Pediatric urologist, Dr. Steve J. Hodges, from Wake Forest University of Medicine and author of IT’S NO ACCIDENT: Breakthrough Solutions to Your Child’s Wetting, Constipation, UTIs, and Other Potty Problems, answers common questions about potty issues..
Get more information about bedwetting, potty training, constipation, and UTIs on at It’s No Accident website or pick up the book.
Q: At what age should I be concerned about nightly bedwetting?
A: Bedwetting is so common that most doctors don’t even consider treating it until a child is 7, and that is a reasonable policy — sometimes. Most children can be cured much sooner, especially if constipation is to blame, and it usually is.
In the book, we list the 11 signs of constipation. Most of these are signs folks don’t typically think of, and the number-one sign is extra-large bowel movements (even if they occur daily). If your kid’s poops often surprise you with their size, I suggest clearing her out with the MiraLAX regimen recommended in our book, and keeping her on a maintenance dose for at least six months. The bedwetting will likely cease within three months. Our bedwetting chapter details a few other helpful therapies as well.
Q: My son just turned 7 and still wets his bed every night. Not on vacation or in another bed, just his own bed. I’ve tried rewards, waking him every 2 hours to use the bathroom, and no water after 6 pm. Nothing works. What should I do?
A: I don’t think we’ll ever understand why some kids wet only certain beds, but it’s a common phenomenon. However, I can tell you that rewards don’t work because bedwetting is not within a child’s control.
Middle-of-the-night wakings don’t work, either, except when you’re using a bedwetting alarm. (In the book, I explain how and when to use one.) The problem is that you’ll rarely time it correctly. And even if you’re able to keep your child dry overnight using this technique, you haven’t really solved anything except possibly a laundry problem; you’ve simply adapted your child’s sleeping patterns to her poor bladder capacity.
Restricting fluids before bed can help but on its own won’t solve the problem.
Focus on the most likely cause of bedwetting: hidden constipation. More than 80 percent of bedwetters stop wetting with this simple therapy alone. Making sure your child pees regularly while awake is also an important component of relieving
Q: Is medication recommended for bedwetting?
A: One of the most common bedwetting meds is desmopressin, or DDAVP, which tricks the body into making less urine at night. I consider this drug a last resort, appropriate only for a week at sleep-away camp, for example. DDAVP doesn’t solve the problem; it just covers it up. Once kids go off this medication, they start wetting the bed again.
Bladder relaxing medicines such as Ditropan or Detrol (oxybutynin) can help relax the bladder muscle so it holds more urine, but these meds can worsen constipation, which is the likely cause of the wetting to begin with. I won’t prescribe bladder-
relaxing medication until an x-ray shows that a child is absolutely not constipated.
The best therapy for bedwetting is a course of laxatives or enemas.
Q: My son had surgery to remove fluid from his testicles at age one. Could this be causing his bedwetting? He’s 6 years old.
A: There is no correlation between hydrocele surgery and bedwetting, unless it is new bedwetting and the surgery was particularly stressful for the child, a rare scenario. By far the most common cause of bedwetting is hidden constipation, which can often easily be addressed with laxatives or enemas.
Q: What’s the best age to start potty training?
A: As I mention in the book, I don’t think children under age 3 should be in charge of their own toileting habits any more than they should be in charge of their college funds. Young kids simply don’t have the good judgment to pee or poop in a timely
manner. Sure, you can train a kid to stay dry in underwear at a much younger age, but this child usually ends up holding too long. Symptoms may not surface for two or three years, but the holding behavior so common among potty-trained two year-olds often catches up with these kids. That’s when they show up at my clinic, with the sudden onset of accidents, urinary tract infections, urinary frequency, or numerous other problems.
Q: Ideally, how long should it take to potty train a child?
A: Once a child understands the concept of peeing or pooping in the potty, and has done it, training happens within a few days or weeks. If it doesn’t seem to click, the child either isn’t ready or has some underlying problem, usually constipation, that
makes it difficult for her to control her bowel or bladder.
For most kids, peeing in the potty is much easier to learn than pooping in the potty. The important thing is to be patient and not push the issue until the child is old enough. On the other hand, if you have a 4-year-old who knows when he needs to go
but demands a diaper to pee or poop, you have my permission to force the issue.
Q: If a child shows interest in potty training before the age of three, should I just go with it?
A: You can definitely go with it; you are just giving yourself a lot more responsibility. The younger a child is when she trains, the more important it is for you to make sure she pees every two hours and poops regular, soft, small stools. You need to instruct
your child to pee regularly, and start MiraLAX at the earliest sign of bowel trouble.
Q: How long should I keep my child in Pull-ups? I’ve heard they should only be used during potty training.
A: It is reasonable to keep children in Pull-ups while they are toilet training. There’s no reason to keep a child in Pull-ups after training unless the child needs them at night. Or, sometimes we take Pull-ups with us when we take our newly trained daughter to a place that doesn’t have clean restrooms around. I’d rather have her go in a Pull- up than hold it all day. If a child was toilet trained before age 3 and began having accidents soon after training, I think it’s much better to put her back in Pull-ups and relieve the pressure of holding than to try to force her to try to stay dry. Often the bladder will recover, and she can then be weaned off Pull-ups much more easily.
Q: My daughter will only poop in Pull-ups. What do I do?
A: I had the same problem with my oldest. It is a common problem, and I’m not sure of the cause, although the simple familiarity of pooping while standing in Pull-ups may be the only way the child feels comfortable going. At some point, as long as you are sure the child isn’t constipated, you need to force the issue. Sometimes it’s not pretty. I’m a big softie, so I literally held an open Pull-up under my daughter as she sat on the potty, and when she went, I moved the Pull-up out of the way. When she saw that she could actually poop in the potty, she was done with Pull-ups. Any creative way you can think of to get her comfortable pooping while sitting and without a Pull-up on is reasonable. Just keep in mind that behaviors such as hiding to poop are often associated with constipation.
Q: My son is 4 years old and still has potty accidents a few times a week. Should I be concerned?
A: Yes, you should be. He shouldn’t be having any accidents. Daytime accidents are a big red flag because they mean he has lost the ability to delay peeing. It’s likely his bladder has become overactive due to excessive holding of pee, poop or both. Our book explains in great detail how to solve the problem.
Q: By what age should a child be able to wipe on his or her own behind? My 7 year old still asks me to help.
A: By 7 years of age a child should definitely be able to wipe his own behind. There is nothing wrong with helping your child, but the problem is that if he feels the need to poop and you aren’t around, he might hold it, and delaying poop can lead to lots of potty problems. I would work to build his confidence and independence with wiping.
Q: What are the main signs of constipation?
A: Sometimes, there’s no doubt a child is clogged up, like when pooping causes obvious pain. You know your kid is constipated if you find her balled up in the corner sobbing every time she needs to go Number Two. But typically, the symptoms are less noticeable. If your child shows at least one of the following signs, she almost certainly is backed up.
- Extra-large bowel movements. If your child’s poops are larger than you would expect from a child—more than 3/4 of an inch wide and more than 6 inches long—he almost certainly has been holding it. (Long thin ones, that look like garden snakes, can be OK.) The large size suggests the poop has extended from his rectum up into his intestines. The width is the key warning sign; poops should be thin!
- Firm bowel movements, as opposed to amorphous, gooey poops. To see what’s normal and what’s not, look at the Bristol stool scale.
- Infrequent bowel movements. If your child is pooping less often than every other day, she’s probably holding her poop. Just know that pooping daily, or even mulptiple times a day, does NOT rule out constipation. The appearance and consistency are more telling.
- Poop accidents. These usually are caused by overflow from a stretched- out rectum. When the rectum is really full, some poop just drops out.
- Poop-stained underwear. This is often explained away as poor wiping, but it’s actually a sign of trouble. Sometimes, when children try to poop with an overly full rectum, they can’t push it all out. Incomplete emptying results in less than a clean break, so the child’s bottom is harder to wipe. The upshot: skid marks, as eleven-year-old boys and goofy pediatric
urologists like to call them.
Check out all 11 signs of constipation in the book, IT’S NO ACCIDENT: Breakthrough Solutions to Your Child’s Wetting, Constipation, UTIs, and Other Potty Problems.
Q: My doctor told me to stop bathing my daughter that has urinary tract infections, and instead giver her showers. She loves her bath! Is that really necessary?
A: Baths don’t cause urinary tract infections! Constipation and excessively holding pee causes urinary tract infections. Irritation of the vulva, or the skin around the urethra, can be a risk factor for infections, but the answer isn’t to avoid baths; simply avoid irritating soaps and bubble baths. Sitting in a bath and washing with pH balanced, mild soaps can be beneficial for children with infections. In a child with existing vulvar skin irritation, oatmeal, baking soda, or vinegar baths can help relieve the irritation and discomfort.