Bedwetting, or nocturnal enuresis, is so common that people often don't regard it as a problem. (Clearly, these people either don't wet their beds at night or have a child who wets.) At five years of age, one child in six will wet the bed regularly. This reduces to about one in 15 by the age of ten - that's two children in an average class. Even in adulthood one person in 100 will still be wetting the bed. Wetting affects children's self-confidence, makes it harder for them to go away for camps and sleepovers, and makes for broken nights and much anguish in the family. The drudgery of frequent laundering or the embarrassment of finding nappies or 'pull-ups' for an older child is often soul-destroying. So let's get a few things straight. Night-time dryness is a skill that we develop with age. We are either ready for it or not, and in much the same way that we can't make children walk before they are ready, it is almost impossible to get them dry before they are ready. A common theme of this book is that if you can do it once you have shown that there is nothing 'medically' wrong. Clearly with Read more [...]

I think we should pay a brief visit to the world of wetting, partly because urinary problems are common in children with stool withholding/constipation, and, more importantly: •    constipation/stool withholding makes urinary problems worse •    it is almost impossible to sort out a urinary problem unless constipation/stool withholding is sorted out first. It seems the simple fact that stool in the rectum pushes onto the bladder, and that the nerves that supply the bladder and bowels come from the same place, means that the two are inextricably linked. Daytime wetting Children who withhold stool are also more likely to hold on to their wee. Sometimes they overestimate their ability to hold on, and will start leaking before going to the toilet. They will pass varying amounts of urine, and again claim to be surprised when it becomes noted. It is much harder to be dry at night than it is during the day. If the wetting is only during the day, it is not going to be due to a medical cause, but is likely to be due to holding on for too long. There are a few other simple causes of Read more [...]

Soiling, or encopresis, is not fun, but we can stop it. It is normally divided into two groups: •    retentive encopresis: soiling in the presence of stool withholding. •    non-retentive encopresis: soiling without stool withholding. In both cases, the children normally claim innocence. 'I didn't feel it coming' or 'I didn't know it was there.' This works as a fantastic defence mechanism as the parents then think that their child has a medical problem and then absolve him of all responsibility. In most cases children don't actually want to soil, but they are aware of what is happening. Essentially, if you have been to the toilet once then you can feel when you have a poo coming and can do it. If you have done it once then you can do it again, and if you can do it again then you can do it always. Playing football by the windows This is my story about soiling. It also helps children to understand that although they may not soil on purpose it is still not an accident. Imagine that you are outside playing football by the windows. When Mummy or Daddy see you they might say, Read more [...]

If you try all of the above without real success then medication's what you need. There is a tremendous, unjustified fear of laxatives, and I will address this shortly. There is a general understanding that stool withholding will take as long to treat as it has taken to develop. This is usually many months or even years. The three questions that you are going to ask about laxatives: 1.   Are they safe? 2.   Will they make his bowels lazy? 3.   Will he become dependent on them? As we will discuss, the answers to these questions, in order, are: Yes, No, No. The laxatives that we will discuss all have good safely profiles and appear to be safe in children. Other than some abdominal pain or diarrhoea, side-effects are extremely uncommon. The right dose is the one that works This is often more than GPs are used to prescribing or pharmacists are used to dispensing. Don't worry. Remember we are going for results here. If we gave a lower dose, and there were still lots of holding on, we might as well not be giving anything at all. I have said that it takes a long time to Read more [...]

It doesn't really matter what you want to use as long as it is safe and easy enough to take. If you want to try prune juice or syrup of figs or something else from the health food shop -enjoy. If you can get enough in, it should have the desired effect of a soft easy daily stool. There is only one rule: Never use suppositories or enemas. They do often help to get the poo out, but they do this at the expense of making things worse. As we have already explained, the real issue is not about getting the poo to come out, but about removing the fear linked with the poo coming out. These children are exquisitely sensitive about their bottoms, and inserting suppositories or enemas will only add to their concern. For example, I saw a 15-year-old girl in clinic for stool withholding and resultant soiling. The referral letter stated that her family were very concerned, but that she was not, and this did seem to be the case. During the consultation I noted that she had been seen about ten years beforehand with a similar problem. I discovered that she had been treated with a few enemas. We discussed this Read more [...]

Assuming that you go daily, imagine the challenge of trying not to go for a week. On the first day nobody would even notice, as your desire to go would be small. By the second day you may have to work a little harder and may have to catch your breath or stiffen a bit as the desire to defaecate becomes a little stronger. Each holding-on episode will require a bit more effort and this may show as lapses of concentration. People close to you may begin to tell that you were not 'quite right'. By the fourth day you will feel an almost constant desire. You will experience excruciating abdominal pain and an unbearable fullness in your anus. Holding on will begin to consume all of your physical energy and concentration and you will quickly learn what makes it easier or harder, including how to stand and sit. You will find it impossible to concentrate on anything else as the feelings come thick, fast and strong. You will be effectively 'paralysed by poo' -yet the outside observer may have no idea what is going on. Because the symptoms of stool withholding may be noticed hours or even days before a child Read more [...]

Most parents whose children are stool withholding worry about serious underlying disease. Fortunately finding a physical cause is very rare. A positive diagnosis can usually be made from the history alone - especially if a child is old enough to explain how he feels about going to the toilet. If your child is well apart from this, then there is unlikely to be anything more worrying going on. The longer somebody has been unwell, the more they tend to worry. In medicine we usually think the other way around. If you have had a condition that does not get much better or worse, the longer you have it, the less likely it is going to be anything serious. Serious stuff gets worse over time. In most children tests are not necessary. There is no simple test to check for stool withholding. X-rays can show if there is a lot of stool in the bowel, but not how long it has been there for. Having an x-ray of the abdomen involves exposing a child - including the sensitive bits - to radiation, which, although probably safe, is best avoided unless absolutely necessary. Ultrasound scans are no good at looking Read more [...]

Almost all children who present with constipation don't have constipation as we think of it. Invariably they are stool withholding. If you investigate their bowels, they are working at least as well as anybody else's; it is merely that they hold on to their stool. All their effort and straining is not trying to poo; it is trying not to poo. And this, in turn, has lots of knock-on effects. The whole process seems to start when passing stool becomes painful or scary. If the experience is unpleasant the child will try not to repeat it. The only way of not having to poo is to try and stop it coming out. Unfortunately, the longer this goes on for, the stool collecting inside the bowel becomes larger and harder. As a result, the next time stool comes out it hurts even more. This reinforces the idea that pooing is to be avoided at all costs and very quickly a vicious cycle is established. 'Poo is pain. I want to stop it. The more I stop it the more it hurts. The more it hurts the more I want to stop it' - and so on. The driving force to hold on is an attempt to avoid this excruciating pain and is Read more [...]

Constipation is one of the most common digestive complaints in the general population. Over 2.5 million people consult a physician and hundreds of millions of dollars are spent on laxatives each year. Although constipation is often defined as a frequency of defecation twice weekly or less, constipated patients may complain of excessive straining with defecation, passage of hard or small stools, difficulty initiating evacuation, or a feeling of incomplete evacuation. Physicians should therefore not rely only on the criteria of defecation frequency when examining patients and managing constipation. TABLE. Laxatives Used in the Treatment of Constipation Laxatives Usual Adult Dose Onset of Action Bulk-forming laxatives Bran 2-4 tablespoons qd 12 to 72 h Methylcellulose 1 to 3 tbsp qd 12 to 72 h Psyllium 1 to 3 tbsp qd 12 to 72 h Calcium polycarbophi 2 to 4 tablets qid 24 to 48 h Osmotic agents Polyethylene glyco 17 g in 240 mL water 24 to 48 h Sorbito 15 to 30mLqd 24 to 48 h Lactulose 15 to 30mLqd 24 to 48 h Saline laxatives Magnesium Read more [...]

Bulk-Forming Laxatives Dietary fiber and bulk laxatives with adequate fluid intake are the most physiologic and safest of medical therapies. However, they may be counterproductive in patients with idiopathic slow transit constipation or with constipation associated with irritable bowel syndrome because they often worsen bloating and abdominal distension in these populations. Dietary Fiber Dietary fiber in cereals contain cell walls that resist digestion and retain water within their cellular structures, whereas those found in citrus fruits and legumes stimulate the growth of colonic flora and increase fecal mass. Wheat bran is the most effective fiber laxative with a clear dose response on fecal output. Patients with poor dietary habits may add 2 to 4 tablespoons of bran to each meal, followed by a glass of water or another beverage. A laxative effect may not be observed for 3 to 5 days. Patients should be cautioned that large amounts of bran can cause abdominal bloating or flatulence; therefore, they should start with small amounts and titrate slowly to the desired effect. Psyllium (Metamucil), Read more [...]