Bedwetting & Elimination Problems

My 5 yo DD was recently diagnosed with constipation, which the doc thinks is causing her incontinence/enuresis. This was shocking to me, since she has always pooped regularly and it was always soft. She never had stomach issues or complained about tummy troubles. We have a high-fiber diet and she eats tons of fruits, veggies and whole grains.

But she constantly had "mini accidents"--she would pee a little bit multiple times/day and her undies were always damp or even very wet at the end of the day. Whenever I asked her about it, she said she "didn't know she had to go." Yet some days she peed every five minutes for several hours in a row. Once we went to a play and she peed seven times in 1.5 hours.

I took DD to the doc five times last year (when she was 3-4 yo) to get her checked for UTIs and diabetes because the peeing was so bad. Everything was clear every time, and the doc said she just needed time for her bladder to grow, etc.

But then the constipation issue came up, and ever since then I have been confused and stressed. At first the doc thought she had a tethered spine (SCARY), but then she decided that constipation was a more likely culprit.

So we did Miralax (two adult doses/day) for two weeks with zero change. Then we did a clean out (eight doses in 32 oz. juice in two hours). It seemed to help curb the mini accidents and constant peeing, but it did nothing for bedwetting. So we did another clean out. No change. We continued the Miralax (two adult doses/day) for another two weeks after the clean out with no change. I felt a little disappointed because nothing seemed to be truly resolved.

We stopped the Miralax a few days ago and the mini accidents have returned. Today DD didn't poop, but she peed twice on herself. I am SO FRUSTRATED! Does this mean we have to give DD Miralax every day for months? Will she ever regularly poop and pee? I feel even more helpless because our doctor's office has suspended most new appointments to limit the exposure to swine flu. I don't want to go in for this "minor" issue and come out horribly sick, so I'm kind of stuck.

Has anyone BTDT? What should I do? Stick with the Miralax and hope for the best? OR should I really start freaking out over the tethered spine thing (or something else?!)? Any info or advice is appreciated. TIA.

It is very common for someone with constipation issues to be on Miralax for months (or even years). It's also possible to have soft stool and still be constipated. However, it sounds like your doc is just kinda guessing. What made him (or her) decide it's a constipation problem? What kind of doctor are you seeing?

Personally, I'd push the doctor to order an abdominal x-ray for your dd. Many times a doctor will want to feel/palpate the belly, but it is NOT an accurate indicator of whether or how much poop is in the intestinal tract. An abdominal x-ray will reveal whether your dd is retaining too much poop and if so, how significant the problem is. You could probably pick up the orders for an x-ray without much risk of contracting H1N1, and your doc could call you with results.

It's possible the extra fluids taken with the Miralax helped your dd urinary issues by helping your dd fill and empty her bladder more regularly. When my dd was seeing a urologist, one of the things they had us try was having dd drink larger quantities of fluid and to drink/void at regular intervals.

Nighttime wetting is usually a different issue than daytime wetting (tho' they can sometimes be inter-connected), so solving the daytime wetting won't automatically stop nighttime wetting. I wouldn't worry about nighttime wetting at this point in the game, esp since your dd is still relatively young.

I don't know enough about tethered spinal cords, but from the little I've read, I'm not sure that your dd symptoms are related to tethered cord. We did have a mom here several months ago whose dd was finally diagnosed with a tethered cord. You could look through the archives for posts from "mom2alexnabbie" if you wanted to see her experiences (look in mid-late 2008/early 2009). Her dd had a lot of UTI's and constipation problems, but I don't remember whether incontinence was a symptom or not. Her dd had surgery earlier this year that appeared to be a success. If it got to the point that your dd needed to be tested for a tethered cord, an MRI can reveal whether it's a problem. I don't know that your dd has enough medical history for spinal cord testing to be appropriate yet, though.

If an abdominal x-ray shows that constipation really is the problem, then it's probably an issue of the bowels putting too much pressure on the bladder. By keeping the bowels empty with regular stool-softening laxatives (like Miralax), you'll take the pressure off your dd bladder which will enable her to hold her urine better. Stool-softening, non-stimulant laxatives are NOT habit-forming (the body does not become dependent on them like it does with stimulant laxatives), so they are safe for long-term, daily use.

If an x-ray reveals that constipation is not the problem, then you may need to follow up with a urologist. You can try getting your dd a timer (or a watch with an alarm or vibrating alarm), to have her drink/pee at regularly scheduled times throughout the day (every hour or so) to help train her bladder. You can also encourage your dd to lean forward after peeing, to put pressure on her bladder, to make sure every last drop of pee is eliminated.

Let us know what happens. Good luck!

Thank you so much for your response. I really appreciate your help. You clearly have a lot of experience with this, and I appreciate you sharing your knowledge!

After I described DD's peeing/accidents at DD's 5-year check-up (and after the pediatrician saw some faint birthmarks on DD's spine that she thought could indicate the tethered cord), my pediatrician ordered an abdominal X-ray to check for constipation. When she called with the results, she said DD is "really backed up." We haven't done a follow-up X-ray to determine how effective the Miralax has been. In your experience, is a follow-up X-ray necessary? Do we need to know how "cleaned out" DD is?

Would you recommend a urologist at this point? Or a GI doc? Or should we stick with the Miralax for a while and see how it goes? Any advice is appreciated...I am swimming in the dark here.

Thanks so much!!!
McKenna

Okay, it sounds like there was a little more to the story I didn't realize, and it sounds like your doc is being more on the ball than I thought. Sorry for misunderstanding.

Here's some more info about constipation. When the bowels get overfull (regardless of whether it's soft stool or dry/hard stool), the bowels get stretched out and lose muscle tone. Without muscle tone, it's more difficult to eliminate stool. Sometimes the bowels can get so overfull, and the stool can be so dry/hard, that the only poop that can get out is really loose watery stool that oozes around the blockage.

To resolve the problem, you need to keep the bowels emptied on a regular basis. A general guideline is that it takes approx six months of the bowels being completely emptied daily, in order for the bowels to shrink back to normal size and regain good muscle tone. Any time the bowels get overfull and stretched out again, that six-month time frame starts all over.

There are two basic types of laxatives: stimulant and non-stimulant. Stimulant laxatives force bowel contractions to semi-quickly eliminate stool. The body can become dependent on them, so they are for occasional use only. Stimulant laxatives are often senna-based products (such as Senekot and ex-lax), though there are other types as well (incl enemas).

Non-stimulant laxatives are usually stool-softening type products. They are not habit forming (the body does not become dependent on them), so they are safe for long-term daily use. They help hold water in the stool to keep it from getting too dry/hard/difficult to pass. Some good ones are Miralax, Fiber Choice (with Inulin), Milk of Magnesia, Benefiber, and mineral oil. If one product doesn't produce good results, you can try another one. Non-stimulant laxatives are slower-acting than stimulant laxatives.

Typically a doctor would recommend that you clean out the bowels by using a stimulant laxative. A 2nd or 3rd dose may be needed, if there's very much stool being retained. Then a doc would typically recommend that you begin a daily regimen of non-stimulant laxatives.

How much laxative you give depends entirely upon the individual. The dosing guidelines are generic guidelines for average people. Some people need more, some need less. You just don't want to give so much laxative that you give your child chronic diarrhea and dehydrate them, but otherwise use as much as is necessary to enable your child to completely empty her bowels daily. (At one point my dd was taking six laxatives a day. That would be way too much for most kids, but wasn't enough for my dd.) The stool should be very soft and easy to pass -- pudding-like in consistency is often a good goal.

If your dd has a tethered spinal cord, then more aggressive treatment may be necessary.

My 15yo dd was born with bowel troubles, probably a result of her high-functioning autism (neurological signals mis-firing). She has slow bowel motility. Additionally, she does not receive the signals to her brain when her bowels are full, so her body does not automatically try to eliminate stool. As a result, we have to keep her stool very, very, very soft, so she can eliminate it without her intestinal tract sending contractions to push things along. It's amazing how much you can learn about poop!

Since you've already had x-ray confirmation that your dd has a history of constipation issues, then you probably don't need to push for another x-ray at this point. You can try getting dd bowels cleaned out, then go back on a maintenance dosage of Miralax (or something similar) to see if there's any improvement. If you're not seeing much change after a month or so, then you might want to request another x-ray to show the doc how your dd bowels are doing WHILE she's on the laxatives.

At this point I'd focus on the bowel stuff before getting involved with a urologist. If the bowels are affecting the bladder, there's not much the urologist can do until the bowels are taken care of. If your pediatrician is able to help you with the bowel stuff, then there's no problem sticking with him/her, but if you're not seeing sufficient progress, then you might want to see a pediatric gastroenterologist (GI doc).

Best wishes.