipation, and none had heard of treating
bedwetting with daily enemas.
So, I’m hardly surprised when parents get pushback from their doctors. One mom in our support group
said her doctor called enemas “dangerous” and suggested her daughter would stop having accidents if
she wore cotton underwear rather than pull-ups, so she would “feel the wetness more and wake up.” This
mom asked me: “How is a mom supposed to stand up to a pediatrician who doesn’t know anything about
this?” Good question.
It’s not easy to disagree with your doctor. Studies show that even confident, assertive people become
timid when faced with the prospect of challenging their physician’s opinion. In one study, only 14% of
1,340 surveyed said they’d openly disagree with a physician.1 Most feared being labeled a “difficult patient”
or damaging their relationship with the doctor. In another study, highly educated patients said they felt
anxious or intimidated about expressing disagreement and feared “rocking the boat.”2
I get it. If you show up at your appointment armed with
studies and printouts, you may worry your doctor will think:
Hey, I went to medical school; you didn’t. And the doctor
may have a point! When patients find studies on the internet, Studies show that even
they may not have the background to put these studies in confident, assertive people
context. Maybe a study contradicts two dozen other studies
become timid when faced
published on the topic, or maybe it was poorly designed,
so the results are suspect. Hey, we doctors did learn a few with the prospect of
things in medical school! challenging their
However, when it comes to bedwetting and accidents, most physician’s opinion.
of us learned very little. Pediatricians, as jacks-of-all-trades,
learn about more conditions than I’ve probably ever heard
of, but most receive little training on treating an overactive
bladder. Urologists, meanwhile, tend to specialize in conditions requiring surgery. For many of my
colleagues, toileting accidents don’t rate much attention, despite the distress their patients experience.
Urologists often prescribe an ineffective drug and call it a day. Some urologists do nothing at all. The mom
of a 17-year-old told me her son's pediatric urologist, at a prominent university, shrugged off her son's
enuresis. "I felt like, if the specialist is being so nonchalant, then maybe
I’m making a big deal out of nothing, You want it to be true that the
bedwetting will just stop."
“Doctors need
I mention all this in hopes of boosting your confidence as you
to know that when approach your physician about M.O.P. Don’t assume your
a kid has a choice doctor has actually read high-quality research on treating
enuresis and encopresis. Listen to your intuition. With luck,
and information, they
your worries about discussing M.O.P. with your doctor will
will choose a proactive prove to be unfounded. Some parents have told me their
solution involving doctors, acknowledging that traditional treatments weren’t
working, said, “Sure, let’s give it a try.” Still, I tend to hear more
enemas over waiting from parents who’ve gotten pushback. As one mom posted:
it out!” “Some doctors are so set in their way of thinking that they’re
unable to think outside that box, even when things clearly aren’t
working.”

1 J.R. Adams, G. Elwyn, et al., “Communicating With Physicians About Medical Decisions: A Reluctance to Disagree,” Archives of
Internal Medicine, 2012;172(15):1184-1186, [Link]
2 D.L., Frosch, S.G. May, et al., “Authoritarian physicians and patients’ fear of being labeled ‘difficult’ among key obstacles to
shared decision making,” Health Affairs, 2012 May;31(5):1030-8. [Link]

section 9 : Your Family, Your Doctor, and M.O.P. | 137

For parents dealing with doctors who oppose enemas, I offer the
following ideas: THE PHYSICIAN’S
GUIDE TO
• Hand your doctor The Physician’s Guide to M.O.P. Section 10
includes the first three parts of the guide, and you can download the Treating Enuresis and Encopresis
with the Modified O’Regan Protocol

complete guide, including the full text of relevant studies, at https:// “M.O.P. works radically better than anything else.”
[Link]/downloads. I wouldn’t expect – James Sander, M.D., Pediatric Urologist,
UT Health, Rio Grande Valley, TX

the packet to work miracles! Parents have reported their doctors “Families and kids are
“It is my mission to get
the word out about
how incredibly effective
dismissed the guide outright or glanced at the packet and then
a lot more receptive to
M.O.P. is.”
M.O.P. than I would
– Erin Wetjen, PT, specialist
have thought.” in pediatric incontinence,
handed it right back to them. Others have had better luck. One mom – Irina Stanasel, M.D., Pediatric
Urologist, UT Southwestern
Medical Center, Dallas, TX
Mayo Clinic, Rochester, MN

posted: “My doctor went through it while I was there and read a bit
of it. His comment was that it makes perfect sense, and he supported
us trying it.” If you give the packet to your doctor, let me know how “No enuresis treatment works as
it goes! By Steve Hodges, M.D.
Associate Professor of Pediatric Urology
Wake Forest University School of Medicine
well as M.O.P. — not even close.”
– Victoriano Romero, M.D., Urologist,
Redding Urologic Associates, Redding, CA

• Ask for research. Flip things around: If your doctor insists enemas are
traumatizing or dangerous, that x-raying for constipation is risky, or The Physician's Guide to
that bedwetting drugs work well, mention that you’d like to read up M.O.P. is directed toward
on that. Ask the doctor to recommend research you can peruse. At doctors and includes a
the very least, you will learn where your doctor is coming from. “Dear Colleagues” letter
from me encouraging
• Ask lots of questions. As a paying customer, you certainly have the physicians to keep an open
right to be inquisitive. Ask: Do you have experience with enema mind about enemas.
treatment? How many of your patients have reported they found
enemas traumatizing? What, specifically, do you feel are the risks of enemas? Why do you feel Miralax
is more effective than enemas? If your doctor pushes DDAVP, ask: What is the long-term success rate
of this drug? Does my child overproduce urine? If so, how do you know?
• Take the “humor me” approach. If your doctor insists your child is not constipated, ask for an x-ray,
and indicate you’ll try a different approach if your child’s rectal diameter proves to be under 3 cm. If
your doctor doesn’t approve of enemas, say, “Well, how
about if I try this for a month and then check in with
you? If it doesn’t work, we’ll try something else.”

Many doctors are shocked What if you still get nowhere? Either implement
M.O.P., anyway, or find an enema-friendly doctor.
and appalled by M.O.P., You don’t need your doctor’s approval. M.O.P. does
for a host of unfounded not require physician supervision or a prescription, and
there’s nothing risky about the
reasons, and they are
protocol. You do need a
not shy about telling doctor to get an x-ray,
parents how they feel. and some families
keep their doctor “Our daughter’s
on board for that urologist still makes
purpose only.
However, x-rays aren’t even available in many countries, and the vast
a stinky face about
majority of families who implement M.O.P. do so on their own, enemas and says M.O.P.
without their physician’s blessing and knowledge. At some point, is a really aggressive
you have to ask: Why am I seeking the approval of a doctor who has treatment choice.”
been pushing remedies that don’t work?

138 | M.O.P. Anthology — 5th Edition

Frustration, Guilt, and
Family Tension: Q&A
With a Psychologist
As a pediatric urologist, I treat dozens of medical
conditions, but only encopresis and enuresis generate
family tension. When a child has blocked kidneys or
refluxing ureters, there’s no talk in my exam room of
emotional exhaustion or power struggles or a child’s
“stubbornness.” Clinic visits feel matter-of-fact: Stuff
happens, so let’s get it fixed.
But when a clinic visit pertains to bedwetting or daytime accidents,
the friction between parent and child is often palpable. I understand
why! Enuresis and encopresis are misunderstood conditions that
prompt kids to behave in ways that seem to defy logic. What’s more,
these conditions carry great stigma in our culture, burdening the Amanda Arthur-Stanley, Ph.D.,
works with families dealing
whole family. No wonder parents and kids alike feel pressure for the
with enuresis and encopresis.
accidents to resolve.
Sometimes, I’m able to ease the family’s anxiety by presenting the simple fact that enuresis and encopresis
are symptoms of chronic constipation. Once accidents are framed as a medical issue, tension eases. But
often, parental frustration does not end with the confirmation of an enlarged rectum. Even when parents
know all about impacted stool and overactive bladders, they are not immune
from frustration, as their children sometimes act in ways that seem
counterproductive to recovery.
“I’ve stopped As a urologist, I’m not well equipped to advise families on how
constantly asking to work through the tensions that stem from accidents and/or
implementing M.O.P. For that important job, I have enlisted the
my daughter to use
help of Amanda Arthur-Stanley, Ph.D., a Colorado psychologist
the toilet. It was making who is knowledgeable about M.O.P. and whose private practice
her mad and making focuses on enuresis and encopresis. In Dr. Arthur-Stanley’s
practice, as in our private support group, the same questions and
her feel like I didn’t themes surface over and over. Here are five questions posted by
trust her.” parents in our group, along with Dr. Arthur-Stanley’s answers and, in
some cases, additional input posted by parents:
Question: What do you do if your child refuses to sit on the toilet to
pee and then has an accident 5 minutes later? My daughter also won’t sit
on the potty after meals, saying, “I don’t have to go.” I understand accidents aren’t behavioral and her
signals are off, but I’m frustrated with this stubbornness and sometimes lose my cool. My daughter is 5.
Dr. Arthur-Stanley: This is a tricky situation, especially when your child will comply sometimes but not
other times. With younger kids, it can be helpful to externalize the potty sits, with a potty schedule or
a watch. This can release the power struggle between parents and kids and help decrease the necessity
of constant verbal reminders. For older kids, try to understand, from their perspective, why it can be hard
to pause and use the toilet, and generate solutions together. You might supply some ideas while also
entertaining your child’s ideas. For example, ask your child, “What are the more challenging times to pause
and run to the bathroom? Is it when you’re playing ‘Minecraft’ or playing sports in the backyard? What can
we do to make life a little easier for everyone?”

section 9 : Your Family, Your Doctor, and M.O.P. | 139

Parent: “I’ve stopped constantly asking my daughter to use the toilet. It
was making her mad and making her feel like I didn’t trust her. Now I
just ask her to sit after breakfast and check in once or twice in the "Even when
afternoon. When she says she doesn’t need to go, I don’t push it. I parents try hard to
know this is giving her back control over her body, and it seems to
be working.” be supportive and non-
Parent: “When I’m on my parenting A game (not always), judgmental, kids can be
I take a deep breath and try to remember to smile and say, ‘It’s sensitive in ways we
OK. Let’s clean this up together.’ It helps me to have a script I never imagined."
can just launch into. We sometimes insist on potty breaks. We
remind her that her body sometimes doesn’t let her know that she -Dr. Amanda Arthur-
has to go, so it’s good to try even if nothing comes out. Sometimes, Stanley
I have to go in another room to have an eye roll or grumble, though.”
Parent: “My son never initiates going to the bathroom. We gave up on
the potty watch, and charts, bribes — nothing works. It became a real power
struggle, but we finally stopped arguing. I don’t think he knows what it even feels like to ‘need’ to go.”
Parent: “I have had to teach myself to really believe my kids when they say
they can’t feel it. Sometimes my son says he gets a small feeling, and he
doesn’t believe he really needs to go unless it’s a strong feeling. I tell
“My son never him it’s important to respond to even small urges, but it’s hard for
initiates going to the him because the sensations are not consistent.”
bathroom. We gave up on Parent: “When I feel myself starting to get angry, I pay
the potty watch, and charts, attention to the physical sensations in my body.
For example, I’ll get a tight feeling in my chest. I’ll notice how
bribes — nothing works. It
big the sensation is, does it have smooth edges or blurry,
became a real power struggle, what color would it be. It helps take my mind off the thoughts
but we finally stopped arguing. that are making me angry, like: ‘I can’t believe she had another
I don’t think he knows what accident. When is this ever going to end?’”
it even feels like to ‘need’ Question: My son won’t tell me when he has pee or poop
to go.” accidents, and then I find his dirty underwear at the bottom of
the trash. Sometimes he outright lies to me when I asked if he had
an accident. I can’t adjust our M.O.P. regimen if I don’t know when
he’s having accidents! How can I get him to tell
me the truth?
Dr. Arthur-Stanley: Even when parents try hard to be supportive and
non-judgmental, kids can be sensitive in ways we never imagined.
Try to get to the bottom of why your child is hiding their undies
or not taking their medication. As much as possible, start from a "How (in the
place of curiosity rather than assuming your son is being devious ever-loving heck)
or trying to get away with something. Maybe he’s feeling
ashamed of having an accident or does not want to disappoint
do you motivate a
you. Maybe Ex-Lax is giving him cramps or he doesn’t like the teen to follow their
taste. If you can pinpoint the reasons, you may be able to make treatment plan?"
small shifts, so he feels more empowered to communicate with
you and explore different solutions. Perhaps he’d like to take his
medicine at nighttime versus the morning. Perhaps having a special,
private basket for soiled undies would allow you to track his accidents
without him having to tell you, “I had an accident.”

140 | M.O.P. Anthology — 5th Edition

Question: How (in the ever-loving heck) do you motivate a teen
to follow their treatment plan? To get dry overnight, my teen
needs to step up. Constantly reminding him to do his enemas
and take his Ex-Lax is annoying to both of us. I know the “The most helpful
bedwetting distresses him, but when I ask why he doesn’t thing for me is to remind
follow through, he just shrugs.
myself where we were then
Dr. Arthur-Stanley: Remember that the adolescent brain is
compared to where we are
still maturing. The last area of our brain to develop is the
prefrontal cortex, the part that controls our ability to plan, now! No, it’s not all fixed, but
to inhibit our impulses, and to think about consequences it IS better than it was —
of our behavior. Try to empathize with your son, knowing
and that deserves
he probably feels shame and embarrassment, no matter
how much you emphasize that bedwetting is not his fault. a pat on the back!”
Let him know you’re there to offer support and problem-solve.
If he doesn’t want to discuss treatment face to face, try texting
or chatting. He could send you a poop emoji when he’s used the
toilet. Ask for his ideas! It’s important for kids to have a voice in the
process. Engage in conversations that are not punitive or rushed, and help your child generate ideas. As a
parent, you want to track all the details, but keep it in perspective. Pooping is just one small part of your
child’s life. He’s a whole person with thoughts, feelings, and ideas — things that have nothing to do with
constipation or bedwetting.
Question: How do I deal with the guilt I feel over all the years I allowed doctors to dismiss my son’s
bedwetting? He’s 15, and only now are we learning his enuresis is due to constipation. Enuresis has
basically ruined this kid’s social life and crushed his self-esteem, and I kept listening to “Don’t worry,
he’ll outgrow it.”
Dr. Arthur-Stanley: Recognize that you were doing the best you could in a difficult situation. Part of
the reason I am drawn to working with families with encopresis and enuresis is my own experience as
a parent (including my own moments of feeling guilt, disappointment, and questioning the next step on
a very long path). I find that parents are often hardest on themselves. Consider this an opportunity to
model being gentle to yourself, as you want your kids to be gentle with themselves. The good news is
that you and your son now know the physiological underpinnings of bedwetting and are working through
a plan to resolve it, and you can provide ongoing emotional support and
encouragement. Once kids understand how a stretched-out rectum
reduces their sensations of knowing when they need to go, they
begin to feel less shame and isolation and more hope.
“I have had Parent: “Please don’t blame yourself. Probably everyone, at some
point follows advice from a doctor that turns out to have been
to teach myself wrong. But we go to doctors because they know more about
to really believe my the subject than we do, so of course we listen to them.”
Parent: “I have a lot of guilt for letting this go on for 4 years.
kids when they say I was told repeatedly ‘not to worry’ and ‘she’ll grow out of it,’
and finally, when an x-ray showed significant constipation, the
they can’t feel it.” doctor said, ‘Enemas are just going to make her more scared to
poop.’ I finally went with my gut and started M.O.P., anyway. I
wish we could have gotten to this point years ago, but I can hardly
blame myself. We rely on our doctors to give good advice.”

section 9 : Your Family, Your Doctor, and M.O.P. | 141

Parent: “No amount of guilt can change the past, and no amount of worrying can change the future.”
-Umar ibn Al-Khattab. This quote has helped me so much, as I carry around a huge burden of guilt. This
quote has helped me lock in what I can do right now for my children. I feel like I let my kids down by
getting upset with them for not going on the potty and by showing frustration when cleaning soiled
clothes. And for not recognizing the constipation and treating it right away. The list could go on and on!
Stay present in the present!”
Parent: “The most helpful thing for me is to remind myself where we were then compared to where we are
now! No, it’s not all fixed, but it IS better than it was — and that deserves a pat on the back!”
Parent: “I am beside myself with guilt, as now I can see my son has been very constipated for a long time.
I knew something was wrong, but we were just told to give him fiber and Miralax. It is a relief to have a
plan in place after being brushed off for so long by people who were supposed to care for my boy.”
Question: What advice do you have for a divorce situation? My 11 y.o. spends half time with dad, who
has the usual concerns/fears about enemas and doesn’t remind our son to take his laxatives. We’ve seen
increased dry nights over 8 weeks on M.O.P., even with only half time, but obviously my kid gets clogged
after 5 days at dad’s, and that causes setbacks.
Dr. Arthur-Stanley: I suggest finding a family therapist to help you work through these issues. I imagine
if you’re experiencing conflicts over encopresis and enuresis, you may also be dealing with conflict in
other areas of parenting. A family therapist could help you and your son’s father resolve communication
difficulties while helping your son find a voice in the treatment process and navigate the differences
between the two homes. If your son continues to see progress and feels empowered to continue his
treatment plan in both settings, perhaps this is the best-case scenario. He may begin to feel ownership
over the treatment process and learn what works and doesn’t work for his body. You and your son’s father
might also consider meeting together with your child’s doctor to review your son’s x-rays and further
discuss the scope of the problem, as well as the importance of finding a treatment that will work for both
families and most importantly, your son.
Parent: “I share time 50/50 with my kid’s dad, and I experience similar things. I feel like when I get the
kids back on Monday morning, I have to get my daughter cleaned out again, even though her dad claims
he did the enemas (my daughter says otherwise). There’s no consistency on how things are done at my
house vs. his house. We have poor communication, too. It’s hard, hard, hard.”
Parent: “Could you start keeping shared records, like a Google Doc, with your ex or have your son write
down the details, so there’s more accountability and you can see what’s really working?”
Parent: “My daughter’s dad disagreed completely about the enema treatment and refused to give her
enemas, so for a month, she didn’t get to sleep at his house. I was very glad to be single at home and
dealing with it myself. My daughter (8 years old) always likes the enema routine, so that wasn’t an issue.”
Parent: “Can you teach him to self-administer the enemas? Does he have a phone or a watch that can
have an alarm set to remind him to take the chewables?”

Managing M.O.P. on Vacation

Even the world’s best-pooping kids can get constipated while traveling, what with the
changes in routine, unfamiliar toilets, long flights or car trips, and more ice cream and
less broccoli than usual. For children on M.O.P., a spring break visit to Grandma’s or a summer
camping trip poses far greater challenges. This is a common topic in our support group. One mom asked:
“If we skip enemas for a week but continue laxatives, will that set us back to square one?” A dad wrote:
“Is there a simpler method we could substitute for a few nights? My daughter has had 5 or 6 accident-free
days and we don’t want her set back while we’re away from home base.”

142 | M.O.P. Anthology — 5th Edition

There’s no easy answer to these questions. Some families, despite tremendous vigilance on the road, do
experience big setbacks, and some even choose to give up travel while they’re in the thick of M.O.P.
Others can dial back treatment on a trip and pick up where they left off, no worse for the wear. Some
families take their M.O.P. show on the road. A mom featured in The M.O.P. Maestro Guide, in Section
10, posted about the "suitcase full of enemas and Ex-Lax" she brought on a car trip with her large family.
I sympathize with folks trying to maintain M.O.P. on the road. Travel can complicate every aspect of the
program. But yeesh, every kid needs a break! So do parents.
Whatever approach you take, map out a plan with your child before the trip, so you’re all on the same
page. Some kids are thrilled to take a break from the routine; others worry about setbacks and want to
stick with the program despite the inconvenience. Some families are so determined to stick with their
regimen on the road that they will even maintain Double M.O.P. at hotels. One mom posted: “I just ask
room service for a bottle of oil to keep in the room and bring an empty Fleet bottle for the enema.” That
family gets extra credit!
Following are tips for managing M.O.P. on vacation, in hopes that your family can balance the need to
stay vigilant with the need to relax.
• Get ahead of the game before you leave. If possible,
work in some “bonus” clean-out measures before the
trip, as a hedge against anticipated rectal clogging. If you can enjoy your
Some families have had good luck doing a few extra
days of Double M.O.P. before a trip, to get their vacation and return home
kids maximally cleaned out. Others have done a high- without a big setback, that’s
dose laxative clean-out prior to vacation. Most kids a victory. And rest assured, all
are willing to take extra steps before a trip, knowing
they’re about to get a reprieve. setbacks can be reversed.
• On the road, use docusate sodium mini-enemas or
LGS. Both are smaller than phosphate enemas or a
bag enema kit. Even if they’re not as effective as your child’s usual enema, they may work well enough
to prevent a setback. Or, you may discover they work better! Homemade LGS with syringes are easy
to make ahead and bring on a trip, too.
• Supplement enemas with stimulant laxatives. When enemas are too difficult to maintain for a week
or two, Ex-Lax can be the next best thing. Before the trip, experiment with the dose and timing, so
you don’t inadvertently stimulate the urge to poop while your child is on an airplane. While on the
road, it’s important to maintain your child's daily osmotic laxative. You may want to boost the dose
slightly, but not so much that your child ends up with diarrhea.
• Travel with a toilet stool. Your child’s pooping posture can actually make a big difference! One mom
in our support group posted: “On our last big trip, my 5 y.o. wasn’t getting much output from LGS.
Halfway through the trip, we had him sit on a Baby Bjorn kids’ potty. He still fit, and it put him in a
big squat. His output went back up, and we started having a lot more success.” For taller children, the
travel version of the Squatty Potty, the Porta Squatty, is a good option.
• Work potty sits and pee breaks into your schedule. It’s hard to get kids to spend a full 5 minutes on
the toilet when you’re rushing off to school or activities. Vacation may actually make things easier.
Set the expectation that your child will be sitting on the toilet twice a day to poop, ideally after
breakfast and dinner, and try to work in family pee breaks every 2 to 3 hours, including on airplanes.
No matter what approach you take on vacation, keep your expectations low, and don’t worry about
making progress. If you have to skip enemas completely, don’t sweat it. If you can enjoy your vacation and
return home without a big setback, that’s a victory. And rest assured, all setbacks can be reversed.

section 9 : Your Family, Your Doctor, and M.O.P. | 143

Section 10

An Anthology of Guides
In this section, you'll find four guides:
• The Enema Rescue Guide
• The M.O.P. Maestro Guide
• The Physician's Guide to M.O.P.
• The M.O.P. Parent's Guide to Advocating for Your Child at School

You can download each guide separately at

[Link]

THE PHYSICIAN’S

The M
.O
.P.
o G ui de GUIDE TO

str
Treating Enuresis and Encopresis
The M.O.P. Parent’s Guide to

Ma e
with the Modified O’Regan Protocol
How to orchestrate
your family’s daily
enema regimen “M.O.P. works radically better than anything else.”
without going bonkers
– James Sander, M.D., Pediatric Urologist,
UT Health, Rio Grande Valley, TX Advocating
12 Strategies
for Your Child
“It is my mission to get
the word out about
to Help Your Child “Families and kids are
a lot more receptive to how incredibly effective
Get Comfortable
with M.O.P.
M.O.P. than I would
have thought.”
– Irina Stanasel, M.D., Pediatric
M.O.P. is.”
– Erin Wetjen, PT, specialist
in pediatric incontinence,
Mayo Clinic, Rochester, MN
at School
Urologist, UT Southwestern
from parents who’ve “I was not expecting to go from
Medical Center, Dallas, TX Few teachers receive training
on toileting difficulties. Here’s
been in the trenches adamant refusal to completely
on board in less than 4 hours!”
how to gain the support of
your child’s educators.

A master class
By Steve Hodges, M.D.,
from parents
and Suzanne Schlosberg
Illustrations by Cristina Acosta From the M.O.P. Anthology 5th Edition. with multiple kids
on the Modified “No enuresis treatment works as
O’Regan Protocol By Steve Hodges, M.D. well as M.O.P. — not even close.”
Professor of Pediatric Urology
– Victoriano Romero, M.D., Urologist,
Wake Forest University School of Medicine
Redding Urologic Associates, Redding, CA
By Steve Hodges, M.D.,
with Suzanne Schlosberg
Illustrations by Mark Beech

Professor of Pediatric Urology,

Wake Forest University School of Medicine

Steve Hodges, M.D.

section 10 : AN ANTHOLOGY OF GUIDES | 145 145

 12 Strategies
to Help Your Child
Get Comfortable
with M.O.P.
from parents who’ve
been in the trenches

By Steve Hodges, M.D.,

and Suzanne Schlosberg
Illustrations by Cristina Acosta From the M.O.P. Anthology 5th Edition.
 Convinced your child will never
get on board with enemas?

Worried the process

will be traumatic?

Unsure how to rebound after

a difficult first experience?

Plenty of parents have been there, only to find themselves

amazed when enemas become routine for their kids — or
when their children actually ask for an enema.
One mom in our private M.O.P. support group was stunned when
her 7-year-old, who is autistic and minimally verbal, came to
“It was
her after his third enema and said, “Bum.”
harder for us as
“I actually found him trying to open a Fleet enema and use the parents to wrap
it on his own,” she posted on our group’s Facebook page. our heads around the
Another mom posted a photo of her idea. The first two nights
4-year-old son “playing constipation” were the hardest. It has
with his marble run. The boy been smooth sailing
“Our pediatrician ever since.”
narrated: “Look at all of this hard
said enemas are
poop. This colon is clogged. It’s
very difficult constipated! But that’s okay, I’ll just
to do with kids. give it an enema!”
Turns out our
This guide is packed with creative and practical tips to help
kid doesn’t mind
your child — or yourself! — overcome apprehension about
them at all.” enemas. We hope you find it helpful!

Enema Rescue Guide | 2

 1 Let your
child take
“If I’m going
to be honest,
charge. I was the one
who was scared,
and I think I was
Children as young as 5 may be able to insert the enema making things
tip on their own; others may prefer you do it. Ask your worse for my
child’s preference, and revisit the question periodically.
daughter.”
Younger children can take control in other ways.
• “Our approach was to have our daughter do the insertion herself, so we talked
through the sensations and had her ‘practice’ with her own finger first (trimmed
nails and clean!).”
• “My 5-year-old was scared the first time I had her administer the
liquid glycerin suppository herself, but she thought the penguin on
the box and the little suppositories were so cute. I just told her to
“My 4-year- practice sticking it in — no pressure — and I would check to see if it
was in the right spot and not touch her at all. Giving her the control
old really likes made all the difference. She got really comfortable with LGS.”
taking the cap • “We ask, ‘When do you want to do your poop medicine? Before we
off and holding the ride bike or after?’ That gives him a sense of authority.”
bottle before we do • “I always wait for her permission to go ahead with the enema, even
if it takes 30 minutes.”
it. I think it gives
him a sense of • “For my kids, having control is key. They all insert the enema
themselves, except the 3-year-old. The 8-year-old does the syringe
control.” with a soft tip LGS, and the 6-year-old and 10-year-old are doing
M.O.P.+. They have control over inserting the enema and allowing
the flow.”

2 Compare the enema

tip to a typical poop.

Some constipated kids poop out giant logs, jumbo sausages, even stools “the
size of a Pringles can,” as one mom posted. An enema tip is teeny by comparison.
• “I showed my daughter how a poop is 1-2 inches wide — a lot wider than the enema tip.”
• “I talked about how the enema tip is way smaller than poop. That really helped. I also did a demonstration
using my hands clasped, palms up. The space where my fingers connected was the enema entry point.
I showed him how I would use Vaseline and his bottom would open up and the bottle would fit in.”

Enema Rescue Guide | 3

When your child’s bottom muscles

3 Help your
are relaxed, the enema tip will slide in
easily. Encourage your child to take
deep breaths, like blowing out birthday child relax.
candles or blowing up a balloon.
• “My kids hug their knees and breathe out. We call it
our cleanse and yoga breathing.”
• “I got the iPad out for my 5-year-old and put on a video of Chip and Dale and Donald Duck. He was so into
it that he hardly budged when I administered the enema. They don’t call TV the ‘boob tube’ for nothing.”
• “My 4-year-old wanted big sister to hold her hand.”
• “The first week was rough, and my son held my hand while Dad did the enema.”
• “I place a soft mat on the floor and use a portable heater in the bathroom to keep it cozy and warm.”
• “My 5-year-old clenches when it’s enema time. Our pelvic PT suggested he
try to push the enema away with his sphincter muscles. That really opens
up the anus, so I can get in there with less discomfort and resistance.”
“If the cat • “My husband lies on the floor with our son, and they watch Mickey Mouse
is around, Clubhouse on the iPad as I do the enema.”

she likes to • “I turn lights down low, cover her with a blanket, and always do it in my
bedroom/bathroom so her room isn’t associated with the procedure.”
cuddle with • “To get her relaxed, I make her cheeks ‘talk’ to me about silly things.”
kitty while • “I sing to my son during insertion and then read to him while he holds it.”
I do it.” • “Make it as spa-like as possible: lay a towel on the floor, give them a pillow,
a stuffed animal, a soft blanket — anything to make them feel comfy and
‘pampered.’”

“When my

4 Acknowledge
your child’s fear.
daughter gets
anxious, we slowly
say the words, ‘I
am brave, I am
Rather than say, “Don’t be afraid,” express empathy strong, I am done,’
and acknowledge any worries your child may have. and it is over. She
• “We did lots of talking beforehand about how lots of kids are so usually holds a
scared they cry and how I was scared when I had to get one before
my colonoscopy. The discussion made all the difference. Now we favorite stuffed
are on day 14 and the enema doesn’t faze her at all. Like, not one
bit. And the enemas have helped SO MUCH.”
animal.”
• “My daughter and I were both nervous. We talked a lot about the
body, and how some parts seem mysterious because we can’t see
them. That was to get over the weirdness of dealing with such a private area. Then, to get beyond a sense
of vulnerability, we had her take some private time with her finger and lube, since she knows perfectly when
to stop or adjust. The first attempt at an enema was still a production but I think partly because she felt
pressure due to being uncomfortably constipated.”

Enema Rescue Guide | 4

 5 Plant the idea and give it time
to take root.
“My daughter
and I were outside
Use Bedwetting and Accidents Aren’t Your talking to our neighbor, and my
Fault or Emma and the E Club to introduce daughter pointed out clumps of dried
mud on the sidewalk. Our neighbor said,
the concept. Both books emphasize that ‘Oh, don’t worry, the rain will wash the hard
loads of kids have accidents and need mud away.’ And my daughter said, ‘Just like
the special water in an enema washes your
enemas. One 10-year-old reader of
poop out!’ The neighbor laughed and said, ‘I
Emma commented, “This book explains guess so!’ Then my daughter said, ‘Do you
everything I went through. Even though know what helps ME with enemas? Vaseline!
And you know what else? THE ENEMA
enemas might seem scary, they are BOOK!’ Our neighbor got an earful, but
actually one of your best friends and will at least my daughter is getting
the message that enemas
make you feel 100 times better!”
are helping!”
• “We read Bedwetting
and Accidents Aren’t Your
Fault together before we began
M.O.P. I had mentioned several times that we might go that
route. When laxatives and clean-outs didn’t work, he was prepared
for enemas.”
• “My daughter and I read Bedwetting and Accidents Aren’t Your Fault
several times when she was just on Miralax, and she suggested trying
the enemas herself.”

“I squirted

6 Appeal to your child’s

inner scientist.
water on a soft
peppermint. It
took a few squirts
to start getting
mushy, which gave
my son a concrete
visual for why
Many kids are fascinated by the workings of an enema.
we are doing
• “We switched to a clear enema bag, and watching the fluid draining out M.O.P.”
fascinated my son. He has a keen interest in science and anatomy.”
• “The inspiration came one morning at breakfast. There was a large, hard lump of
sugary flavoring at the bottom of my son’s instant oatmeal packet. I told him this is what his poop is
like in his colon: hard and dry and hard to break up. I asked him to try to squish it, and he couldn’t. I
placed it in a bowl and poured water over it. While it dissolved, I told him that’s what happens when
we use the enema.”

Enema Rescue Guide | 5

 7
Screen time, toys, treats —
whatever works. Any child unlucky Offer a reward.
enough to have to undergo
M.O.P. deserves a prize!
• “Bribes for our 4-year-old include: glow-in-the-dark toys, dollar-store trinkets,
bouncy ball, blowing candles out of a giant marshmallow, phone call to
Grandma and Grandpa to tell them he pooped on the potty.”
“My daughter
• “We started with Starbursts and moved on to the iPhone.” asks every day,
• “We have a ‘super pooper party’ after each enema. My son gets a small ‘Can we do my bum
treat with a candle in it. We sing, ‘You’re a super pooper’ to the tune
medicine?’ because
of Happy Birthday. It’s ridiculous, but it works.”
she gets to watch a
• “I offered my son a Lego set in exchange for 30 days of enemas. We show while sitting
hung a calendar on the wall, and by the end of the first week, it was
no big deal. After the month, he got his Lego set, and we kept doing on the potty.”
enemas. He never said, ‘You only said 30 days.’”
• “My 6-year-old has started a candy collection. He gets 1 lolly for a
spontaneous poop (from Ex-Lax) and 3 lollies for a ‘bottom rocket’ (enema).
Going to start buying diabetic candy to be better on the teeth.”
• “I paid 6 bucks last night for him to let me do it. Other nights, I’ve given $1 or candy. Gotta do what I gotta
do! He’s saving up for a new Xbox.”

Have your child try

8
“Our son
prefers lying on
his back with one a different position.
of us holding his
legs towards his
chest.”
Most kids prefer lying on the left side, knees bent, but
some feel more comfortable facing down, butt upward.
• “I have my kiddo lay down on his forearms, butt in the air, and we sing ‘Put your butt in the air like you just
don’t care’ while he’s watching the iPad. I then put the tube in the anus at the same angle of his body.”
• “She lies across my lap, with her bottom in the air, while clutching her favorite toy.”
• “My daughter lies on her back with me holding her knees to her chest. She won’t do it any other way.”
• “On her knees, chest down, bum up — that’s how we do it.”
Add K-Y Jelly, Vaseline, Aquaphor,
“We use

9
or coconut oil to the tip and/or the
child’s bottom. a Death-Star-
size glob of
• “There’s no such thing as too much lubricant.
We use Vaseline and K-Y together.” Vaseline.”
Glob on • “Really grease it up! Even though the enemas
come pre-lubricated, it is not enough for us.”

the lube. • “Put an enormous amount of petroleum jelly on that sucker! The default
amount on the tip isn’t even close to sufficient.”

Enema Rescue Guide | 6

 “I casually showed

10 Give yourself my kids the enemas after

school. ‘Nope. Nope. Nope.’
an enema. was the response. I said, ‘I’ll
try it myself this weekend.
We’ll see how it goes.’ Bedtime
rolls around and the younger
What better way to show solidarity and offer a
one says, ‘I want to try the
scouting report? Children greatly appreciate enema.’ I was shocked. After
this gesture. half the bottle, she said, ‘That’s
• “I did it on myself, and my daughter watched and saw it didn’t enough for tonight.’ Then: ‘My
hurt. Worked wonders!”
tummy feels empty. I want to
• “When I did one in front of my son to show him that it doesn’t keep doing the enemas.’ She
hurt, that tipped the scales to get him to try it.”
reports to big brother, who
• “One thing I learned when doing it on myself is that it helps says, ‘When do I get to
tremendously if you bear down like you’re pushing out a poop. That
will relax the muscles and make it pretty effortless.” try the enema?’”

• “After giving myself an enema, I realized how much more comfortable it is

when you’re lying on your left side. No wonder my daughter freaked out when
we tried it on her right side.”
• “I let my 6-year-old give me an enema. It showed her I wouldn’t ask her to do something I wasn’t willing to
do. It also gave her a sense of control and partnership.”

11 Explain why
enemas work
so well.

“I say, ‘Yay!
Explain that the lump of poop is stuck in the rectum, You got all the
near where poop exits, whereas oral laxatives come icky poop out that
from the top down and can’t do as good a job cleaning was stuck in
out the hardened mass at the bottom. your belly.’”
• “We say, ‘Good job buddy! Your belly is so happy now!’”
• “For my 5-year-old, showing him pictures of the bladder smashed by a
rectum overfilled with poop was helpful at the start. I explained how the
enemas would help fix it, and I let him see and handle the supplies. That helped him get on board.”
• “Telling my son the enema is like a straw for the butt made my kid laugh and convinced him to try it!”

Enema Rescue Guide | 7

12 Try a different
enema or enema tip. “My son prefers
large-volume
enemas because the
flow is more gradual,
Phosphate (Fleet) enemas, liquid glycerin suppositories, rather than the ‘squirt’
you get from store-
docusate sodium mini-enemas, Microlax (common in
bought enemas.”
Europe and Oceania), large-volume enemas with glycerin
or Castile soap — there’s no shortage of options.

• “My son said phosphate enemas burned inside. He’s fine with liquid “My daughter was
glycerin suppositories.”
terrified of the blunt tip
• “Liquid glycerin suppositories make my son nauseous and sometimes of the Pedia-Lax LGS and
throw up or cause him to gag. He has no problem with phosphate
refused treatment for
enemas.”
months. When I found
• “My teenage son likes Enemeez mini-enemas because they are small long-tipped oral syringes,
volume and more discreet for sleepovers than other enemas.”
she could see how tiny the
• “We were nervous to try the large-volume enema with my 8-year-old, tip was and that made it a
but it isn’t as scary as I thought it would be, and my daughter finds
them more comfortable.” breeze to administer!”

• “I’m in Australia. We got little output from Microlax, sometimes none at

all. We switched to Fleet enemas, and they are FAR more effective, with big
output every time.”

tubing
enema
bag

or or or or
clamp

hook

nozzles

Docusate sodium Homemade LGS Liquid glycerin Phosphate enema Large-volume enema kit
mini-enema suppository

Enema Rescue Guide | 8

 The M
.O.P.

o G u i d e
Ma e st r How to orchestrate
your family’s daily
enema regimen
without going bonkers

A master class
from parents
with multiple kids
on the Modified
O’Regan Protocol

By Steve Hodges, M.D.,

with Suzanne Schlosberg
Illustrations by Mark Beech
 INTRODUCTION
A while back, a mom with 5-year-old triplets on M.O.P. joined our private Facebook
support group. Yes, triplets on M.O.P.! We’ve also had many members with two,
three, and even four children on the protocol.

That’s not surprising, given that chronic constipation

has a strong genetic component. But it’s also kind of
amazing. I marvel at these moms (yes, so far, they’ve
Remember, all been moms) for all that they juggle — the logistics,
M.O.P. is not the supplies, and the monitoring, not to mention the
cheerleading and cajoling. These folks post about
forever. You
bins full of DIY enema supplies, pill boxes lined up on
won’t always the kitchen counter, color-coded spreadsheets, and
be playing organizing the evening “enema assembly line” amidst
musical toilets. showers, pajamas, teeth brushing, and bedtime reading.

I often think of these parents as orchestra conductors.

They’re “interpreting” M.O.P. — deciding which kids will
follow which enema/laxative regimen — while setting
the tempo of the daily routine, keeping a range of personalities in sync, and working
to bolster the spirits of the whole crew. But unlike orchestra conductors, these folks
did not train for the job! Of course, they’re also conducting an ensemble that did not
sign up for it, either.

And yet, these accidental conductors manage to make it all work. With a bit of
practice, one mom says, “it all becomes much more routine and easier to manage,
just like any other routine.”

If you’re overwhelmed by the prospect of managing M.O.P. with two, three, or four
children, this guide is tailor-made for you. Our goal is to save you time and money

The M.O.P. Maestro Guide | 1

and encourage you to push forward. If you’re new to M.O.P. and worry the protocol
will be too disruptive for even one child, the perspective offered here may ease
your concerns.

Over the years, folks with multiple kids on M.O.P. have posted wisdom and
encouragement to newer members. To collect their ideas in an organized fashion,
we asked them to fill out a survey, which became the basis for this guide. I’m grateful
to these parents for sharing their unvarnished advice.

Despite the obvious challenges of conducting a duet,

trio, or quartet of children on M.O.P., one theme
evident in the surveys is that life on the regimen beats
the alternative. Managing
all the kids
“M.O.P. is so much better than accidents all the time,”
one mom reported. “My kids are more confident, and
is definitely
they’re proud of themselves for doing the work to get less difficult
better.” Their work paid off on a road trip to a national than I
park. “It was the first vacation we’d ever had without a anticipated.
single accident. Sure, I brought a suitcase full of enemas
and Ex-Lax, but it was well worth it to be able to go
hiking and swim in the hotel pool without worrying
about accidents!”

Several parents have reported that while they agonized over starting their first
child on M.O.P., procrastinating because enemas seemed so “extreme,” they didn’t
hesitate with their younger children, who benefited from early treatment. “Knowing
how much M.O.P. helped the older two made it so much easier to do with my
younger kids,” one mom of four wrote. “At first, I felt awful making my reluctant
7-year-old do an enema. Now I feel like it’s just necessary medicine. M.O.P. is so
much easier and less painful than having the kids take so many oral laxatives.”

Every family’s arrangement is different, and every conductor has their own style!
I hope you can pick up ideas to make M.O.P. more harmonious for your family.

GETTING STARTED
Take the plunge, and worry about the details later.
You can’t predict what type of enema or laxative any child will respond best to, so
just pick a starting point. “Don’t worry about figuring out the perfect routine before
you start,” one mom advises. “Just do it, and make adjustments as you go.”

The M.O.P. Maestro Guide | 2

 Consider starting every child on the same protocol and
then gradually making individual changes. “That was
what helped my sanity,” one mom wrote. “I was the
Start M.O.P. at the most stressed when I was trying different things for
first sign that a different kids.”
sibling is withholding
Another mom applies the assembly-line concept across
or having accidents.
the board. “Each child has an extra pair of underwear
I wish I’d recognized
in a Ziploc bag in their backpack, and I put them in the
the signs in my
same pocket of each backpack, so I know where to
younger guys earlier.
check. I always ask the kids, ‘Did you poop today?’ right
before an enema. Keeping as many things the same as
possible helps.”

Banish all blame!

Enuresis and encopresis are plenty common but rarely
discussed, so many parents feel responsible when Give yourself
a child doesn’t outgrow accidents. When accidents grace, and
strike multiple kids, feelings of responsibility are often understand it may
compounded. “At first, I thought it was an outlier that be a long road.
this happened with one child, and I didn’t think it was Whatever you’re
possible for multiples,” one mom of four wrote. “Then I doing is better
thought I did something wrong that all my children had
than nothing.
the same issue. I’ve had to adjust my thinking.”

In some families, everyone needs eyeglasses. In other

families, everyone needs enemas.

Don’t assume your kids will resist M.O.P.

Many parents are surprised to learn their children aren’t as apprehensive about
enemas as they themselves are, and siblings often encourage each other. “I think it
helped that my youngest saw his older brother go through the process before we had
to start with him,” one mom wrote.

A mom of three posted that her 8-year-old was afraid to do the first enema, but by
the third, she was asking to administer it herself and asking to do it earlier in the day
because she felt so much better. “My 5-year-old was very resistant but now doesn’t
mind at all. My 8-year-old offered to let the 5-year-old watch to show her how easy it
was. The 3-year-old was so used to seeing her sisters do enemas that when I said we
were going to start doing them with her, she said, ‘Oh yeah, I love butt medicine!’”

The M.O.P. Maestro Guide | 3

 Celebrate small improvements.
As I often remind families, a rectum stretched for years
We are much won’t shrink back overnight, and aggravated bladder
happier without the nerves can take months to settle down. What’s more,
constant checking of the habit of holding poop can be difficult to overcome.
underwear, laundry, So, it’s important to temper your expectations and
finding poop crumbs celebrate the small wins, like when one child starts
on the floor, and sensing the urge to poop or another begins self-
doing weekend administering enemas, freeing you up a bit. Celebrate
oral clean-outs. when one kid stops having poop accidents and another
moves on to Phase 2 of M.O.P.

“My advice is to not expect fast progress,” one mom

wrote. “Learn to appreciate that daily emptying through
enemas allows your children to participate in life without poop everywhere. As the
soiling improved, the stress definitely lessened. We were able to go swimming, go to
parks, take vacations, and get through a school day without accidents.”

Rest assured, M.O.P. will end.

Though your kids may be on oral laxatives for six months
to a year after accidents cease, the high-intensity portion
of the regimen won’t drag on indefinitely. “Remember
M.O.P. is not forever,” one mom wrote. One day, when
your family is liberated from enemas, this era in your
life will seem like a blip, and you’ll feel a grand sense of
accomplishment.

“I can’t even begin to explain the relief of resolving encopresis,

especially for a kid who was just starting middle school,” one
mom wrote. “It was nearly unbelievable to not have to worry
about packing a change of clothes, wipes, plastic bags,
working out a place for him to change at school, secret
signals for teachers to let him know he had to go change,
worrying constantly about other kids being mean to
him because of the smell. After looking for a solution
and worrying so much for so long, well, there are no
words for how much M.O.P. improved our lives.”

The M.O.P. Maestro Guide | 4

 ORGANIZING YOUR ROUTINE
Get help anywhere you can.
You may be directing the show, but this does not mean you
need to take on 100% of the tasks. Delegate! If you have a
spouse or partner, even one who’s not fully on board with
M.O.P., assign them some of the easier jobs. “I do all the
enemas per my children’s request, and I direct who is on what
medication,” one mom wrote, “but my husband does morning meds.” Another wrote,
“My kids all like me to help administer the enemas, but their dad helps them clean up.”

If your spouse won’t go near enemas, insist on tag-teaming for the bedtime routine.
“My husband would read books while I was finishing up enemas,” one mom reported. “He’s
not comfortable doing the enemas, but if I was going out with girlfriends, he would
happily set a timer and tell the kids when they were done.”

Your children can help, too. Depending on their age and maturity, they may be able to
self-administer enemas, track their progress in a chart
(or at least report to you), and stay on top of their oral
medications. When kids take a big role in the process,
they tend to feel more in control and invested.
We have pill
cases for the Here’s how it works for one family: “At night I deal with
the 4-year-old and his baby sister. She starts in the bath
week, so I can
while he’s on the toilet. My husband tackles the older
see if anyone two. First, they take their oral medicine, which has been
has forgotten laid out on the counter, and each gets an enema in
their laxatives. their own bathroom. Our 9-year-old has started self-
administering enemas, so that helps. The children now
know exactly how much medication to take. They treat
it like vitamins.”

Aim for consistency.

Missed enemas or laxatives can delay or reverse progress. I know consistency can
be a challenge when you have kids on different school and activity schedules, and
with different levels of motivation to comply with treatment. Do your best to keep
your family in a groove. For example, one mom wrote: “All four of my kids take their
oral laxatives in the morning. We have pill cases we fill for the week, so I can see if
anyone has forgotten. My younger two both do enemas right after we get back from
dropping the big girls at school. The big girls do their enemas before bed.”

The M.O.P. Maestro Guide | 5

This mom keeps the pill boxes on the kitchen island. “The reminder is helpful since
they don’t always eat breakfast at the same time. If I flip one pill box sideways after
the kid has taken pills, it’s even more of a visual reminder that two still need to take
theirs. Mom-brain needs all the help it can get!!”

Another mom explains how her family managed to squeeze M.O.P. in at night
despite an early bedtime: “I would do an enema for one kid, and then start the timer
on my phone, and during the 10-minute wait, I’d have the others shower, read books,
get pajamas on, and brush teeth.”

Here are a few examples of how different families organize their routines:

Laxatives are taken

We take turns. We do one kid
at breakfast and/or
at a time. The big kid
dinner. Each kid takes One kid gets
does his own enema.
a bathroom for potty the enema and They watch screens
time after breakfast. poops, and then for 20 minutes
Enemas are done
we move on to while they sit after
before bedtime,
the next kid. their enemas.
one after another.

Don’t be afraid to switch up the routine.

I know I just said consistency is critical, and I meant it. But it’s also important to adjust
the regimen after any 30-day period without progress. In other words, be consistent,
but be flexible, too! A finely tuned routine won’t help if your kids’ rectums aren’t
emptying. At some point, you may need to disrupt the routine you’ve worked so hard
to establish.

“I found that it helped to maintain the status quo for my two youngest while trying
to specifically figure out what would help my oldest,” one mom wrote. “Getting her
completely off enemas has freed up my brain to now focus on my youngest.” Another
mom noted that making a change is never as bad as she feared. “A couple of days
into a new protocol, it gets easy to do. Managing all the kids is definitely less difficult
than I anticipated.”

The M.O.P. Maestro Guide | 6

 TRACKING PROGRESS
How much detail you record is a matter of personal preference. For those who prefer
old-school paper tracking, we offer monthly and weekly calendar sheets on our
website, plus a simplified monthly calendar for tweens and teens to track their own
progress. But these charts are not designed for tracking multiple kids at once, so
you’ll need to get creative.

“We use the monthly M.O.P. charts, but it’s a bit

messy,” one mom noted. “I update every other day,
before I forget details. I ask the kids each day about
their pooping and do a summary of dry nights,
accidents, etc., at the top of each month’s chart, so I
can easily compare progress from month to month.”

Some folks use one calendar for multiple kids. “I use

a paper calendar with the twins,” one mom wrote. “They each have a square of the
calendar.” Other parents find it easier to fill in a separate calendar for each child.
“I have a blank calendar printed out for each of the four kids and staple a new one to
all the previous months, so I can flip through and see progress,” one mom explained.
“All the kids like to show me their SPs [spontaneous poops], so I get a great reporting!
My 8-year-old and 10-year-old tell me if they pooped at school, and I write it down.”

Another mom prints out our calendars and keeps them on a stand outside the
bathroom door, so she doesn’t forget to fill them in. “For each kid, I note what meds
they took, SPs, enemas, and accidents v. dry pull-ups.”

We keep a I don’t do any

I bought a yearly
My advice: calendar for the tracking, except the
planner, and I write
Write everything two oldest. The 5-year-old writes
daily events there,
down!! Otherwise, youngest is on a whether she was
like which kid had an
there is no way modified regimen, dry or wet on her
enema. I get morning
I can know who as he has made the unicorn calendar,
reports from each
is struggling. most progress, so with different
kid re: whether their
we don’t track color markers.
pull-up is wet.
for him.

Other parents prefer to create digital charts. “Google Spreadsheets helps me

keep things simple with three kids,” one mom says. “I track accidents, enemas,
and who pooped that day. I color-coded the chart to differentiate among the kids.

The M.O.P. Maestro Guide | 7

My youngest was dealing with night wetting, so she got two rows for accidents, one
for daytime and one for overnight.”

You might assume tracking less information would be easier for folks with multiple
kids on M.O.P., but some parents insist that tracking more data actually frees up their
brains and reduces their stress. “Track everything so you have less to remember,” one
mom advises.

Tracking each child’s progress, however you choose to do it, can help keep your
spirits up, several parents have noted. “When one kid is having a setback, I feel like
everything is falling apart and we will be drowning in poop forever,” one mom wrote.
“Then I can look at my calendars and see that, actually, things are going fine for the
other three and remember that we will be OK.”

SAVING MONEY
Given the expense of store-bought enemas, most families with multiple kids on
M.O.P. make their own liquid glycerin suppositories with syringes. Just know
that for some kids, LGS isn’t effective. “We moved to homemade LGS for all three
kids to save money, but for one of them, we had to go back to Fleet enemas,” one
mom wrote.

Another mom tried buying generic phosphate enemas to save money,

but her youngest said they burned, so that child went back to the Fleet
brand. “My other two kids were fine with generic,” she wrote, “but even
that got too expensive, so we switched to homemade LGS.”

On the osmotic laxative front, generic PEG 3350 can be found online
in large quantities. But don’t invest in a big tub until you know that
laxative is effective for your kids. For those who prefer magnesium
hydroxide, milk of magnesia is much less expensive than Pedia-Lax
chewable tablets. However, many kids don’t like the taste of liquid milk
of magnesia and aren’t able to swallow the pills.

As for stimulant laxatives, generic versions of Ex-Lax work as well as

the name brand. Some parents report the most
cost-effective approach is purchasing 25-mg
Ex-Lax tablets that come in a bottle of 90.
However, those can’t be broken into smaller
pieces, so if you need to adjust a child’s dose
in smaller increments, generic 15-mg chocolate
squares may be a better option.

The M.O.P. Maestro Guide | 8

 Mallory’s Story:
It’s amazing on the nights when I only have to
do an enema for one kid.
Our oldest was never dry at night and started having daytime accidents at age 4.
Over the years we tried so many things, including tracking diet, timed bathroom
visits, and daily Miralax. Each time she might show some improvement but would
always lapse back into regular accidents. I was so frustrated and crying every day
because I just didn’t know what to do.
I found M.O.P. when she was 9, and she was fully on board. It took a lot of trial and
error, trying different enemas and laxatives, to find the right formula for her. What
finally worked was senna pills in the morning followed by a large-volume enema
at night with glycerin and Castile soap. After a relapse, we started over and then
tapered more slowly, skipping just one enema a week. After another month we
skipped two enemas a week. We continued this way until she had her last enema.
She is still taking her senna pills daily.
My two youngest are also on M.O.P. as they had each had regular accidents. They
are both in different stages of tapering. Our nights are slowly getting more relaxed
as we get to skip more and more enemas! It’s amazing on the nights when I only
have to do an enema for one kid.
A few years ago, I had no hope that this would ever be resolved. I had many years
of guilt and frustration and sometimes anger. Now we are so much happier.
This past summer we drove to a family cottage, as we do every summer. It’s 9 hours
away and we usually have to stop SO many times for bathroom breaks. This last
time, we only stopped once for gas and once for food. Little things like that are
amazing and something that families without this problem wouldn’t even think
twice about.

Keep up what you are doing because this process works!

The M.O.P. Maestro Guide | 9

 THE PHYSICIAN’S
GUIDE TO
Treating Enuresis and Encopresis
with the Modified O’Regan Protocol

“M.O.P. works radically better than anything else.”

– James Sander, M.D.,
Pediatric Urologist, UT Health, Rio Grande Valley, TX

“It is my mission to get

“Families and kids are the word out about
a lot more receptive to how incredibly effective
M.O.P. is.”
M.O.P. than I would
– Erin Wetjen, PT, specialist
have thought.” in pediatric incontinence,
– Irina Stanasel, M.D., Pediatric Mayo Clinic, Rochester, MN
Urologist, UT Southwestern
Medical Center, Dallas, TX

“No enuresis treatment works as

By Steve Hodges, M.D. well as M.O.P. — not even close.”
Professor of Pediatric Urology – Victoriano Romero, M.D., Urologist,
Wake Forest University School of Medicine Redding Urologic Associates, Redding, CA
 The Cheat Sheet of M.O.P. Variations, Resources for Families, and Full Text of Key Studies are included
NOTE: TOC in the complete Physician's Guide to M.O.P., downloadable at [Link]/downloads.

Contents

A Letter to Colleagues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Premise Behind M.O.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Origins of M.O.P.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Yes, Daily Enemas Are Safe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Nope, Enemas Don’t Traumatize Children (Accidents Do). . . . . . . . . . 4

Three Lessons From a Decade Prescribing M.O.P.. . . . . . . . . . . . . . . . 5

• X-Rays Are Invaluable
• Enuresis and Encopresis Should Be Treated Promptly
• No Cases Are “Refractory” to Treatment

Cheat Sheet of M.O.P. Variations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Resources to Share With Families. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Key Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
 April 2023

Dear Colleague,
I am writing to share a treatment protocol for enuresis and encopresis that works far better
for my patients than Miralax, Ex-Lax, medication, alarms, or other treatments I learned
in my medical training or used early in my career. It is an enema-based regimen called
the Modified O’Regan Protocol. M.O.P. is based on the published research of pediatric
nephrologist Sean O’Regan, M.D., who practiced at the University of Montreal Hôpital
Sainte-Justine in the 1980s and is now retired.
Dr. O’Regan’s original and highly successful protocol lasted 90 days:
• 30 consecutive days of enemas
• 30 days of enemas every other day
• 30 days of enemas twice a week
I have “modified” Dr. O’Regan’s protocol based on my own research and clinical experience
and discussions with Dr. O’Regan himself. Most significantly, I recommend:
• Extending the daily enema phase until all accidents cease. I do not recommend
tapering until the child has completed at least 30 consecutive days of enemas and has
been accident-free for 7 days and nights.
• Adding a daily osmotic laxative to the enema regimen. One exception: encopresis
patients should avoid osmotic laxatives for at least two weeks.
• Adding a daily stimulant laxative for children who do not “spontaneously” poop (in
addition to pooping after the enema). Senna/Ex-Lax can replace the osmotic.
Physicians unfamiliar with M.O.P. may consider it overly aggressive, perhaps “traumatic” for
children. Some worry daily enemas will cause dependence or electrolyte imbalance. These
concerns are unwarranted. I’ve used M.O.P. with thousands of patients, without incident and
with excellent success. Electrolyte imbalance is a non-issue; patients can use liquid glycerin,
docusate sodium, or other enema solutions. Enemas quickly become routine. As one mom
told me, “You know what’s traumatic? Wearing diapers to school every day in 5th grade. To
my daughter, enemas are no big deal.” I hear this all the time.
Enuresis patients are often told, “Don’t worry, you’ll outgrow it.” But many don’t. I treat
countless teens whose accidents were dismissed or attributed to “deep sleep” or “stress” —
kids prescribed PEG 3350 or useless meds for years on end. These kids, highly distressed
and left out of sleepovers and camps, are grateful for a treatment that works.
I have made enuresis and encopresis the focus of my research and clinical practice and
am eager to share with colleagues the regimen that has worked so well with my patients.
This packet briefly explains the rationale and scientific support for M.O.P. The different
M.O.P. variations are described in The M.O.P. Anthology 5th Edition, a comprehensive
guide for parents. I urge physicians to become familiar with the variations, as M.O.P. is not
one-size-fits-all. I am happy to email you a .pdf of the book, and I enjoy discussing enema
effectiveness and safety with colleagues. Email me and we’ll set up a time to talk!
Warmly,

Steve Hodges, M.D.

Professor of Pediatric Urology
Wake Forest University School of Medicine

The Physician’s Guide to M.O.P. | 1

The Premise Behind M.O.P.
Standard remedies for enuresis and encopresis miss the boat in one of two ways: 1.) They don’t address
the root cause of accidents, chronic constipation, or 2.) They are inadequate to the task of resolving
constipation.
The first category includes bedwetting alarms, bladder medication,
sleep strategies, fluid restriction, and behavioral or psychological
therapy. These approaches fail because they are beside the point.
As I discuss in the M.O.P. Anthology 5th Edition, accidents are not
caused by deep sleep, urine overproduction, a hormonal imbalance,
an underdeveloped bladder, stress, anxiety, “attention seeking,” or
Hey,you’re
Hey, you’re “acting out.” Rather, the culprit is a clogged, dilated rectum. You can
gettingon
getting on see it plain as day on an x-ray.
mynerves!
my nerves!
With enuresis, the enlarged rectum aggravates the bladder nerves,
triggering random and forceful contractions. With encopresis, the
Bladder
Bladder dilated rectum loses sufficient tone and sensation, and stool falls
nerves
nerves Pooppile-up
Poop pile-up
out, without the child noticing. It doesn’t matter what form enuresis
takes — daytime or nighttime, primary or secondary. It doesn’t
matter whether a child has autism, ADHD, or a family history of
enuresis. In a child with an intact spinal cord, wetting accidents
do not happen in the absence of constipation. Stool accidents, too,
cannot occur unless a child’s rectum is stuffed with poop.
For these reasons, treatment for enuresis and encopresis must focus on resolving constipation. More specifically,
the rectum must be completely emptied and must remain empty long enough (about three months) to shrink
back to size, stop aggravating the bladder, and regain full tone and sensation. This is a deceptively difficult task in
children with enuresis and/or encopresis. Daily osmotic laxatives rarely suffice, and in the case of encopresis, osmotic
laxatives often make accidents worse. Oral “clean-outs” are similarly inadequate. The rectum quickly fills back up,
and accidents persist.
I know this because early in my career, Miralax was my go-to treatment. I did not x-ray my patients and did not grasp
how clogged their rectums were. I simply followed what I’d been taught. But my success was limited. Fifteen years
later, I know what works: M.O.P.
The Modified O’Regan Protocol has numerous variations, but at its core, the treatment begins with a daily enema and,
in most cases, a daily oral laxative (osmotic or stimulant, depending on the case). Once accidents reliably cease, the
child gradually weans from enemas and then laxatives. The most aggressive and effective variation, Multi-M.O.P.,
involves two or three docusate sodium mini-enemas per day and no laxatives. (Yes, it’s safe!) The Cheat Sheet of
M.O.P. Variations, included in this packet, summarizes the options. I discuss each variation in depth in the Anthology
5th Edition.

Origins of M.O.P.
Sean O’Regan was not the first physician to link enuresis Are enemas safe for daily
and encopresis with chronic constipation, but he was the
use in children? Yes. Do they
first to prove a causal connection and to demonstrate that
daily enemas resolve these conditions — safely and highly traumatize children? No.
effectively. It’s a fascinating story.
Enuresis and encopresis were not Dr. O’Regan’s area of research or
interest. But his 5-year-old son was wetting the bed nightly, and
Dr. O’Regan, prompted by his wife, wanted to help the boy. At this time, bedwetting children were thought to have
psychological and/or anatomical problems, such as an excessively narrow bladder neck. Dr. O’Regan rejected both
theories and searched for answers at the renown McGill University Medical Library. There he found several papers,
dating back to the 1890s, referencing a connection between constipation and urinary dysfunction.
Intrigued, Dr. O’Regan enlisted a colleague, Dr. Salam Yazbeck, to test his son’s rectum using anorectal manometry,
the gold standard diagnostic tool. Dr. Yazbeck reported to Dr. O’Regan, “The kid’s got no rectal tone.” Dr. O’Regan

The Physician’s Guide to M.O.P. | 2

 began giving his son nightly enemas. Within a week, the boy enjoyed his
first dry nights. Within two months, his enuresis had resolved.
“We knew the root Based on this success, Dr. O’Regan conducted studies using the protocol
cause of bedwetting he’d tested on his son: daily enemas for a month, tapering to every other
was incomplete rectal day and then twice a week. He spread the word to local pediatricians and
attracted most of the French Canadian population of children with urinary
emptying. And enemas
dysfunction. I urge you to read the full text of Dr. O’Regan’s studies. In one
were the only way to investigation, Dr. O’Regan tracked 47 girls with recurrent UTIs who also had
solve the problem.” encopresis, enuresis, or both. After three months on the step-down enema
regimen, UTIs had resolved in 44 of the 47 girls. Encopresis resolved in 20 of
– Sean O’Regan, M.D. the 21 patients with this condition, and 22 of the 32 girls with enuresis had
stopped wetting.1 Among the girls who didn’t improve, most of their parents
conceded they hadn’t followed the regimen fully.
Dr. O’Regan told me he got no pushback from physicians regarding the use of enemas. None suggested enemas
would damage a child’s physical or emotional health or that oral laxatives would be preferable. (Though PEG 3350
wasn’t available back then, senna and magnesium were.) “We knew the root cause of bedwetting was incomplete
rectal emptying,” Dr. O’Regan told me. “And enemas were the only way to solve the problem.”
I have come to agree. A decade ago, I considered Miralax (“clean-outs” plus “maintenance”) to be a reasonable
alternative to enemas. I have long since changed my mind. Enemas work far better — it’s not even close. For
example, in one study, my clinic compared a Miralax regimen to Dr. O’Regan’s protocol in 60 patients with daytime
enuresis, with an average rectal diameter of 6 cm. After three months, daytime wetting had ceased in 30% of the
Miralax patients, compared to 85% of the enema patients.2 The data explained why: Among the Miralax patients, the
average rectum remained dilated, to 5 cm on average. The slight improvement was enough to help a few kids but
was inadequate for most. By contrast, rectal diameter among the enema patients had retracted to 2.15 cm. Among
the three enema patients whose wetting persisted despite enemas, the rectum remained enlarged. These are the
kids who require the more aggressive variations of M.O.P.
In children with enuresis and encopresis, Miralax is a poor remedy, no matter the dose or the regimen. Most of my
patients can’t get anywhere near accident-free in the long-term without persistent enema treatment. It’s indisputable
that enemas work better. But are they safe for daily use in children? Yes. Do they traumatize children? No.

Yes, Daily Enemas Are Safe

I have never had a patient harmed by enemas, and I
have treated thousands of children with M.O.P. When I
asked Dr. O’Regan if any of his patients had ever suffered There is no evidence enemas
complications, he responded, “Our only complication was a
7-year-old girl who clogged the toilet at our hospital after are harmful or even risky
an enema. She was legendary.” Yes, the damage was to the to the physical or mental
plumbing, not the patient!
health of children with
Dr. O’Regan wasn’t the only researcher of his day who treated
accidents with enemas. A Johns Hopkins team, in a 21-week study enuresis or encopresis, and
on children with severe encopresis, described its enema regimen there’s plenty of evidence to
as “highly effective,” “rapid and easy to perform,” “involving minimal
risk,” and “the treatment of choice for encopresis.” The Hopkins the contrary.
folks noted the treatment’s success “seem to gratify parents and to
encourage them to cooperate with the treatment regimen.”3
Yet, today, enemas are perceived by many physicians as damaging and coercive. What changed? One mom posited
a theory that seems plausible to me: “I wonder if the shift toward viewing enemas as ‘abusive’ and a last resort is

1 O’Regan, S., Yazbeck, S., & Schick, E. (1985). Constipation, bladder instability, urinary tract infection syndrome. Clinical
Nephrology, 23(3), 152–154. [Link]
2 Hodges, S. J., and Colaco, M. (2016). Daily Enema Regimen Is Superior to Traditional Therapies for Nonneurogenic Pediatric
Overactive Bladder. Global Pediatric Health, 3, 2333794X16632941. [Link]
3 Lowery, S., Srour, J., et al., Habit Training as Treatment of Encopresis Secondary to Chronic Constipation, Journal of Pediatric
Gastroenterology and Nutrition, 4:397-401, 1985. [Link]

The Physician’s Guide to M.O.P. | 3

connected to the greater awareness of child sexual abuse and a subconscious connection between that and enemas.
Obviously, greater awareness of child sexual abuse is a good thing, but I do wonder if enemas have been tainted by
association.” That sounds about right.
There is no evidence enemas are harmful or even risky to the physical or mental health of children with enuresis or
encopresis and plenty of evidence to the contrary. Below, I counter the concerns I’ve heard from colleagues. For an
extended discussion, see Section 1 of the Anthology 5th Edition.
Dependence: Enemas do not cause “lazy bowel.” In a chronically constipated child, the bowel is already not working
normally. Once the rectum rebounds, the child will no longer need enemas. If a patient is able to poop only after an
enema, this is not a sign of dependence on enemas. It is a sign the child’s rectum remains dilated.
Electrolyte imbalance: This issue applies only to phosphate (Fleet) enemas, so any physician with the slightest
concern about phosphate can simply recommend another type of enema, such as liquid glycerin or docusate sodium.
However, even phosphate enemas are plenty safe in children with normal kidney function. Children simply void the
extra phosphate. Electrolyte imbalance is practically unheard of. A review of 39 studies conducted over 50 years
found just 15 cases of electrolyte imbalance in children ages 3 through 18. Over half a century. Most of these cases
involved children who had a chronic disease or were given more than one phosphate enema in a day.4
Damage to the intestinal mucosa: While some children do feel internal burning from phosphate enemas, switching
to a different enema solution solves the problem.
Elimination of helpful gut flora: I believe that for chronically constipated children, the benefits of stimulating full
evacuation every day far outweighs any reduction in helpful gut bacteria. Some children take probiotics while on
M.O.P. to prevent elimination of good bacteria. I don’t know if this helps, but there’s no downside.
Physical pain: Understandably, many parents and children worry enemas will hurt, and sometimes they do hurt,
because the child isn’t relaxed or lying in the right position or because the tip needs more lubricant. But families
quickly solve the problem, and inserting an enema becomes no big deal. Many of my patients, even as young as
6 or 7, insert their own enemas, as they prefer the control and privacy. Our Enema Rescue Guide helps parents
troubleshoot.

Nope, Enemas Don’t Traumatize Children

(Accidents Do)
Many physicians reflexively assume enemas will I urge physicians to keep an
“traumatize” children, but this is unfounded conjecture.
For example, in a Dutch study that compared enemas and PEG open mind about enemas
3350 for the treatment of fecal impaction, the researchers and to avoid speculating to
noted, “It is often assumed that children strongly dislike
enema administration.”5 And yet, in contradiction to their own families about how children
expectations, their study found the enemas were just as well may feel about this treatment.
tolerated as Miralax, not to mention more effective and far
less messy.
But I don’t need studies to tell me enemas are well tolerated
among children with enuresis and encopresis. I see it every day in my practice. It is accidents, not enemas, that
cause emotional trauma.
Many of my patients are teased at school, terrified of slumber parties, and panicked the accidents will never stop.
They shoulder much shame and blame and often feel hopeless. Here is a small sampling of what parents in our
support group have posted on the subject of “trauma”:
•“When I told our doctor we were getting good results with enemas, she told us to ‘stop that right away.’ The most
upsetting thing was her language around the ‘trauma,’ which has not been our experience at all. Enemas are just
part of our evening routine, like brushing teeth.”

4 Mendoza, J., Legido, J., et al., (2007), Systematic review: the adverse effects of sodium phosphate enema. Alimentary
Pharmacology & Therapeutics, 26: 9-20. [Link]
5 Bekkali, NLH, et al., Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG,
Pediatrics (2009) 124 (6): e1108–e1115. [Link]

The Physician’s Guide to M.O.P. | 4

 •“It is way more traumatic to poop in the middle of class and stink up
a room full of kids who don’t yet have a verbal filter. A quick, painless
“Clean-outs gave enema is much easier.”
my daughter messy •“My daughter asks for enemas and her confidence has increased five-fold
accidents, humiliation, because she’s not smelly. She used to be unsure and would ask me in a
whisper if she smelled OK. It broke my heart. Now THAT was traumatic,
and painful rashes. My especially when you’re in middle school.”
daughter loves
•“M.O.P. was literally life saving for my son, who was repeatedly
her enemas.” hospitalized for suicidal ideation due to encopresis and enuresis. He
was on board to try enemas because nothing else had worked. It still
shocks me how much resistance we got from everyone — the GI doctor,
the pediatrician, the mental health care providers, his dad. But we did it anyway, and it worked. My son is 16,
and I was finally able to buy him underwear.”
•“Clean-outs gave my daughter messy accidents, humiliation, and painful rashes. My daughter loves her enemas.”
I could provide hundreds more posts like these. I urge physicians to keep an open mind about enemas and to avoid
speculating to families about what children may feel about this treatment.

Three Lessons From a Decade

Prescribing M.O.P.
Based on my experience with M.O.P., here are three valuable lessons
I’ve learned:

Lesson #1: X-Rays Are Invaluable

I x-ray all my enuresis patients and urge other physicians to do the same. Is this
a safe practice? Yes. The radiation dose of a KUB is what you’d get from living
on this planet for three to six months. I am absolutely opposed to the overuse
of x-rays in children, but the amount of good an x-ray can do for a child with
bladder dysfunction far outweighs any risk.
A KUB is an invaluable tool on many fronts. Specifically, I use x-rays to:
• Rule out alternative causes of wetting. In rare cases, wetting accidents are
caused by conditions that are unrelated to constipation and require surgery,
such as tethered cord syndrome or posterior urethral valves. I’ve seen a few
cases of both. In my clinic, we use
the term “O’Regan sign”
• Assess the extent of a patient’s constipation. Today’s common diagnostic
tools — patient history, patient exam, Sitz marker studies, Rome criteria, to refer to this common
the Bristol Stool scale — are highly unreliable. Many severely constipated pattern: rectal poop
children poop daily, and small, lean children can harbor massive amounts of plus an accumulation
stool that cannot be palpated. I’ve had countless patients with grapefruit- of poop in the right
sized rectal masses that went undetected by the referring physician (ascending) colon.
because no x-ray was ordered.
I look for what I call the “O’Regan sign”: stool in the rectum and right colon. It is untrue that the rectum
“always has some stool.” Stool in the rectum signals constipation, A rectal diameter measurement adds value.
A measurement greater than 3 cm indicates constipation. In most
of my enuresis patients, the rectum measures 6 cm or greater.
• Establish a baseline to guide treatment. I don’t routinely order
second x-rays, but if accidents persist on M.O.P., I may use a I x-ray all my enuresis
follow-up x-ray to adjust treatment. For example, if the rectum
remains severely backed up, I will recommend Multi-M.O.P. or
patients and urge other
M.O.P.x. If the rectum is empty, or nearly so, but remains dilated, physicians to do the same.
I may prescribe bladder medication in addition to M.O.P. to get
the child “over the hump” while the rectum heals.

The Physician’s Guide to M.O.P. | 5

 • Prove to families that accidents are not the child’s fault. As one
mom told me: “The x-ray really decreased our frustration with
our 5-year-old son. We thought his accidents were a behavior or “When I started x-raying my
anxiety issue. Now we all have better attitudes, as we view the patients and could see how
wetting as a medical issue.”
much their rectums were
Lesson #2: Enuresis and Encopresis Should Be distended, I realized enemas
Treated Promptly were the only thing that would
Many parents are told nocturnal enuresis is a “normal part of child make a difference.”
development” and is not worth treating until age 5, 7, or even age
10. I strongly disagree. I treat nocturnal enuresis with M.O.P. at age – James Sander, M.D. Pediatric
4, and I treat daytime accidents — whether enuresis or encopresis Urologist, UT Health, Rio
— in any toilet-trained child, no matter how young. If a 2- or 3-year- Grande Valley, TX
old continues to have accidents after toilet training, the child is
almost certainly constipated and at high risk for accidents to persist.
Children with both daytime and nighttime symptoms are the least
likely to outgrow enuresis. One-third of teen and tweens with nocturnal enuresis also have daytime accidents.6
Accidents may be common, but “common” is not the same thing
as “normal.” Left untreated, chronic constipation often worsens.
While it is true that most children eventually outgrow nocturnal
Many parents are told enuresis, hundreds of thousands of children do not, and many
suffer distress, shame, and teasing in the meantime.
nocturnal enuresis is a “normal
Though physicians often reassure patients, “Don’t worry, you’ll
part of child development” outgrow it,” you can’t actually make that assumption. The longer
and is not worth treating until accidents persist, the less likely the child is to spontaneously
outgrow the condition. Without effective treatment, children
age 5, 7, or even age 10. with enuresis at age 9 are highly likely to be wetting at age 19.
I strongly disagree. Parents should be informed that wetting can persist.
I believe no child is served by spending an extra two, five, or 10
years in diapers, especially when accidents are highly treatable
with a regimen such as M.O.P.

Lesson #3: No Cases Are “Refractory” to Treatment

In a 2022 study on the (failed) use of fluoxetine for persistent nocturnal enuresis, Egyptian authors argued that
many enuresis cases are “refractory to treatment” and therefore we must search for “novel and more efficient
therapies,” such as antidepressants.7
In reality, novel treatments for enuresis aren’t needed. Efficient treatment already exists, even for the most difficult
cases. When a child is declared “refractory to treatment,” this signals to me the child was not properly diagnosed or
treated for chronic constipation. Indeed, in the fluoxetine study, constipation was assessed only by patient history,
not x-ray or anorectal manometry, so the results are highly unreliable.
When I have an enuresis case that proves resistant to the standard M.O.P. regimen, I turn to more aggressive
variations and, if x-rays guide me in that direction, bladder medication. In the most persistent enuresis cases, I use
bladder Botox, a nearly sure-fire way to halt accidents. On the rare occasions when Botox fails and/or doesn’t last
three months, it’s always for the same reason: the child remains severely constipated. My enuresis patients who fare
best with Botox are those who got close to dryness with M.O.P. but needed help through the home stretch. As
always, aggressive bowel emptying is the key to resolving enuresis. Getting to the root of the problem remains more
effective than covering it up.
My experience with bladder Botox provides additional evidence that enuresis is caused by constipation, not deep
sleep, an underdeveloped bladder, anxiety, or urine overproduction. If those conditions caused wetting, Botox would
not stop accidents. But it does.

6 Yeung, C., Sreedhar, B., Sihoe, J., Sit, F., & Lam, J. (2006, April 6). Differences in characteristics of nocturnal enuresis between
children and adolescents: a critical appraisal from a large epidemiological study. BJU International, 97(5), 1069-1073.
[Link]
7 Hussiny, M., Hashem, A., et al., The Safety and Efficacy of Fluoxetine for the Treatment of Refractory Primary
Monosymptomatic Nocturnal Enuresis in Children: A Randomized Placebo-Controlled Trial, The Journal of Urology, 208(5),
1126-1134. 1 Nov 2022, [Link]
The Physician’s Guide to M.O.P. | 6
 The M.O.P. Parent’s Guide to

Advocating
for Your Child
at School
Few teachers receive training
on toileting difficulties. Here’s
how to gain the support of
your child’s educators.

Professor of Pediatric Urology,

Wake Forest University School of Medicine

Steve Hodges, M.D.

Introduction
School can be a harsh place for children working to overcome enuresis and/or encopresis.
Students may be teased or ostracized for having accidents in class or feel “stupid,” as one child
put it, for needing to wear pull-ups to school. Teachers often perceive accidents and urinary
frequency/urgency as psychological or behavioral issues — kids “seeking attention,” “acting out,”
“being disruptive,” or “in need of more potty training.” School counselors, relying on textbooks
that erroneously classify enuresis and encopresis as mental health disorders, may have the same
misconceptions. School nurses are in such short supply that your child’s campus may not even
have a nurse on site. Administrators, for their part, may be so overwhelmed by vandalism and
vaping in the toilet stalls that they restrict restroom access, making life harder for your child.

You may be your school’s only source of accurate information about enuresis, encopresis, and
chronic constipation. Certainly, you are your child’s best and most important advocate.

The M.O.P. Anthology 5th Edition explains how to resolve accidents in the most effective, permanent,
and speedy way possible. But as the book emphasizes, the Modified O’Regan Protocol is not an
overnight fix, progress is not linear, and setbacks are common. Children of any age on M.O.P., from
preschool through high school, need support at school. Unrestricted restroom access, discreet
reminders to use the toilet, access to the school nurse’s bathroom — accommodations like these
can help your child comply with treatment and feel less anxious at school. Sometimes, all you need
to do is ask. In other cases, you may need to establish a legally binding health plan.

This guide, a supplement to the Anthology, will help you corral the support your child needs. The
strategies come from parents in our private Facebook support group, some of whom are teachers
themselves. In their experience, and my own, most school personnel want to help — they just don’t
know how.

Only 18% of elementary teachers receive training on

toileting dysfunction, according to a University of California,
San Francisco (UCSF) survey.1 Few teachers know that When my
children with encopresis can’t feel poop accidents or that daughter stopped
suppressing the urge to pee at school can exacerbate an having accidents at
overactive bladder. In a University of Iowa survey, just 15% of school, her social
teachers suspected underlying health problems in children anxiety disappeared,
who wet or soiled their pants or asked to pee more frequently and she has
than normal.2 As a result, teachers may base decisions on blossomed.
faulty assumptions. For example, 88% of teachers encourage
students to hold their pee, and 36% do so with rewards or
punishments.

You can make a difference! By educating teachers and administrators, you’ll not only assist your
own child but also help current and future students who walk the same halls and struggle with

1 Lauren Ko, et al, Lower Urinary Tract Dysfunction in Elementary School Children: Results of a Cross-Sectional Teacher Survey, Journal
of Urology, April 2016;195(4 Pt 2):1232-8. [Link]

2 C.S. Cooper et al, Do public schools teach voiding dysfunction? Results of an elementary school teacher survey, Journal of Urology,
September 2003, 170(3):956-8. [Link]

The M.O.P. Parent’s Guide to Advocating for Your Child at School –1–
the same issues. You can be certain your child is not the only student at your school dealing with
enuresis and/or encopresis.

Know, too, that the combination of school support and M.O.P will accelerate your child’s recovery
and boost their confidence. “Before we started enemas, my daughter was afraid to hug other kids
or make friends,” one mom posted. “I think she was nervous about kids smelling her if she had
an accident. But when she stopped having poo and pee accidents at school, her social anxiety
disappeared, and she has blossomed.”

Strategy #1:
Explain that your child has a medical condition.
In the school setting, as in society at large, enuresis and encopresis are widely perceived to
have psychological or behavioral roots. “One teacher said she was perplexed by my daughter’s
accidents because her daughters were so easy to potty train,” one mom posted. “She didn’t
understand why older kids would keep having accidents.” Another mom received a toilet-training
“action plan” from the school principal, as if more effort and instruction would do the trick. Yet
another mom posted that her daughter was asked to leave her private school because of her
accidents. “They didn’t understand her accidents were involuntary and a true medical condition.”

I suspect the same school does not expel children with diabetes because they can’t regulate their
insulin! To help your school understand the medical nature of enuresis and encopresis:

• Use medical terms, such as enuresis, encopresis, urinary urgency, dilated rectum, and
overactive bladder. You might add that your child is “undergoing treatment” or “following a
treatment protocol.” (You need not reveal the details of your child’s treatment, though some
parents do, particularly if their doctor supports M.O.P.)

“I told my daughter’s teacher she was being treated for encopresis and enuresis and, as such,
the doctor said she needs to use the bathroom more regularly and not rush,” one mom posted.
“I think it helped to use the technical terms. My feeling is that if I had just said, ‘Oh, she has
accidents,’ the teacher might have been
less accommodating.” The teacher was Mrs. Of course,
so receptive that she made sure to inform Zuckerman, Zoe.
substitutes about the student’s condition. may I go
to the
• Bring a doctor’s note documenting the restroom?
diagnosis. Of course, nothing screams
“medical condition” like a note from a medical
doctor. “Having worked for a school district,
I am not quick to jump on the parent’s side,” Advocate
for your
one mom posted, “but I found that bringing in child to have
a doctor’s note from our children’s hospital unlimited
was very helpful in starting conversations.” restroom
access.
Not every teacher will be persuaded — one
mom said that despite a doctor’s letter, “the

The M.O.P. Parent’s Guide to Advocating for Your Child at School –2–
 teacher seems like she still suspects my daughter of using restroom privileges to get out of
schoolwork.” Still, she wrote, “the teacher is honoring the note.”

• Print out The K-12 Teacher’s Packet on Student Toileting Troubles. This free download,
available on our website, explains that a chronically stretched rectum is the root cause of
enuresis and encopresis and how teachers can help. You might deliver copies to all your
child’s teachers, plus the principal and school counselor. The Mental Health Professional’s
Guide to Enuresis and Encopresis, also free on our website, may bolster your case.

Strategy #2:
Communicate in person.
Email is important for documentation, but
when requesting accommodations for your
child, try to meet face-to-face with school
personnel. It’s much harder for teachers and
administrators to be dismissive or push back
if you’re looking them in the eye. Your own
approach will likely be softer, too. “Emails
often can sound harsh and judgmental, even
if you don’t intend them that way,” one mom
cautioned. “By talking in person, you will have These two free guides, available at
a better and more lasting understanding with [Link], explain that
enuresis and encopresis are medical conditions.
the teacher.”

Another mom added: “You will be a more effective advocate if you listen to the teacher’s point of
view and don’t get mad at her. Teachers are under increasing stress these days.”

Talking face-to-face is especially helpful for diffusing a conflict. One mom posted that her 5-year-
old had to “move her behavior clothespin” as a penalty for using the restroom without permission.
This mom was livid, given that her daughter was desperately trying to avoid an accident. But
instead of firing off an angry email, this mom spoke to
the teacher while volunteering at school. The teacher
felt terrible about what had transpired and changed
Emails often her policy. “Until we chatted in person, she didn’t
can sound harsh and understand the impact the policy had on my daughter.
judgmental, even if you Now everything is OK, and we all feel better.”
don’t intend them that way.
Another mom requested a conference at her preschool
By talking in person, you
shortly after starting M.O.P. To clear up “major
will have a better and more misconceptions” the school had about potty training
lasting understanding and accidents, she brought Bedwetting and Accidents
with the teacher. Aren’t Your Fault. “The teachers requested to read it, so I
left it for a few days. We had a really great conversation.”
The book and discussion made an impact. “They’re
slowly moving away from a potty-training deadline and

The M.O.P. Parent’s Guide to Advocating for Your Child at School –3–
instead letting parents give input on when their child is ready. I’m hopeful for when my young kids
go through!”

The mom of a second-grader mentioned her son’s condition at an open house before school
started, speaking with the teacher and school counselor. She left them printed materials and
followed up with an email, cc’ing the principal. “Our school didn’t know much about encopresis and
enuresis. That’s why I sent such a detailed email after talking to them in person. I wrote about my
son’s struggles and how accidents would return after weekend clean-outs. I mentioned the M.O.P.
treatment was approved by our pediatrician. Our school has been VERY accommodating.”

Strategy #3:
Enlist the help of your school nurse.
A school nurse can be invaluable in securing accommodations for your child and reducing your
child’s anxiety.

“Our school nurse was fabulous,” one mom posted. “We had a written communication log that went
back and forth every day. She would document if my son initiated going to the bathroom or if the
school encouraged him to go; what time he would go;
what he was doing just prior to going potty, or if he had an
accident. When his potty watch vibrated every 90 minutes,
Our school he would go to the nurse’s office. We kept extra clothes
nurse was fabulous. and wipes in her office just in case.”
We had a written Another mom brought a footstool to the nurse’s office,
communication log so her son could use it on bathroom breaks. In general,
that went back and a school nurse can act as a liaison between you and
forth every day. your child’s teacher, reinforcing the importance of free
restroom access, troubleshooting, and texting you if your
child has an accident. “Our school nurse understood the
issues and how to fix them,” one mom posted.

If your school nurse doesn’t spend enough time on campus to meaningfully help your child,
maintain a dialogue with the school counselor or social worker. “Early in the school year, I
connected our school’s psychiatric social worker to support my son with anxiety and any social
isolation,” one mom posted.

Strategy #4:
Establish a 504 plan or equivalent.
If your child’s school isn’t sufficiently responsive to your requests, you may need to up your game.
In most countries, publicly funded schools are legally required to make accommodations for
children with documented medical conditions. All the child’s teachers — including P.E., music, and
art teachers — must follow the plan.

The M.O.P. Parent’s Guide to Advocating for Your Child at School –4–
In the United States, it’s Section
504 of the Rehabilitation Act
of 1973 that mandates these
accommodations.3 In the United
Kingdom, it’s Section 100 of
the Families Act of 2014. The
U.K. guidance, echoing the U.S.
regulation, states: “A child’s mental
and physical health should be
properly supported in school, so
that the pupil can play a full and
active role in school life, remain
healthy and achieve their academic
potential.”4 The older their students,
the less mindful teachers are
You typically start the process about the need for children
to practice healthy toileting
by meeting with your school’s habits, according to a UCSF
counselor and providing medical study. Kindergarten teachers
documentation. Yes, it can be a are the most aware.
hassle, but these plans can be
invaluable. “The 504 plan has been life-changing for my second-grader,” one mom posted. “Before,
he was bullied in the boys’ restroom when he tried to change, and we were always trying to pack
extra clothes in his backpack. Now he has organized support and privacy, and it’s helped take the
pressure off him. We regret we didn’t do it sooner.”

Plans like these are especially useful in schools that stringently enforce restroom restrictions. A
mom who teaches middle school, and whose own child has struggled with accidents, posted that
she’s not allowed to let her students out of the classroom room within 10 minutes of a passing
period, because students were hiding in bathrooms or meeting up to fight or vape. “As teachers,
our hands are tied,” she wrote. A 504 plan can untie them.

For children with enuresis and/or encopresis, health plans often include:

• Unrestricted restroom and water access

• Use of the school nurse’s restroom

• Timed reminders, by the teacher, to use the restroom

• Storage of extra clothing and supplies in the nurse’s office

• Prompts to the child to change clothes in case of an accident

• Extra time for assignments missed due to a restroom visit

3 Protecting Students With Disabilities: Frequently Asked Questions About Section 504 and the Education of Children with Disabilities,
U.S. Department of Education, [Link]

4 [Link]
cRqjhQUzAFMb3dWs2eumkYHwax1r_tSehyjHQZDNKFho

The M.O.P. Parent’s Guide to Advocating for Your Child at School –5–
A few other tips when requesting a plan:

• Inform your child they are legally entitled to these

accommodations. If the school isn’t following
through, the child can say, “It’s in my 504!” As one The 504 plan
mom posted, “That will get the immediate attention has been life-changing for
of anyone who has had any education training at my second-grader. Now
all. Just knowing she has those words makes my he has organized support
daughter more confident.” and privacy, and it’s helped
take the pressure off him.
• Spell out how you’d like the school to handle
We regret we didn’t
accidents. Teachers may not handle it the way
do it sooner.
you would. In fact, the UCSF survey found that even
after witnessing accidents during class, only 77%
of teachers instructed students to change their
clothes, and only 64% informed parents. “My son
will not tell anyone if he has an accident,” one mom posted, after her son came home “caked in
poop and pee.” She added: “Is it too much to expect that they will notice and either have him go to
the school nurse or call me to come get him?” That’s something you may need to detail in writing.

• Adjust the plan annually or as your child’s needs change. Your child’s situation may change
significantly, especially with M.O.P. treatment. Meet with your child’s counselor, nurse, and
teacher to update the plan.

One Child’s School Care Plan

“Do not praise or mention ‘no accidents’ to my daughter, as this is not something she can control.”
This plan was submitted by a mother in 4) Encourage her to tell an adult when she has
the United Kingdom. A template can be had an accident and praise her for doing
downloaded at ERIC: The Children’s Bowel this. (We just say, “Thank you for telling
and Bladder Charity in the United Kingdom.5 me.”) Sometimes, she is unaware when
she has done an accident and can be very
1) Our child should be allowed to go to the reluctant to be changed. However, when wee
toilet as often as she needs. She can be shy accidents are left, she gets chafing at the top
about asking. If she has to wait for an adult of her legs, and when poo accidents are left,
to acknowledge her, this may be too late. she gets a very sore, red, spotty bottom, both
2) Encourage our child to go to the toilet every can cause her a lot of pain.
2 hours, including after lunch, before P.E. 5) Offer positive praise for trying on the toilet.
and before going to after-school club. Do not praise or mention “no accidents,”
3) Encourage her to drink often (she should as this is not something she can control
drink at least 2 bottles a day). If she drinks and then she can get upset when she does
too much too quickly, she often will have a have accidents.
wee accident within 1/2 hour, even when she 5 [Link]
IwAR0gxe3E3m -PH6Hi0UZjoCPMiLIUeO2iyT8m8HAWM
has just been for a wee. SnBrB0fi9vUdBzMKo8

The M.O.P. Parent’s Guide to Advocating for Your Child at School –6–
Strategy #5:
Describe the emotional toll of your child’s condition.
Before becoming a physician, Lauren Ko taught second grade at a New York City school with
highly restrictive restroom policies, and she witnessed numerous accidents. This experience
made such an impression on her that years later, as a medical student, she developed the survey
of elementary teachers I mentioned earlier — the survey that found only 18% of teachers receive
training on voiding dysfunction.

“I know accidents were really humiliating for the students,” Ko told me a while back. “It’s just a
horrifying experience for a kid.”

I imagine most teachers are quick to recognize that horror. However, they may not fully grasp the
emotional toll enuresis and encopresis can take on a child. You may want to fill your child’s teacher
in. While a doctor’s note should secure your child the necessary accommodations, restroom access
is not the same thing as compassion and discretion. The more your child’s teacher understands,
the more empathy and encouragement the teacher can offer.

“My son has been teased for wearing a pull-up,”

one dad posted. “We addressed it with the teacher
and counselor, but his self-confidence and self- It took me a
esteem have taken a huge hit. He says he feels
‘stupid’ because he is different and ‘feels like a baby’
few days to make the
because he has accidents.” connection: the clogged
toilet incident had
One mom told her daughter’s teacher about the
embarrassed her so badly
girl’s strategies for concealing her pull-ups, such
as wearing long tops and skirts, so the teacher she had stopped using
could discreetly alert her student in case her the restrooms
pull-up was showing. all together.
Another mom posted that after her daughter clogged
the school toilet, she started coming home wet
from school. “It took me a few days to make the
connection: the clogged toilet incident had embarrassed her so badly she had stopped using the
restrooms all together. Luckily, her teacher was very supportive.”

The M.O.P. Parent’s Guide to Advocating for Your Child at School –7–
 Emma and the E Club, a novel for ages
8 through 12, is available at Amazon in
paperback or hardcover. The .pdf is available
at [Link].

“Clever, validating, and informative

all at once – brilliant!”

old Story!
– Tina Payne Bryson, LCSW, Ph.D., New York Times Bestselling

U n t co-author of The Whole-Brain Child

Emma and
The

the E Club
An Epic Episode About Eliminating
Enuresis and Encopresis
THIS
IS ME,
EMMA THAT’S THE
HAIRBALL DR. DRAIN
EXTRACTED FROM
OUR BATHTUB

BY SUZANNE SCHLOSBERG with Steve Hodges, M.D.

Illustrated by Mark Beech
 The E club is for kids who have enuresis or
encopresis. Or both, like me.
I’ve had enuresis and encopresis most
of my life, but until this year, I didn’t even
know accidents had official names. I just

Chapter 1 thought accidents were, you know, accidents—

embarrassing episodes that pretty much only
happened to me.
But I was in error! It turns out lots of kids,
Hi, I’m Emma Easly, and I’m the chief everywhere in the world, have enuresis and
executive of the E Club. That means I’m in encopresis. It’s just that no one talks about it.
charge. I’m ten and a half and in fifth grade, except me, evidently! I’m an
Well,
and the club was entirely my idea. extrovert, as you can tell. I’ve always been
expect you want to know what the E stands for.
I outgoing, and I like to think out loud.
Well, for one thing, E stands for enuresis. You’ve probably noticed I elect to use words
That’s the official name for pee accidents, either that start with E. That’s because
overnight or during the day. 1.) my first and last names both start with
E also stands for encopresis. That means you E and 2.) I enjoy playing with words. In fact, I
have poop accidents.

1 2
excel at it. That’s not an exaggeration! Excellent, eh? You can check my work!
I’m endlessly entertained by word When I grow up, I plan to be employed as
searches, crossword puzzles, and word an essayist. That’s a writer who expresses
scrambles. For example, I found forty-six words opinions.
using the letters in “encopresis.” I have a lot of opinions.
In this game, you can use any of the letters For example, in my estimation, a.k.a. my
in any order. (Try it!) opinion, 1.) red licorice is superior to black
Some words I found easily, like these: licorice (which is barely even edible), and
corn 2.) my mom exaggerates how much she
nice exercises.
open In case you weren’t sure, a.k.a. stands for
Other words took more effort: “also known as.” My aunt, Jennifer, says “a.k.a.”

noise all the time, and I’ve started emulating her,

crisp a.k.a. being a copycat.
For example, yesterday Aunt Jennifer said,
score
“Emma, my haircut is a catastrophe, a.k.a. a total
I even found an eight-letter word:
princess English sheepdog.”
disaster, a.k.a. I look like an
She did. Her bangs extended into her eyes,

3 4
 Whenever I encounter an E word, I enter it
into my notebook. I’ve clipped the notebook to
a shoulder strap, so I essentially wear it, like a
like a mop. I agreed with her, but she didn’t purse. I keep my E list handy at all times, except
seem happy about it. during recess, P.E., and soccer. I doodle in my
AUNT JENNIFER notebook and draw a next to words I didn’t
(DEF.
like a mop. I agreed with her, but NEEDS A
she didn’t know before.
NEW HAIRCUT.)
Whenever I encounter E enter
an word, I it
seem happy about it. One new word on my list is enema . An
into my notebook. I’ve clipped the notebook to
enema is a treatment that helps you poop. My
AUNT JENNIFER essentially
a shoulder strap, so I wear it, like a
(DEF. NEEDS A doctor told me about it. You squeeze medicine
E
purse. I keep my list handy at all times, except
NEW HAIRCUT.) up your bottom through a small tube.
during recess, P.E., and soccer. I doodle in my
You’re probably thinking: Ewwww!
notebook and draw a next to words I didn’t
That’s exactly
know before.
what I thought. To be honest,
enemas do feel strange at first, but they don’t
One new word on my list is enema. An
hurt. I was surprised about that.
enema is a treatment that helps you poop. My
There’s one kid in the E club, Lucas, who
doctor told me about it. You squeeze medicine
hasn’t had an enema. So far, Lucas has been
up your bottom through a small tube.
emphatic .
You’re probably thinking: Ewwww!
For fun, I collect words that start with E. In That’s exactly
“No way,” he told me.
what “Not happening.”
I thought. To be honest,
fact, I have an enormous list of E words—1,038 enemas
“Never,” he strange
do feel added. “In case Ibut
at first, didn’t
theymake
don’t
6
as of today. myself
hurt. clear.”
I was surprised about that.
Whenever I encounter E
For fun, I collect words an
that start
word,with enter
I E. In it “Oh, you
There’s one kid Iinreplied.
did,” “OneLucas,
the E club, hundred
who
fact,my
into I have an enormous
notebook. I’ve clipped E words—1,038
list ofthe notebook to percent.”
hasn’t had an enema. So far, Lucas has been
5
of [Link], so I essentially wear it, like a
aasshoulder emphatic.
purse. I keep my E list handy at all times, except
during recess, P.E., and soccer. I doodle in my
5 6
notebook and draw a next to words I didn’t
know before.
One new word on my list is enema. An
enema is a treatment that helps you poop. My
doctor told me about it. You squeeze medicine
up your bottom through a small tube.
You’re probably thinking: Ewwww!
CHILDREN’S HEALTH/BEDWETTING

WHAT IS
M.O.P. is the Modified O’Regan Protocol, an
?
enema-based regimen that resolves enuresis and
encopresis far more effectively than oral laxatives,
bladder medication, alarms, and other treatments.

CIAN’S
THE PHYSI E TO
GUID
opresis
resis and Enc
Treating Enu O’Regan Protocol

Includes
dified
with the Mo
else.”
than anything
radically better tric Urologist,
“M.O.P. works , Pedia

4 NEW
es Sander, M.D.
– Jam y, TX de Valle
UT Health, Rio Gran to get
“It is my missionabout

What’s New in the 5th Edition: “Families and kids

are
ptive to
a lot more rece I would
the word out ctive
M.O.P.
effe
how incredibly is.”
PT, specialist
– Erin Wetjen, incontinence,

Guides!
n in pediatric
M.O.P. tha .” Mayo Clinic, Roch
ester, MN
ght

• Multi-M.O.P., a new protocol

have thou
M.D., Pediatric
– Irina Stanasel, hwestern
Urologist, UT Sout
Dallas, TX
Medical Center,

for the toughest cases

tment works as
“No enuresis trea— not even close.”

• The Slow Taper regimen to

well as M.O.P. ero, M.D., Urologist,
By Steve Hodg
es, M.D. – Victoriano RomAssociates, Redding, CA
Redding Urologic
gy
Pediatric Urolo
Professor of ine
School of Medic
t University
Wake Fores

prevent recurrence of accidents

t’s Guide to
• DIY enemas to save money The M.O.P. Paren

Advocating
• Updated tracking calendars for Your Child
12 Strateg
to Help Yo ies
ur
Get Comfo Child
at School rtable
• Q&A with a psychologist on frustration Few teachers receiv
e training
with M.O
from pare
.P.
nts who’ve
and family dynamics been in th
lties. Here’s
on toileting difficu
how to gain the
support of
tors.
e trenches “I was not
expecting
to g
your child’s educa adamant
refusal to
on board comp
By Steve Hod in less than
ges, M.D., 4h
and Suzanne
Illustrations Schlosberg
by Cristina

• Advocating for your child at school

Acosta
From the M.O
.P. Antholog
y 5th Editi
on.

• Managing M.O.P. with multiple children

• Bladder Botox update
Urology,
Professor of Pediatric
y School of Medicine
Wake Forest Universit
M.D.
Steve Hodges,

“[Link] “M.O.P. works

“Invaluable book radically better than
is an incredible resource. Takes for either urine or
out all the shame and brings anything else.”
stool accidents.
updated, science-based advice.” – James Sander, M.D., Pediatric
We’re so grateful.” Urologist, UT Health, Rio
– Tina Payne Bryson, Ph.D., co-author, Grande Valley, Texas
– Wes Dollar, United States,
The Whole-Brain Child
Amazon review

CHILDREN’S HEALTH/BEDWETTING
About the Authors and Illustrators $76.95
Steve Hodges, M.D., is a professor of pediatric urology at ISBN 979-8-9866795-3-2
Wake Forest University School of Medicine. He and Oregon health writer 57695>
Suzanne Schlosberg are co-founders of [Link]
and co-authors of seven books. Cristina Acosta ([Link])
is a California illustrator and artist, and Mark Beech, a popular children's
illustrator, lives in the United Kingdom ([Link]).
9 798986 679532