Treat Bedwetting, Constipation, & Accidents with Dr. Steve Hodges

Forget everything you think you know about bedwetting, poop accidents, and potty training. Dr. Steve Hodges, a professor of Pediatric Urology at Wake Forest University School of Medicine joined Dr. Amy and Sandy on this episode of Brainy Moms to drop some serious truth bombs about what’s really going on with most kids and teens who have accidents. (HINT: It’s not about bad behavior, deep sleep, or an underdeveloped bladder…and it’s never the kid’s fault.) You’ll hear what he stumbled upon during surgery as a pediatric urologist, what he recommends that parents do and don’t do, and why we’ve missed the mark on accidents for so many years. Learn what myths to let go of and the latest ways to treat bedwetting, daytime wetting, constipation and poop accidents, as well as things to consider during potty training. From Botox and InterStim to stool softeners, enemas, and diet, he shares the best options available, depending on the severity of the issues your child or teen is experiencing. He also touches on IBS, children with autism, and the value of x-rays in confirming the best approach. Tune in for this conversation with a leading expert who’s working on the cutting edge of these common medical conditions. 

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Transcript

DR. AMY:  Hi, smart moms and dads. Welcome to another episode of the Brainy Moms Podcast brought to you today by LearningRx Cognitive Skills Training Centers. I'm your host, Dr. Amy Moore. I am here with my co-host, Sandy Zamalis, and Sandy and I are super excited to welcome our guest, Dr. Steve Hodges. Dr. Steve Hodges is a professor of pediatric urology at Wake Forest University School of Medicine. He's a leading authority on childhood toileting issues. He is dedicated to debunking common myths surrounding bedtime and daytime wetting and poop accidents, emphasizing that these issues are never a child's fault. Dr. Hodges resides in Winston Salem, North Carolina with his family and has authored eight books for both parents and children, such as “The MOP Anthology” and “Bedwetting and Accidents Aren't Your Fault.” He is here today to share valuable insights from those books, through his blog, and from his brain. Welcome, Dr. Hodges.

DR. HODGES: Thank you, guys, so much for having me. Appreciate it.

SANDY: Yeah, absolutely. We are tickled to have you on the show. As we were prepping for this episode, we thoroughly enjoyed looking through your books and reading through everything. So, we always like to start with having our guests kind of tell us how they got interested in this specific topic area and to share a little bit about how and why you got interested in studying childhood toileting issues specifically, including why you wrote books on this topic.

DR. HODGES: Yeah, it's an interesting story. We joke, I don't think anyone grows up wanting to be a urologist, you know? It's not one of those, it's not like a fireman or a pilot. So I didn't even know much about urology until I got into medical school. I had no reason to really and I only did urology as an elective because one of my mentors was a member of a church and I knew him and I was like, “Oh, you know, you know, he's a great guy” and he was, and I wanted to work with him and it really opened my eyes to the great field of urology. And then when in urology, within urology, I decided to do pediatrics, kids just because I was drawn to it. My personality, kind of the patient population, so forth, was a lot of fun. And so I did, you know a full urology training for adult MPs and then did a fellowship in San Diego for just children and I came back to work. Most urologists honestly don't see what you call the “bedwetters” or the” “daytime wetters” because it's not a surgical problem. Most of our time is spent doing surgery. That's what I was doing today. And so, nurse practitioners or PAs or other physician extenders will see those patients and there's been this kind of established cookbook of how to treat this problem. My practice, as it turns out, we didn't have those physician extenders, so we were seeing them all and it was actually a blessing in disguise because when I started doing it, I started doing the traditional cookbook therapy and seeing them back and they were not getting better. It was really interesting to me. And I think this is probably the case in a lot of professions. There's almost a little bit of, the emperor has no clothes or people just go along with something that other people do because everyone says it works. And so people were doing this stuff and I'm like, “Am I the only one seeing that this stuff's working? It's not working.” And so I was really racking my brain at what I was doing wrong, and a couple things happened all at once that really affected me. One is that I had a child that needed surgery for a related problem, meaning related to constipation.  And I had already had her on laxatives, and when I started the surgery, when we got inside to work on her bladder, her bladder was really affected by the massive poop in her rectum. Like, there was so much poop in her that it was making the surgery hard.  And I was like, “This is nuts. How much poop is in this kid's bladder?” I knew I had her on laxatives so when I finished the surgery, I had to ask the parents and they said, “No, she's been on MiraLAX for like a year. She poops every day.” And I was like, “That is so weird.” And these were with-it folks. They were really in-tune parents. So I knew they were on top of it.  And then the next week, as fate would have it—I remember because I was sick, I'm sick this week too, it was probably a similar time of year— I went to Cincinnati for a course on anorectal anomalies that an expert, Dr. Pena was giving, and Dr. Levitt. And at that course, they were talking about constipation, unrelated to, you know, the case I just told you, but for the patients they see, and how they use x-rays to diagnose constipation. So I said, you know what I'm going to do? I'm going to start getting x-rays, because this is, you know, made me think about the kid I just operated on. So I remember the first kid I saw back, you know, it's like, “You're having accidents?” “Yes.” “Are you pooping okay?” “Yes.” “Let's get an x-ray.” Get the x-ray, and the kid's just full of poop. I mean, everywhere. Like, not even a little bit.  And so I started treating the x-rays more than the, you know, the symptoms of pooping and way better results. It was unbelievable. So much so that I thought like, “This is, I'm going to get a Nobel prize. This is crazy. You know, I just cured bedwetting.” And so, so I told the resident, “We got to write this up. This is unbelievable.” And she started looking at it and she found a bunch of papers written on the same exact topic in the 1980s by a nephrologist in Canada. And I was like, “This is nuts.” I read the guy's name, but no one ever put it the way he would put it in those papers in the way now I understood it as a problem. It kind of got, I think the terminology for constipation makes it confusing, because it means different things to different people. And so I found him, I looked him up. He was living in Arizona, I called him up and he's like, “Yeah, totally. No one's doing it right. I can't, you know, I've kind of written it off.” I'm like, “This is insane. We should write this up.” And so, we started treating constipation aggressively. He actually had, you know, a brilliant guy. He's still in Arizona. His name is Sean O'Regan.  He was a nephrologist. He cured his son's bedwetting. I don't want to go on too long, but it's a really interesting story. So, his son was wetting the bed. Nephrologists, they deal with kidney disease. They don't deal with bedwetting at all. But he's trying to figure out, “Okay, why is my son wetting the bed?” He went and investigated all this stuff on his own and came to the same conclusion I did, but just 30 years earlier or whatever. And so he goes, “Well, it's the poop. He didn't use an x-ray though. He goes, “I'm going to check my son's rectum. I bet you it's stretched out.” Cause he knew stretching of the rectum affected the bladder. He did this test called an anal rectum manometry on his own son. He put a tube up the butt and blow up a balloon and see if they feel it. This kid didn't feel the balloon until it was really big. And then he had this brilliant notion. He goes, “I'm just going to give him enemas every day. And I bet you'll stop wetting the bed.” And he did it and he stopped wetting the bed. And then he kind of applied that to bedwetting, daywetting, UTIs, and that's kind of what I picked up and ran with. You know, you mentioned our first book is called, one of our books is called, “The MOP Anthology.” MOP stands for Modified O’Regan Protocol, named after Dr. O’Regan because we just took his protocol and kind of tweaked it a bit. It's a long story, but that's kind of like the past 20 years in a nutshell.  

DR. AMY: Yeah, it's fascinating. And I think super exciting when you can find something in the literature from decades prior, right, that somehow did not catch on, but it's brilliant. And, I mean, we could talk about that with, you know, diabetes and blood sugar, right? Like, and so I, I love that you found that and ran with it. And so let's talk about some stuff related to that. Okay.  So you talk about, you actually open your new book by saying that bedwetting and accidents are never a child's fault and they aren't a normal part of childhood.

DR. HODGES: Correct.

DR. AMY: Right, so let's hear more about why they aren't normal.  

DR. HODGES: So I don't think any, I don't know how, if you want to look at it, like, I don’t think God designed people, or evolution of all people to wet while they're sleeping, right? So it's a reflex, it's not normal. And I don't know, maybe some sick animals do it. I'm not up to date on all animal literature, but I think it's pretty rare in the animal kingdom in general to wet the bed. And so, I know it's pathological, and so I don't know. And kids do definitely have behavior that sets up the bedwetting, but it's not like anything unique. So what I think my model, my head is like, humans are too smart for their own good, right? So we're at this huge brain and we overthink everything. I don't know if you guys have kids, but like, what are the three hardest things for kids, this three simplest things in the world: eating, sleeping, and going to the bathroom, right? It's just like the things that are, should be like, just every other animal does without even thinking about it. And since we overthink it, like, “What are we going to eat?” You know, “I only want to eat, you know, plain pasta or whatever. I don't want to sleep because I'm not tired.” You know, everything is overdone and messes up. And so totally the same way, it's where, you know, peeing is easy to do, it's not really uncomfortable, but pooping is pretty uncomfortable, whether it's too hard or too soft. And so very early on kids develop this kind of holding behavior, and you see it in newborns, it may phase out, but it's probably the most common medical condition in kids in terms of fecal retention from discomfort while pooping. And, you know, you've probably all seen it, when they change diet, they get antibiotics maybe, or they, or they start dairy, they get backed up, and they start holding. I would say all kids hold to some degree. A subset of those kids prone to this reflex that leads to bladder erectivity. And it's a little tricky, but basically everyone that gets a dilated rectum because they hold their poop won't, won't get the same response in their body. So it's kind of not fair. It's like when I see kids with kidney stones, you know,  they probably drink plenty, as much as their friends, but they need to drink more just because the way they're wired, they need to, the way they're built, they need to drink more. It's those kids that are prone to bedwetting. They may hold the poop not much more than their friends, but because their bladder is more sensitive to it. They start wetting the bed because it happens when you're really young and people tend to outgrow it. People write it off as a normal part of childhood, but it's definitely treatable and preventable. And so, yeah, I think, I don't want to imply that if you peed and pooped perfectly, that you, you would have problems too. So kids do retain poop, but I think every kid does. I think some adults do. So that's why it's not really their fault. And a lot of times, unfortunately, they get blamed for the accidents when, you know, they don't even know why they're happening. Their parents don't even know why they're happening really. 

DR. AMY: Right. But it's assumed that it's behavioral. I mean, in fact, that's why my field, why the mental health field ends up with these kids, right?

DR. HODGES: Yeah, and I don't know where on what mountain to shout it out on as the highest mountain to shout it on top of is that that it's a major cause of abuse. I'm sure you've seen it too. It's really, really sad and I hate it when a simple misunderstanding, you know. Misunderstandings cause all problems mostly in humanity, but this one is really, you know to have a kid that doesn't know any better, doesn't even know why their wetting, punished because their wetting, that breaks my heart. So hopefully we can educate parents about that so that doesn't happen. 

DR. AMY: Yeah, absolutely. I actually watched like a Friday night movie in the late ‘70s. Remember it was like Friday night of the movies on NBC or whatever on television. It had such an impact on me as a child. There was, you know, a character in the movie who wet the bed and he was probably nine or 10, and the mom would actually strip the sheet off his bed and hang it from the balcony in the front of the house. So that as his friends rode by on their bikes after school, they would see this urine-stained sheet. It had such an impact on me at, you know, eight, nine or 10 that I never forgot it. And I actually then remembered it as I was reading your book again. And so it, it breaks my heart too.  

DR. HODGES: I mean, you can watch, what my pet peeve now, and I, you know, it's funny because certain things, appropriately catch on as inappropriate, right? Like, you shouldn't say certain words anymore. Like, there are words we, you know, we don't say now that maybe were said when I was a kid and it's fine. But like every time I turn on the news, I hear somebody say a “bedwetting politician” as a derogatory term. And it like drives me … and I'm like, “Wow, why was that?” Like, it's like usually pretty well-meaning, educated people on TV saying that. It's like, it's all over the news. I'm like, that is so horrible to think about. Calling someone a “bedwetter” because they worry a lot or something, or, you know, I don't know. It's just, I don't know why that is allowed yet. We should make a pact to make that stop. 

DR. AMY: Yeah, let's do it. 

DR. HODGES: I tried, I tried to write a blog about it. No one cares. It's not really …

DR. AMY: Somebody will find it, you know, 30 years from now, right?

DR. HODGES: I know, yeah. 

DR. AMY: And then you get back out and go, “This guy was a genius.”

DR. HODGES:  Yeah, exactly. But yeah. So we don't want these kids to feel bad about it. It's already embarrassing enough. And I'd like them to know that you can treat it and make it better. And it's not their fault.  

SANDY: So Dr. Hodges, it's, you're basically saying is that most bedwetting or accidents is caused by chronic constipation, but it's not always obvious to us as parents, or even to the person who's having the accidents, that it's a constipation issue. Like you had told us about the surgery that kind of kicked you off this thing. 

DR. AMY: That even pooping every day …

SANDY: Yeah, even pooping every day …

DR. AMY: Doesn't mean you're not constipated.

SANDY: Right? 

DR. HODGES: Yeah, I think the problem is constipation is probably not the right term, but it's a term that people get. They understand like constipation makes sense like you're backed up, but it also implies other things that that don't jive with what we're talking about. And so, in that first call with Dr. O’Regan, I said, “You know, these kids aren't constipated. It’s that the rectum's dilated, you know?” And he said, “Exactly right.” I remember his voice, because he's got an Irish accent. It's incomplete emptying of the rectum. And that, and that's the best way to put it. And so, if you, if you hold your poop, when the poop gets to the rectum, and you feel it, and you go poop right then, like nature intended, you don't have problems. But if you wait, which I don't think the human body was ever designed to do, like sit there and wait, you know, for days or whatever. Then when you do go later, you won't get it all out because you over stretched it, and then you kind of reset the, the sensation of fullness to a larger volume. So you turn the rectum from a sensing organ, an emptying organ, to a storage organ. And that's the problem. And so, I've struggled, with this, you know, for 20 years now, like, what to call it. Because incomplete emptying of the rectum is, sounds weird. No one gets that either. Rectal dilation sounds weird. So we try to say constipation with, but with a caveat/ But you're very right. You can't have, most of the kids I see have no symptoms of bowel dysfunction at all. And you know, it's even more interesting when I first figured this out, I was like, “Great, I'll just send this to these kids to GI and then they'll be, they'll fix them and they'll be fine.” And the GI sent them all back saying they're fine with no, you know, no treatment. They even did like, sitz marker test. If you give these kids sitz markers, the things that go, like little things that show up on an x-ray that go through the colon, they go through normally, the transit time. So it's not like it's, the road is moving through, it's just, you've made a huge road. So instead of a one-lane highway, you've got like a six-lane highway now, and that's the issue. So you gotta shrink it back down.  

DR. AMY: Yeah, so you talk about in your children's book, you kind of use the analogy of a balloon, right? And so that when you, when you're not fully emptying your rectum, then that's putting pressure on a balloon that has a, I mean, the balloon always has a hole in it.

Right? And so then that pressure causes urine to leak out?

DR. HODGES: So the kind of real estate model is a good one for diagramming it because it makes sense to people. And I think probably most women that have been pregnant have had some urinary frequency just because their bladder's pushed on. But the real reason is more neurologic, it’s just a little bit more complicated. So the nerves that go from the bladder to the spinal cord to tell you you're full. So these nerves, like in the wall of the bladder, as they stretch, the bladder stretches, it stretches the nerves, and it sends a signal. And it's almost like, think of it like a, you know, there's like, kind of like, metal detectors that beep that you get closer to metal, whatever, they start beeping more. So that beeping might get faster as the bladder gets more full. The problem is if you, at some level, it will set a reflex off to make you peep, whether you want to or not. And the rectum is right between the bladder and the spinal cord, and so it stretches those nerves as well when it stretches out, and the body doesn't know the difference because it just knows the signals coming through. So you have this heightened state of fullness of the bladder, even though it's not full. The body thinks it's ready to go, so just a little bit of urine adds to it, and it just fires off a reflex. And so the analogy is a lot more like instead of leaking through a hole, kind of like if they hit your knee with a reflex hammer and your knee kicks, there's no stopping it, right? And you don't have any control of that. Your bladder is going to squeeze the same way. It's just going to autopilot and empty. And so that's why when these kids go to bed, they don't wake up. And that's why when they have accidents while awake. A lot of times they don't even know they wet. It's very interesting. Like I've had kids pee on themselves in my clinic in front of me and I said, “You just peed.” And they said, “Oh, did I?” And it freaked me out so much at the beginning, I was like, “Do you have like nerve damage?” You know? Cause you ... I did like pin-prick tests on this one kid to see if he could feel everything because it freaks you out. But now I know it's just part of the, part of the disease process—not disease, but you know what I mean? The condition.  

DR. AMY: Right. How common is this?  

DR. HODGES: You know, a quarter of kids at five years of age have an incontinence of some kind, mostly bedwetting, but, so, very common. You know, I struggle sometimes with how big a deal is it if, like, a 4-year-old wets the bed. Is it that big a deal? You know, like, cause the treatment's not easy either. You know, I think kids could, should, should be on a regular bowel regimen. They should be pooping fine. I take, one of my daughters was wetting the bed when she was young and I just gave her a little bit of MiraLAX and got her emptied out and she was fine. And so, I do think if people jumped on her early, it would be cured a little bit more easily. But if you have a child that you've done some, some simple bowel routine and they're still wetting the bed, you have to make a decision, you know, “Do we want to go all in or do we want to wait a little bit?” Because the caveat of our treatment is that some kids do get better on their own. You just don't know when they're gonna get better. About 15% get better a year … at the age of five.  So, you know, your, your child could be wetting the bed at five and then be dry at six. Or they could still be wetting at 16. You know, you never know how it's gonna settle out.  

DR. AMY: Right. And I think you mentioned it's a pretty high percentage of kids untreated, 9-year-olds who are still having accidents at 18.

DR. HODGES: Yeah, I think if your kids, I'm pretty aggressive. I think 4 years of age, you know, or so. But if they're starting school and still wetting the bed, I would kind of start the treatment. You don't have to be as aggressive as we are in some of the, you know, the enema therapies we use. You can start something oral, but then if they aren't getting dry, you know, you can get an x-ray, see how backed up they are, and then kind of up the ante, because, and that's for two reasons. One is, I don't think it's healthy for a colon to be that dilated anyway. We have this theory that these kids grow up, if they're untreated and get IBS because their colon is so dilated they can't, you know, process their bowel normally, their fecal load normally. And the other is we're seeing a lot more evidence that this affects sleep. People used to think that bedwetting is caused by deep sleep, but in reality, it's a sleep disruptor. And so if you have kids wetting the bed, they're probably not getting restful sleep. And so it's affecting their brain development. You know, you guys know as well as I do how important sleep is for young brains. So that's why I'm like, just jump on it, try and knock it out as fast as you can so they can have a kind of normal brain development, if that makes sense. 

DR. AMY: All right, so before we talk about what we should be doing, let's bust some myths on why some of the typical strategies aren't the way to go. Like limiting liquids.  

DR. HODGES: Yeah, the main thing that's going to set off the bladder spasm is going to be this kind of rectal dilation we're talking about. But it's obviously multifactorial. Like if you made no urine, you would not wet the bed, obviously. And so the amount of urine you make and the speed at which you make it can influence how likely the bladder contracts, but at what cost, you know? You know, if your child's thirsty and they're dehydrated, they're constipated already, do you want to really limit fluids? And the reality is that, you know, we can all drink whatever we want and go to bed, you know, and we're fine. So it doesn't really solve the problem. It can be a contributor to getting dry if you're really just trying to get dry nights, but it's not the root cause. It's more of an ancillary kind of feeder into the problem.

SANDY: What about like learning how to hold it, like having your child stretch their time?

DR. HODGES: Yeah, that's a good one. So I think, you know, yeah, because, you know, this, this process as a kid growing their bladder does stretch and grow, but forcing the issue is just not helping anybody. And I do feel bad for those kids. Cause you know, one of the conditions we see is, um, frequency, because the nerves that are coming off the bladder, they're all in the pelvis. And the nerves that make you feel like you need to pee are different than the nerves that make you actually pee, you know. And so, we have some conditions where the kids sleep fine at night, but during the day they have to pee, like, so often. And the parents are, “Just hold it, you just went. Just hold it, you just went.” And I just hate the thought of them … all they know is their brain's screaming they have to pee, and someone's telling them, “Don't go pee.” You know, I hate that thought. So, you can't stretch a muscle forcefully. You’ve got to fix the root cause, which is this neurological.

DR. AMY: So then rewards aren't going to fix the underlying neurological cause either, right? Like I think you said, overactive bladders do not respond to M&Ms. 

DR. HODGES: Exactly, you know, and they don't respond to logic either because I do, I see that. I see that a lot with like … a good example is like getting a kid to poop on the potty. One of the things we deal with or getting them to go to the bathroom. When you have the normal sensations, you will go to the bathroom in a way, the right way. It is amazing. I've seen kids with their parents say, “These kids won't go to the toilet.”  Immediately start peeing normally without any other coaching other than fixing their bladder so the sensations come through normally. I often tell parents, “What if I told you to go home and not eat until I told you.” Right? You could say, “Okay, I'm not going to eat until you tell me.” If I didn't call you for a few days, you would be like, “I got to eat” because your brain is driving it. If I said, “Go home and don't sleep till I tell you,” I mean, you would fall asleep. Even if I told a parent, “Go home and hold your pee until you have an accident,”they would not be able to do it because the urge is so strong. And so when you fix the condition in their pelvis, the kids get these normal sensations. When the urge to pee comes on, they go normally. And you don't have to reward them, you don't have to explain it to them, it's just … It's like your dog. You let him out and go pee. You don't have to explain it to him. It comes naturally and that's what we want to restore, this kind of normal physiology so the body works like it's supposed to.  

SANDY: Is potty training too soon a concern?  Like is it, is there kind of an ideal time to start the process of potty training?

DR. HODGES: Yeah, I appreciate you bringing that up because you know when I first started, I was really dogmatic about this. You can find some articles back in the day. Because I'll give you a good example. When we see UTIs in little girls, which is a common occurrence in 3- or 4-year-old girls, it's right after potty training.  It's amazing. It's like they were fine. They were fine. And as they come in and say, “My daughter's had five UTIs in five months.” And I'm always like, “Let me guess. You just started potty training five months ago.” They go, “How'd you know?” And so I knew from that fact alone that withholding or holding stuff in  happens, you know, is initiated with the potty training part of it, or it gets worse at least. And so I said, look, these kids are getting backed up. And then you have this kid that is three and you can tell them maybe, “Hey, try to go pee” versus a kid that's two or one. How are you going to have those conversations? So I said, if we have these kids and they're peeing and pooping in the diaper and they're getting out of it, health, you know, why are we forcing to put them in underwear? And then potentially start this withholding and then get all these problems that then we deal with five, six years down the road. And so I really pushed for, “Listen, let's just wait until they're three and a half. You can talk to them about it. They understand what's going on.” And even then, you know, what other behaviors do you leave up to a three-and-a-half-year old? None. You know, so I still need guidance, even after probably training. I hate being dogmatic about it, but you know, ‘cause I know people have other concerns. They have schools, they have economic factors or diapers and stuff like that. So I've softened it a bit saying, “Look, you know, you can train a kid whenever, as long as they're going to the bathroom regularly and emptying completely.” And I do know now that it varies amongst, you know, genetic, there's a genetic variation in that. And so some kids can get backed up and not have problems. So a parent says, “I really want to train my kid early and we have no history of bedwetting in our family or UTIs.” I'm like, “Okay, your genes may be okay, just make sure they poop.” But kids that have history of it, I tell all my kids that when they graduate from like my program, “When you have kids, we're getting them pooping regularly, we're not training them early.” So, I think the earlier they train, the more they hold, but holding doesn't necessarily affect all kids the same, if that helps.

DR. AMY: So, can you estimate what percentage of kids will be successful in training early, like without holding? 

DR. HODGES: Well, yeah, I think, you know, that's a good point. So, if you look at all of the studies they've done, roughly about a third of kids, if they get rectal dilation, get bladder overactivity. So, a third of the kids are going to get bedwetting or overactive bladder, to varying degrees. A third of kids will get bladder underactivity. So, they'll be the ones that, right when you train them, you'll be like, “Oh man, they go all day without peeing, isn't that weird?” And most people don't see a doctor for that. They just kind of comment about it as being a unique party trick or something and so those kids never see us. Once in a while they do. And a third of the kids don't have any change in blood function. So we're only seeing about a third of the kids. But, you know, it's not always so easy to predict. I've seen some kids whose parents had no issues. Maybe the way the genes came together just caused this problem. But, in general, and even if you didn't get potty accidents from being backed up, being backed up isn't healthy, I don't think. It changes your microbiome and doesn’t make you feel good. So I think we could really promote kind of regular pooping in all kids, hoping that we don't get problems in any of them.  

SANDY: So let's talk about what does work. We talked about what doesn't. What's the healthier way to approach this from a parent perspective and trying to help their child evacuate thoroughly.  

DR. HODGES: Yeah. So I look at like two ways. One is like, you know, just kind of getting them potty trained or getting them regular before potty training. And then after potty training, if they have accidents, we have like a little … we have a book called, “Pre-MOP,” which is setting you up so you're pooping the right way. And that is just, when you have a baby, just kind of really be observant. I think there's a lot of info out there from pediatricians, especially if there's a child that's breastfed, that okay, they can go a week without pooping, it's normal. You know, and I don't want to get into all that, but I do think you should really watch them like a hawk. And if they're straying to poop, struggling to poop, putting out poop smears instead of regular poops, you should just really talk to the nutrition about getting them going more regularly. And you can definitely find a program with your doctor or you know with changes or all the medications available, a laxative available to counter, to get a kid regular. And if you're setting them up for potty training, definitely don't even try until they have regular mushy bowel movements every day. Some of the signs that people really write off early on are hiding the poop. They think, oh, they just like their privacy. But hiding the poop is highly associated with constipation and it makes sense if you think about it. Pooping should be like … what I like to see in these kids is they're playing Legos or whatever, pause, poop, keep playing. You know, that's like the ideal kid that's like 3 years old in Pullups and ready to potty train. They're not even thinking about it. It's not even in their head. These kids are like, “I gotta poop. I'm in the corner. Don't look at me. I'm in the closet. My reds, my face is red.” They're, they're backed up. I can guarantee you, cause they're struggling to get it out.  

DR. AMY: My own kid!

DR. HODGES: Yeah, right. It's so common. And so I have a memory literally behind the couch.

DR. AMY: Me too.  

DR. HODGES: My mom says I regressed. And so it's funny. There's a comedian that has a joke about his first memory as a child is letting out a hard poop. It's like “It brought me online.” So it's traumatic. So that's my key. So if you have them on the right protocol, whether diet or, you know, people may or may not want to use MiraLAX or magnesium, you can get them pooping, nice mushy poop. Another trick is if they need help, if they're, if it's in their brain, you know, they're one of us, an anal retentive, they're going to hold it no matter what you do for a long time until they know better. So if you get them through, people will often give them a little bit of MiraLAX or something, get them pooping and say, okay, now they're off the MiraLAX, they're fixed. And it comes back and like, “Oh no, what's wrong with my kid?” There's nothing they did. They just don't like pooping hard poop. So you got to keep it soft somehow.  And that's kind of prepped for it. Then potty training, once you're at three and a half and pooping, okay. I just like to put potties out, tell them, you know, “This is where we like to do it.” And they'll feel it fine and they'll do it. Peer pressure, positive peer pressure takes over. And the only issue we run into sometimes is kids get so comfortable pooping and Pullups that they don't want to poop in the potty. And so we've had to develop a couple of protocols to kind of get convinced them to do it there. But if you do it that way and you take your time with it, you're much less likely to have a backed up kid that's having accidents for years after the potty training.  

DR. AMY: Alright, so let's talk a little bit about MiraLAX and lactulose and magnesium citrate. And so, what do you say to parents who say, “Well, I don't want my kid to get hooked on it.” Number one. And number two, do you prefer the two natural solutions over the MiraLAX? You know, for parents who are uncomfortable with, you know, the polyethylene glycol.

DR. HODGES: Yeah. Yeah, totally.  So I think that modern human's poop is a lot probably firmer than it should be.  think the fiber intake's way lower than caveman diet, that's for sure, right? And so, poop was probably a lot, it had a lot more bulky fiber in it. And so it was less uncomfortable to poop back, you know, 10,000 years ago, whatever. And so getting to that with diet, I just think is almost impossible in modern culture. Like what are you going to feed them? Like just raw broccoli and nuts and stuff? And so I think that you probably almost to get to where you need to be for the poop to be soft enough, for a kid to not want to hold it in, you're going to need to use something like Magnesium Relax or MiraLAX. The reason MiraLAX became so popular is because it is, you know, it dissolves in anything, tasteless, and it's, you can dose it so easy. You give it a little bit, it poops a little softer, you give it a little bit more, it poops harder. And it does have an unfortunate name, because polyethylene glycol implies a lot of stuff. Everything I've seen on it, meaning, and I studied the pharmacokinetics, is that it's completely dissolved, pardon me, completely, removed from the body through the colon and no absorption. And I have no reason to doubt that, but, you know, there are people that take it, there's reports, I've had patients that say, well, you know, it affected their, my child, and obviously you would not want to take something like that if it affects your kid. And so, there are options. Lactose is a prescription version. Lactulose actually has more side effects than MiraLAX because it causes a little bloating, and there's not a really good clean out protocol. Like MiraLAX, if you really want to get a good poop, you can get a ton of it, and just clean them out. Lactose doesn't offer that. And magnesium is a good supplement, but again, magnesium levels are something you've probably got to keep an eye on, and it's just  harder to give, it has a taste. And the, actually the big beef I have with magnesium is that it's very  easy to give and very healthy to give as a supplement in low doses, helps with sleep and migraines, but the actual laxative dose is much higher, and so people sometimes get confused, and they'll use, like, the supplement dose. And I don't care what dose they use if it makes the kid poop better, but sometimes they maybe not get the progress they wanted to because they're underdosing the magnesium. So I would just play around with all the options. There's plenty out there. There's a lot of reputable pediatric laxative sellers that will sell you some stool softeners and laxatives. But to your point about whether or not you get addicted, all it does is make the poop softer. And so it's not affecting how the colon works, and actually, I would think it makes the colon work a little bit better because kids are less likely to retain it and start stretching things out, probably making kids poop more like they should than eating just, you know, even the regular best diet you can, you know, given limitations on the modern diet.

SANDY: Okay. So in extreme cases, you do talk about enemas, which is kind of an aggressive approach. I would, from a parent perspective …  

DR. AMY: Right. And we were actually talking about a scent as well with that too. I mean, so I'd love to, I'd love to talk about the aggressiveness of it and why you love it, right? Cause obviously it's effective, but then what do you do when your child is kicking and screaming and refusing it? Like I can remember holding my kid's butt together. You know, using the glycerin suppositories. Yeah. You know, while they're screaming at me and I'm holding their butt cheeks together. Right. 

DR. HODGES: And no fun for anybody, right? 

DR. AMY: Right. 

DR. HODGES: Yeah. So I, when I started out, I was doing MiraLAX only. Because you know, I'm a urologist. I have no training in GI care. So I picked this up as I've learned through the course of my career. But when Dr. O’Regan, when I first talked to him, he's like, I found his papers, he's like, “enemas all the way.” And I was like, you know, it's brilliant because the problem is there, right? The problem is in the rectum. It's not up top. It's at the end of the colon. He's going right to where the problem is. And so, when I started doing that, my results got way better. So it's like, you know, and it's been like a series of just like trying to find the best way to get a kid empty. And that's, I don't even know the theoretical fastest way, you know, if I could have a magic wand and I emptied the kids rectum completely, how fast could they get dry from bedwetting? You know, I don't even know. So a lot of times I'll tell the parents, you know, it's not a race, you know. We want to get there But how fast do you want to get there and what's best for your family and definitely the treatment can't be worse than the disease. You know, the kid minds bedwetting less than they mind enemas then you could probably take a different approach. The corollary to that is though is that if your kid has, needs a vitamin or something, you know, they don't wanna take that either and you gotta give it, or they need an antibiotic, you know, you find a way to give it. So I do like to temporize a little bit, people's fear of enemas says, you know, it's just a take your mind out of it. It's just a treatment for a medical condition. Most kids have to do fine with them and once they, once they start doing 'em, they actually ask for 'em. Not in a weird way, just 'cause they know that they're not getting empty. They can feel it. And so. I know people tend to write off enemas as kind of never go there kind of deal. But I would say keep an open mind because a lot of the concerns about enemas, we put on the children, not the children. But I do have some memories of that. I have one where my daughter, you know, y'all get to that point where they can't poop right from something. So common. Especially kids like ours. And so I gave her one and she's screaming and then she poops because, “Ah. Thanks, Daddy.” I'm like such a such a contrast of like …  but she did say, “Thank you, but I don't want to do that again tomorrow.” And so, you know, but the kids we treat, they see the light, you know, because they start getting feeling better and they do ask for them and I think that that's not a bad thing. I think that they realize their body was not functioning normally and they want to be back to kind of normal. And so, yeah, keeping an open mind for the treatments, but we have a million different protocols. And we would never have a parent do something they don't want to do. They don't want to use MiraLAX, they don't have to. They don't want to use enemas, they don't have to. We just gotta find a way. If you came up tomorrow with a new way to get kids empty that was better than what I have, I would start, you know, recommending that one because I just want to get the kids empty and better.

DR. AMY: All right. We need to take a break, let Sandy read a word from our sponsor. And when we come back, I just want you to touch on a couple of those other alternative surgical treatments, Botox, InterStim, you know, they're out there and just love for you to speak to that when we come back. 

DR. HODGES: Perfect.  

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DR. AMY: And we're back talking with Dr. Steve Hodges. So just touch briefly a little bit on bladder Botox and InterStim and these other options that parents might be looking at. 

DR. HODGES: Yeah, if you have an older kid, so, you know, I'm completely confident that if we shrink the rectum down, people stop having accidents, but it's not that easy to do easier said than done. Sometimes, you know, if you have a chronically dilated rectum, it takes a lot of work and some kids—we have are teenagers are getting ready to go to college. They need to be dry like now. And so Botox has been great. You know, Botox basically, there's some oral medicines you can take to block the signals that are coming to cause the bladder to squeeze, but they're minimally effective. Botox is much more effective. And at the right dose it can provide temporarily from accidents. And I've had great success with it. Some kids I've given to it and by the time the Botox wears off they're cured anyway. And so they never would again. I've got a lot of satisfied customers. And so I think, yeah, it's definitely something to consider because it's an option, right? It's expensive. It's a procedure. You're under anesthesia. There's hope. So these kids can see, okay, if I can try this and this, and then I can get to Botox and it works really well. And I really like it. Honestly, you know, this protocol is not for everyone too, right? There's some families, they don't have the economic or mental bandwidth to just do all this, you know, these enemas. And so if you have a nice medical procedure, it can help them. Another one is the InterStim. InterStim is like interesting because it stimulates the same nerves the rectum is stimulating to cause the accidents. It just reverses the stimulation. So when I figured out how InterStim worked, I was like, “Oh, it's like a superhero rectum.” It's like, it's the opposite of the rectum. It's coming to do the, you know, or the rectum is like an evil InnerStim. Basically, it's making the bad signals. So, it's like a little pacemaker. You put it in. I've had only a few kids do it because it's an implant. It's a little device and so it's not for everyone. But it can cure the symptoms immediately, again, because it's overriding these signals. It doesn't fix the actual problem, but it's permanently blocking the signals that are causing the problem. And it lets you take your time. You say, okay, my colon's full. I know what's causing these issues. Let's fix the bladder, and then I'll slowly get empty by doing some kind of oral laxative. So in 10 years, my colon's rehabilitated, but I haven't been having accidents for those 10 years. So there, these are things that, you know, obviously you shouldn't jump to the last resort if you failed medical medications, but I want families to know that there are options out there. There's no reason to be having accidents for years because you can get treated, one way or another.  

DR. AMY: So do you have any statistics on the correlation between childhood constipation and then later adult health issues like IBS? Or do you, do you see that or? 

DR. HODGES: I don't. It's my kind of like gut feeling, which is not very scientific. It's just, I see these kids, right? And I'm like, okay, I'm seeing how many kids? Not that many, I'm just one guy. And they're all full of poop. And some, there's kids probably 10 miles down the road, they don't see me. They're wetting the bed.  And the bedwetting goes away, and it ties into one of my theories, is because this reflex, this is an important point. So when you had a baby, remember, they would pee and they wouldn't even know they were peeing, right? Before they were conscious. It was the little thing would light up on the diaper and they were wet. They didn't know they peed. That's because they peed with this sacral reflex.  And that sacral reflex is what persists when kids have accidents. Persists because of the rectal dilation, but it's a very, it's a primitive infant reflex. That reflex will go away eventually, that's why kids stop going to bed with or without resolution of the constipation. So if you, some kids will get better, dry at 12 or whatever, but they're still constipated. So then they have this colon that's really dilated, and they're gonna have this disrupted stooling pattern, because it's hard to maintain regular bowel movements if your colon's like 10 centimeters wide. And so then when I would see adults, and I would see their x-rays of IBS patients, I'd be like, well, wow, these look a lot like the kids I treat. And then when you look at the treatment for IBS, it's basically laxatives. So that's kind of where that theory come from. I don't want to claim it as fact because it's not, but it definitely jives. And I had weird “Aha” moment with another interviewer the other day. She was saying do you think these conditions could be tied into IBS at all? I'm like, “Were you reading in my mind? You've been spying on me?” And she's like, “No. My son was a bedwetter and he had IBS when he grew up.” I was like, “You know, make sense. Something to keep in mind.” Definitely not healthy to have a  hugely dilated full colon. 

DR. AMY: No, I can't imagine that it is.

SANDY: You had talked about in your book about there being a high correlation of constipation with children and adults with autism. Can you talk a little bit more about that as well. Is that. What does that stem from? How does that connect? 

DR. HODGES: Yeah, so I can't really put a finger on the reason why it happens. I just know it happens. And it kind of like it makes sense, right? So you have an autistic kid that have trouble with expressing their emotions or their feelings. They have … very sensitive to stimulation in different ways. And so, the thing that sets off this withholding, this anal retinitis, is just amplified in autistic kids. “My bottom hurts. I squeeze my bottom and the pain goes away, so I'm going to do that all the time.” So these, so the problem with them as well is that if you see an autistic kid in the clinic and they're not potty trained at six, doctors may write that off because they're like, “Well, you know, they're developmentally behind anyway. They're just not ready to be potty trained.” When in reality, they may be just so backed up full of poop that they can't be potty trained. And so the withholding is very common in kids on the spectrum and to a greater degree, I think some of the worst x-rays I've seen on kids have been kids that are autistic. So I would definitely encourage all parents of children with autism to keep a real good close tabs on their children's bowel habits and treat that. And I have a couple that, yeah, I'm not trying to make crazy snake oil claims, but I have parents, I have an email I got the other day from Australia. And she said, “My kid was constipated. Awful. We saw this protocol, we fixed it, and his behavior's improved a lot.” And I think it makes sense. I mean, I don't care what kind of behavior you have. If you're uncomfortable all the time, you're not gonna be behaving to your optimum ability.

DR. AMY: Absolutely. Well, and poop is getting your body, I mean, it's removing the toxins from your body or the parts that you don't need from what you've ingested anyway. So I mean, if you keep that in your body, there has to be a little bit of reabsorption happening, right?

DR. HODGES: Yeah, I think the main thing that messes you up is that, and they've proven this, is that your microbiome, it changes for the worse if you just hold the poop in there. Like if the poop is flowing through normally, you have a certain microbiome. If you hold it in there, it gets worse. And how that ties into your gut-brain and all that stuff is beyond my training, but it's definitely not a good thing. 

DR. AMY: Well, sure. Because like people with slow motility have a greater chance of developing small intestinal bacterial overgrowth. Right?

DR. HODGES: It's all goes up. Yeah, it's amazing. These kids, you know, they, they'll have constipation in the colon and you give them an enema and they throw up if they're really full. You know, you see that tie and like, it's going all the way up the nerves are all, all the way up to the stomach and causing a reflex. And, you know, freak parents out, like, or if they take a lot of MiraLAX or something, or magnesium, you know, there's only so much you can hold in there. And they think that maybe the treatment is causing nausea. It's not the treatment. It’s that they're so full. It's hard to get them empty without the body kind of reacting in a negative way.

DR. AMY: All right. So all of this great information is in your book. Right?

DR. HODGES: Oh, yeah. And we do have a website. It's probably the best place to go. It's www.BedwettingAndAccidents. com. And that way you can get kind of links to me, to the books, everything you need. Kind of, it's a good home base for all things body accidents.

DR. AMY: Fantastic. Anything that you didn't get to say that you still want to share with our listeners?  

DR. HODGES: I just think, you know, don't accept accidents as a, as a normal part of the child's life. You know, there are small percentage of kids that have real problems, you know, congenital, neurologic, or anatomic issues that could be a cause of the incontinence. So, you know, you see your doctor, make sure they don't have anything serious going on. And if they're worked up and they're otherwise healthy, then the constipation is the cause. You could come find us and we'll get them empty and get them sorted out. But definitely don't ignore it.  

DR. AMY: Fantastic. All right. Dr. Steve Hodges. thank you so much for being with us today. Listeners again his website is BedweddingAndAccidents.com. We will put that link in the show notes along with a link to his books. All right. Thank you so much for listening today. If you liked our show, we would love it. If you would follow us on social media at the Brainy Moms. We'd also love it if you would review us on Apple podcasts. If you'd rather see our faces, we are on YouTube. And of course, don't forget to check out Sandy on TikTok at the Brain Trainer Lady. So look, that is all the smart stuff we have for you today. So we're going to catch you next time.

SANDY: Have a great week.