Why Constipation Needs to Be Considered When Treating Enuresis

You’ve seen this dynamic before.

You walk out to the lobby of your rehab department and see a little boy sitting next to his mother.

You say his name and his mother eagerly stands and walks toward you. The boy follows behind with his head down, avoiding eye contact.

You introduce yourself with a smile and lead them to your treatment space. In your hand is the boy’s file with a referral to evaluate and treat enuresis.

You have a couple of toys you think the boy might like, but instead of playing with them, he sits next to his mother, looking at the ground.

Daniel is 9. He politely answers questions when you ask, but his mother does the rest of the talking. Daniel wets the bed. And not just sometimes, but every single night.

Mom is eager to get help for Daniel, but frustrated and leery about the prospect of a solution. His doctor assured her Daniel would grow out of his bedwetting, but at 9 years old he’s still in pull-ups.

You ask lots of questions. Questions about development, toilet training, medical history, diet, sleep, and daytime bladder leaks. All appears to be “normal”, except Daniel has never had a dry night, ever.

You dig deeper and ask how often Daniel has a bowel movement. Mom quickly replies, “every day!” She says pooping has never been a problem. Then Daniel speaks up and says, “Actually, I don’t go poop every day.”

You ask more questions and find out Daniel has a bowel movement maybe 3 times a week. He doesn’t like to poop at school and sometimes he needs to push really hard to get the poop out. He says his poop looks like “little balls”.

Mom had no idea Daniel was having a hard time with pooping. Daniel is constipated. It’s clear you need to treat Daniel’s enuresis and constipation.

Today we’ll discuss:

• The relationship between enuresis and constipation
• How the pelvic floor therapist can help
• Where you can learn more

Enuresis is a term for those who leak urine, especially children. The term “nocturnal enuresis” was traditionally used interchangeably with bedwetting, however the International Children’s Continence Society (ICCS) has recommended discontinuing use of this term and describes all intermittent incontinence while asleep as just “enuresis”, regardless of the causes or accompanying daytime symptoms.

In my last blog article, we identified the primary causes of enuresis:

• Failure to produce the antidiuretic hormone (ADH) with or without obstructed airways
• Detrusor Overactivity
• Constipation

Constipation remains a controversial topic as a contributing factor in enuresis. And honestly, it is difficult to find supporting research. But don’t let this fool you.

With over 30 years of clinical experience in this field, I’ve frequently observed constipation as a contributing factor in children with enuresis.

Dr. Steve Hodges, a urologist from Wake Forest Baptist Medical Center, conducted a small study in 2012. He took 30 patients with an average age of 9 years of age complaining of enuresis. He found 80% of these children were constipated. And only 10% of these children and their parents reported symptoms.

Using x-ray, Dr. Hodges noticed children were storing stool in their rectums and not having regular bowel movements. This causes the rectum and colon to stretch to make room for the extra stool.

When the rectum stretches and the child continues to withhold stool the communication loop between the brain and the body shuts off. The child no longer senses an urge to have a bowel movement.

As the rectum stretches, filling up with more stool, it begins to add pressure on the bladder. The added pressure prevents the bladder from holding larger amounts of urine. This added pressure also makes the bladder irritable and it will involuntarily empty.

Recognizing this, Dr. Hodges used laxatives to treat constipation. Of the children studied, 80% of them no longer wet the bed once their constipation was resolved.

A recent study out of Taiwan showed a significant association between children with enuresis and constipation. When constipation was successfully treated, 63% of children no longer reported enuresis.

Don’t be fooled! The link between constipation and enuresis certainly exists. I’ve seen it in my practice and there are glimpses of it in the research. But this doesn’t mean all children who wet the bed are constipated. So how do you know?

As a pelvic floor therapist treating enuresis it’s important you ask specific questions. Some red flags indicating constipation as a contributing factor related to enuresis include:

• A history of constipation
• Infrequent bowel movements
• Hard stools or stools clogging the toilet
• Needing to strain or push to have a bowel movement
• Leaking stool or smearing in their underwear
• Lacking the urge to have a bowel movement
• Withholding bowel movements

Having the child and parents complete a bowel diary can be an effective way to identify your patient’s bowel regularity.

Other diagnostic tools including x-ray and ultrasound can identify if a child is constipated. Recognizing constipation in your patient as a primary cause of enuresis is only half the battle.

Once you understand the impact constipation can have on your patient’s bladder it’s important to provide effective treatment and avoid what I call the constipation carousel.

Pelvic floor therapists need more training to work with children and their families frustrated with enuresis. Your role is to find tools and strategies which work for each individual family to help them achieve dry nights.

It’s important to build a relationship with the child and their families. And create an environment where they feel safe, understood, and like part of the care team.

Most parents are frustrated and don’t know what to do. Take time to ask questions during the evaluation and subsequent treatment visits. Get a clear picture of what these families are going through.

Ask your patients questions like:

• What is your evening and bedtime routine like?
• Do you wake up when you wet the bed at night?
• What does your poop look like?
• Do you use the bathroom at school?

Stay curious. Don’t assume you know the answers. Sometimes it’s a tiny detail that’ll lead you to make a bigger impact in their progress toward having dry nights.As a pelvic floor therapist, you need to look at the whole child. You need to look beyond the pelvic floor and address problem areas which may be influencing a child’s ability to stay dry. But what should you be looking at?

Treating children with enuresis and constipation can be hard. Working with their families can be hard. Avoiding the constipation carousel is really hard.

To be effective in treating enuresis and constipation, you need to have a thorough understanding of bladder and bowel dysfunction.

You need to understand things like:

• The anatomy and physiology of the developing child
• How postural control and the diaphragm affect intestinal motility
• How to differentiate comorbidities of enuresis

You’ll learn this and more after taking my course, Peds Level 1 — Treatment of Bowel and Bladder Disorders: Evaluation and Treatment of Dysfunctional Voiding, Bedwetting, and Constipation.

It’s also perfect for the experienced pediatric pelvic floor therapist looking to dig into updated research and treatment methods. Because who has time to stay updated with a full patient load? Learn how you can help.

If you haven’t already, download my free ebooks on bedwetting and constipation to share with your patients and their families.

Sources:

1. Management and treatment of nocturnal enuresis—an updated standardization document from the International Children’s Continence Society – ScienceDirect
2. Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment
3. Occult megarectum–a commonly unrecognized cause of enuresis
4. Association between constipation and childhood nocturnal enuresis in Taiwan: a population-based matched case-control study