Pelvic Floor Therapy for Children

Pediatric pelvic floor therapy helps children whose bladder and bowel muscles do not work together, and it is one part of a wider plan for daytime wetting, constipation and soiling.⁠^1,12 It teaches relaxation, breathing, toilet posture and body awareness, alongside the routines and medicines your child's doctor directs.⁠²

What is pediatric pelvic floor therapy?

Pediatric pelvic floor therapy is physical therapy for bladder, bowel and pelvic pain problems in children, from birth to age 18.⁠¹ The therapist teaches your child to relax and use the pelvic floor and belly muscles at the right moments, to sit well on the toilet, and to notice the body's signal that it is time to go.⁠²

When the pelvic floor muscles tighten at the wrong time, they can cut off the flow of urine before the bladder is empty, and the urine left behind may leak.⁠¹³ In constipation, incorrect use of the pelvic floor and belly muscles is called dyssynergic defecation, and the 2026 constipation guideline names it as one target of pelvic floor therapy.⁠²

Children's continence specialists use a broader word, urotherapy, for every treatment of childhood bladder problems that is neither surgery nor medicine.⁠¹² It has become a mainstay not only for daytime wetting but also for bedwetting, constipation and soiling.⁠¹² Standard urotherapy means information, instructions, lifestyle advice, counseling and keeping a record of symptoms; specific urotherapy adds tools such as alarms, biofeedback, pelvic floor training and nerve stimulation.⁠¹² The International Children's Continence Society (ICCS) recommends urotherapy as the first-line treatment for most types of lower urinary tract problems in children.⁠¹²

Care is matched to your child's stage. APTA Pelvic Health describes caregiver-led toilet posture and belly massage for infants and toddlers, play-based pelvic floor training and structured bowel routines for preschool and early school-age children, and multimodal programs for teenagers.⁠¹

This page is the children's guide within our pelvic floor therapy guide for every age. The adult condition guide lives at pelvic health for adults.

Which children need pelvic floor therapy?

Pelvic floor therapy is for children whose bladder or bowel problems come from delayed toilet training, constipation, holding, or muscles that do not coordinate.⁠¹ Problems it addresses include:

• Daytime wetting. NIDDK lists holding urine too long, an overactive bladder, an underactive bladder and disordered urination as the problems behind daytime wetting.⁠⁴
• Urgency and holding. Signs include sudden urges, going 8 or more times a day, going only 2 to 3 times a day instead of the usual 4 to 7, and squatting, squirming, leg crossing or heel sitting to stop a leak.⁠¹³
• Dysfunctional voiding. The sphincter or pelvic floor muscles cut off urine flow too soon, before the bladder empties all the way, and the urine left behind may leak.⁠¹³
• Constipation. Fewer than two bowel movements a week, or stools that are hard, dry, lumpy, or difficult or painful to pass.⁠¹⁴ Children most often get constipated from holding in stool.⁠¹⁵
• Soiling (encopresis). Doctors call it encopresis when a toilet-trained child over 4 still passes stool into clothes, and one cause is constipation, with liquid stool leaking around hard, stuck stool.⁠¹⁶
• Bladder and bowel dysfunction. Constipation together with bladder symptoms such as urgency, daytime wetting or bedwetting; it raises the risk of urinary tract infections and kidney damage.⁠¹⁷
• Repeated urinary infections with voiding problems. In children with dysfunctional voiding, a 2024 meta-analysis found that biofeedback lowered the rate of urinary tract infections,⁠⁷ although a 2015 meta-analysis found no difference in infections.⁠⁸
• Pelvic pain. Pediatric pelvic health physical therapy also treats pelvic pain disorders, and teenagers can have painful periods, persistent constipation, urgency or pelvic pain that call for multimodal care.⁠¹

These problems are common. Functional constipation affects about 9.5% of children worldwide.⁠² Almost 1 of every 20 visits children make to a doctor are because of constipation.⁠¹⁴ Soiling has been reported in 75% to 90% of children who come to care with functional constipation.⁠¹⁸ Most children with bladder control problems are physically and emotionally normal.⁠⁴

Wetting and soiling can weigh on a school-age child: accidental wetting can cause emotional distress and poor self-esteem, and untreated soiling can lead to low self-esteem and problems making and keeping friends.⁠^4,16 Our school-age guide covers the wider picture for this age group.

When is daytime wetting a problem?

Children normally gain bladder control somewhere between ages 2 and 4, and by age 4 most stay dry during the day.⁠⁴ Wetting that continues past that point is worth raising with your child's doctor, who can check for a medical cause or reassure you that your child is developing normally.⁠¹³

Occasional wetting is common even in 4- to 6-year-old children.⁠⁴ About 1 in 10 children still has trouble with daytime wetting at age 5, and daytime wetting is more common in girls than in boys.⁠⁴ Studies of 7-year-olds put daytime wetting at 3.9% to 9.0%, with about 0.5% to 0.8% having severe wetting.⁠¹⁹ In research definitions, bladder symptoms such as daytime wetting count toward bladder and bowel dysfunction from age 5.⁠¹⁷

Loss of urine is almost never due to laziness, a strong will, emotional problems or poor toilet training, and NIDDK asks parents to approach it with understanding and patience.⁠⁴ Reward your child for following the plan rather than for staying dry, because a child often cannot control wetting.⁠⁵

If your child wets both day and night, the doctor is likely to treat the daytime wetting first, because children usually stay dry during the day before they gain bladder control at night.⁠⁵ For what children typically do from birth to five, see our developmental milestones guide.

Can pelvic floor therapy help bedwetting?

Not for bedwetting on its own: the recommended treatments are simple behavior changes, then a moisture alarm or the medicine desmopressin.⁠^6,20 Bladder and bowel therapy has a role when bedwetting comes with daytime symptoms or constipation: NICE advises considering treating daytime symptoms first when they predominate, and it names constipation as a common problem that can cause bedwetting and needs treatment.⁠⁶

NICE recommends an alarm as the first-line treatment when advice on fluids, toileting and a reward system has not worked, and desmopressin for children over 7 when an alarm is inappropriate or undesirable, or when rapid improvement is the priority; NICE also allows considering it from age 5.⁠⁶ A 2022 review in American Family Physician found that alarm therapy is more likely to produce long-term success, while desmopressin brings earlier improvement.⁠²⁰ When bedwetting comes with daytime symptoms, the same review says treatment should focus primarily on the underlying cause.⁠²⁰

About 14% of children who wet the bed stop each year without treatment.⁠²⁰ NICE says desmopressin should not be used for children who only have daytime wetting.⁠⁶

Our bedwetting guide covers nighttime causes, alarms and medicine in detail.

Can pelvic floor therapy help constipation and soiling?

It teaches your child to relax the pelvic floor and push correctly on the toilet, as an add-on to laxatives and toilet routines.⁠² The only treatment with a strong recommendation in the 2026 ESPGHAN/NASPGHAN guideline is the laxative polyethylene glycol (PEG).⁠²

Why holding stool turns into soiling

Holding in stool often starts after a hard, painful or frightening bowel movement.⁠¹⁸ The held stool gets harder and larger, the next bowel movement hurts, and the holding repeats in a circle that can be hard to break.⁠¹⁸ A large mass of stool can build up in the rectum, and soft stool then leaks around it.⁠¹⁸ To a parent, this overflow can look like diarrhea in the underwear.⁠¹⁵

What the 2017 trial found

In a Dutch trial published in 2017, 53 children aged 5 to 16 with functional constipation received standard medical care (education, toilet training and laxatives), with or without added pelvic physical therapy.⁠³ After six months of follow-up, treatment had worked for 92.3% of the children who had pelvic physical therapy and 63.0% of those on standard care alone.⁠³ Significantly more children in the therapy group stopped using laxatives, and both parents and children reported larger gains in quality of life.⁠³

Not every trial agrees. A larger study of 134 children in primary care did not find an added benefit from pelvic physiotherapy.⁠¹⁸

Where the guidelines stand

The 2026 ESPGHAN/NASPGHAN guideline, which identified 102 randomized trials, suggests pelvic floor physical therapy as an adjunct treatment for functional constipation in children, a conditional recommendation on low-certainty evidence.⁠² It notes the recommendation could be based on only one small study, and that no conclusion could be drawn about pelvic floor therapy as a stand-alone treatment.⁠² It suggests referring children with suspected dyssynergic defecation and a developmental age of 6 or older to a pelvic floor physical therapist who specializes in children.⁠²

In the guideline's description, therapy includes information and advice, toilet training, relaxation and breathing exercises, and exercises on the toilet that teach correct pushing and relaxing, toilet posture and body awareness, so your child recognizes the urge to go and responds to it.⁠²

Constipation pressing on the bladder

Constipation can cause wetting: NIDDK says doctors treat constipation so that hard stools do not press against the bladder and lead to wetting.⁠⁵ In a 2026 Danish trial of 94 children aged 5 to 14 with bladder and bowel dysfunction, bowel treatment alone reduced daytime wet days over 12 weeks, and adding standard bladder urotherapy brought no additional benefit.⁠¹⁷ Children whose constipation resolved had larger reductions in wet days.⁠¹⁷ The ICCS has a separate consensus document on managing constipation in children who also have bladder symptoms.⁠²¹

What happens at a child's first visit?

A first visit gathers your child's history and symptom records and explains the plan, much as a doctor's visit starts with questions about symptoms and habits:⁠²² standard urotherapy consists of information, instructions, lifestyle advice, counseling and a record of symptoms.⁠¹² Therapists individualize the assessment to your child's cognitive, motor and emotional stage.⁠¹

Keep a bladder and bowel diary

Before the visit, write down when your child uses the toilet, how much urine is passed, when leaks happen, and when and how much your child drinks, including before bed.⁠²² Because constipation can cause wetting or make it worse, record how often your child passes stool and whether it is hard or soft.⁠²² For bowel problems, tracking bowel movements and what the stools look like for several days or weeks before the visit helps.⁠²³

Questions to expect

Expect the kinds of questions doctors ask: symptoms, when and how often wetting happens, dry periods and any family history of bedwetting.⁠²² For constipation, expect questions about how often your child has a bowel movement, what the stools look like, blood on the toilet paper, daily routine including potty training and day care, eating habits and medicines.⁠²³

Expect questions about mood and behavior too. An ICCS document recommends screening every child with constipation, soiling or bladder and bowel dysfunction for psychological symptoms, because 30% to 50% of children with constipation or soiling meet the criteria for a clinically relevant psychiatric disorder.⁠²⁴

Privacy, consent and you in the room

Good pediatric care accounts for your child's autonomy, privacy and any history of trauma, and it includes coaching for you so you can carry the plan home.⁠¹ For a rectal examination by a doctor, NICE calls for privacy, documented consent from the child or a parent, a chaperone, and respect for your child's preferences about how much of the body is exposed and the gender of the examiner.⁠²⁵ Ask the clinic before the first visit whether you can stay in the room.

Is pelvic floor therapy for kids internal?

For preschool and early school-age children, APTA Pelvic Health describes play-based pelvic floor muscle training and biofeedback with surface EMG sensors or ultrasound imaging.⁠¹

Internal methods do appear in some research. In one constipation trial reviewed by the 2026 guideline, pelvic floor exercises used biofeedback with an electrode inserted through the anus.⁠² A doctor working up constipation may also perform a rectal exam.⁠²³

Because methods differ, ask the clinic exactly what any exam or sensor involves before the first visit, and say so if you or your child are not comfortable with something.

What exercises and techniques are used?

Much of the work is daily habits your child learns in sessions and you reinforce at home: timed toilet trips, the right drinks, a good sitting position, relaxed breathing and pelvic floor training through play.⁠^1,2,5,17

Timed voiding and double voiding

Timed voiding means urinating on a schedule every 2 to 3 hours. Double voiding means urinating twice in one visit, which may help the bladder empty completely in children with an underactive bladder or vesicoureteral reflux.⁠⁵ In the 2026 Danish trial, timed voiding was supported by a timer watch, usually every 2 hours.⁠¹⁷ A wristwatch alarm set to vibrate can remind your child privately, without help from a teacher or parent.⁠⁵

Drinks

Your child's doctor may suggest more liquid, mainly water. NIDDK advises avoiding drinks with caffeine or bubbles, citrus juices and sports drinks, which may irritate the bladder or produce extra urine.⁠⁵ The Danish trial's fluid guidance was 1,200 to 1,500 mL a day.⁠¹⁷

Toilet posture

A relaxed posture with proper foot support and the knees lifted at or above hip level helps reduce the angle that stool has to pass through.⁠¹⁸ Taking extra time in the bathroom to relax and empty the bladder completely helps with daytime wetting.⁠⁵

Relaxation, breathing and body awareness

For constipation, therapy includes relaxation and breathing exercises and aims to improve the function of the diaphragm, belly and pelvic floor muscles.⁠² For infants and toddlers, APTA describes belly massage and diaphragmatic-breathing games led by the caregiver.⁠¹

A bowel routine

Ask your toilet-trained child to sit on the toilet after meals, and use a reward system for regular toilet use.⁠²⁶ The 2026 guideline also recommends a toilet training program with a reward system that encourages trying to have a bowel movement after meals.⁠²

Home exercises for parents

Urotherapy aims to normalize bladder and bowel patterns through repeated training.⁠¹² Coaching parents to carry strategies home is part of good pediatric care.⁠¹ Reward effort rather than dry days: taking back rewards, shaming, penalties and punishments do not work.⁠⁵

What is biofeedback for kids, and does it work?

Biofeedback uses a sensor, such as surface electrodes or ultrasound imaging, to show a child what the pelvic floor muscles are doing so the child can learn to relax and tighten them at the right time.⁠^1,2 It helps children with dysfunctional voiding empty the bladder better; its effect on constipation is weaker,⁠² and reviews disagree on wetting.⁠^7,9

NIDDK says a few sessions of biofeedback can retrain muscles that do not work together in the right order.⁠⁵

For bladder problems

A 2024 meta-analysis of randomized trials in children with dysfunctional voiding without a nerve cause found that biofeedback increased urine flow, reduced the urine left in the bladder and lowered urinary tract infections; improvements in muscle activity and voiding patterns lasted more than a year.⁠⁷ The same review found its effect on constipation, daytime wetting and bedwetting was not substantial.⁠⁷ A 2025 meta-analysis of four trials with 244 children and teenagers found that EMG biofeedback improved urine flow and emptying, and called it well tolerated; it also found improved bedwetting, with wide uncertainty.⁠⁹ An earlier 2015 meta-analysis of four trials with 382 children found similar rates of resolved incontinence at six months with or without biofeedback.⁠⁸

In a trial of 50 children aged 5 to 16 with an underactive bladder, adding animated biofeedback and pelvic floor exercises to standard urotherapy increased the number of times children urinated each day and reduced repeat urinary infections over a year.⁠²⁷

For constipation and soiling

For constipation, the 2026 ESPGHAN/NASPGHAN guideline rated the evidence on biofeedback as very low certainty and says it has no role as a stand-alone treatment, though it may be useful within wider pelvic floor physical therapy for selected children.⁠² NICE says not to use biofeedback for ongoing treatment of idiopathic constipation in children.⁠²⁵ A meta-analysis cited in a 2022 review found no evidence of benefit from adding biofeedback to conventional treatment in children with constipation.⁠¹⁸

How long does it take, and does it work?

Expect weeks to months, not days. In two trials on this page, programs ran for 2 to 3 months,⁠^17,28 and the 2017 constipation trial measured its results after six months of follow-up.⁠³

Number of sessions

In a trial of 56 children aged 5.9 to 15.2 with bladder and bowel (dysfunctional elimination) problems that earlier treatment had not improved, one group had 24 training sessions over 3 months and the other 16 sessions over 2 months, and urinary continence improved with both programs.⁠²⁸ Only the children who also had biofeedback showed a significant drop in urine left in the bladder.⁠²⁸ NICE advises referral to a specialist if a child's constipation does not respond to initial treatment within 3 months.⁠²⁵

How well it works

Results depend on the problem. In a European trial of children with daytime wetting, cure rates were similar whatever was added: 39% to 44% in children with an overactive bladder (placebo, oxybutynin or bladder training), and 52% versus 49% in children with dysfunctional voiding (controls versus pelvic floor training).⁠²⁹ The authors concluded that the standard cognitive treatment every child received was the key to success, not the added interventions.⁠²⁹ A 2023 meta-analysis found that about half (48%) of children with daytime wetting were continent after urotherapy with wearable alarm reminders, with definitions of continence varying between studies and very low certainty, and adding the alarms did not significantly improve results.⁠¹⁹

For constipation, the 92.3% success with added pelvic physical therapy comes from a single small trial, and the 2026 guideline rates the evidence as low certainty.⁠^2,3

Does it last, and are there risks?

In dysfunctional voiding, the biofeedback benefits on voiding patterns persisted for more than a year.⁠⁷ Soiling often comes back, so some children need ongoing treatment, though most respond well.⁠¹⁶ The pelvic physiotherapy trials reviewed for the 2026 guideline did not report adverse events.⁠² A 2025 meta-analysis described EMG biofeedback as well tolerated.⁠⁹

Pelvic floor therapy for toddlers: is it ever needed?

For toddlers, guidance is aimed mainly at parents: APTA describes caregiver-led toilet posture, belly massage, breathing games and early voiding schedules for infants and toddlers.⁠¹ The 2026 constipation guideline suggests referring children with suspected dyssynergic defecation to a pelvic floor physical therapist from a developmental age of 6.⁠²

Toilet training usually starts between 21 and 36 months, and constipation in children peaks around the same age, with a median age of onset of 2.3 years.⁠¹⁸ Most toddlers younger than 2.5 years are not toilet trained, which is why the Rome IV criteria treat toilet-trained and not-yet-trained toddlers differently.⁠³⁰

Rome IV signs of toddler constipation

Under the Rome IV criteria, doctors diagnose functional constipation in a child up to age 4 when at least two of these are present for one month:⁠³¹

• two or fewer bowel movements a week⁠³¹
• a history of excessive stool retention⁠³¹
• a history of painful or hard bowel movements⁠³¹
• a history of large-diameter stools⁠³¹
• a large mass of stool in the rectum⁠³¹
• in toilet-trained children, at least one episode of stool leakage a week, or large stools that may block the toilet⁠³¹

Spotting withholding

Children who hold in stool may stand on tiptoes and rock back on their heels, clench their buttocks or make unusual, dancelike movements.⁠¹⁵ NICE lists a straight-legged, tiptoed, back-arching posture as a sign of withholding.⁠²⁵

NIDDK suggests taking a break from potty training until the constipation stops.⁠²⁶ If a child over 4 has soiling, MedlinePlus advises contacting your provider for an appointment.⁠¹⁶ For toilet skills and routines in the years before school, see our occupational therapy for preschoolers guide.

Autism, sensory differences and toileting

Autistic children are more likely to have wetting and soiling and to take longer to become continent.⁠^32,33

In a study of 40 autistic children (mean age 11.3) and 43 age-matched controls, bedwetting affected 30.0% versus 0%, and daytime wetting 25.0% versus 4.7%.⁠³³ Bowel control was delayed to age 4 or later in 42.5% of the autistic children versus 7.5% of controls.⁠³³ A 2018 systematic review of 33 publications found higher rates of incontinence in autistic children than in typically developing children, though many studies had limits such as no control group.⁠³²

Toileting resistance is also common. In the Study to Explore Early Development, among children aged 4 to 5, parents reported toileting resistance in 49.1% of autistic children, 23.6% of children with other developmental delays and 8.0% of children from the general population.⁠³⁴ Constipation was linked to toileting resistance only in the autistic children.⁠³⁴

Interoception: noticing the urge

Interoception is the ability to sense internal body signals, and pediatric occupational therapists are starting to use it in assessment and treatment, though evidence to support those methods is still lacking.⁠³⁵ Pelvic floor therapy for constipation also works on body awareness so a child recognizes the urge to go.⁠² Our interoception guide explains this sense in detail.

What helps

In a pilot of 34 families of autistic children aged 2 to 8, parents coached by telehealth over 10 to 12 weeks reported significant improvements in toileting behavior.⁠³⁶ NICE says desmopressin should not be ruled out for bedwetting in children with developmental and learning difficulties when an alarm is not suitable and the child can keep to evening fluid limits.⁠⁶ See our autism guide for therapy across the spectrum.

Who provides pediatric pelvic floor therapy?

Pediatric pelvic floor therapy is a physical therapy specialty, and the 2026 constipation guideline suggests referring children with suspected dyssynergic defecation to a pelvic floor physical therapist who specializes in children.⁠^1,2 The ICCS says a team approach works best, with shared and discipline-specific expertise.⁠¹²

• Physical therapists with pediatric pelvic health training lead the pelvic floor work. APTA Pelvic Health runs a Level 3 Pediatric Pelvic Health course and a pediatric special interest group.⁠³⁷ Read more in our physical therapy guide.
• Occupational therapists work with children whose sensory processing affects daily activities, including interoception.⁠³⁵ See our occupational therapy guide.
• Your pediatrician treats constipation and urinary infections and prescribes medicine when needed.⁠^5,26
• A pediatric gastroenterologist sees children with soiling when first treatments are not enough, and may use biofeedback.⁠¹⁶
• A pediatric urologist sees children with bedwetting that does not respond to treatment, when a structural or nerve problem is more likely.⁠²⁰
• A child psychologist with expertise in constipation can help when there is poor adherence, high family stress or a suspected behavioral condition.⁠²

The pelvic floor therapy hub explains the specialty for every age.

Is pediatric pelvic floor therapy covered by insurance?

For children on Medicaid, the EPSDT benefit requires states to provide medically necessary services that can correct or ameliorate a condition, even when the state's Medicaid plan does not otherwise cover them.⁠¹¹ For private insurance, check your plan's physical therapy benefit before the first visit.

EPSDT covers children under age 21 who are enrolled in Medicaid.⁠¹¹ Physical therapy and occupational therapy are both listed among 1905(a) Medicaid services, which is the group EPSDT draws on when a service is medically necessary.⁠^11,38

Do you need a referral? All 50 states, the District of Columbia and the U.S. Virgin Islands allow either provisional or unrestricted direct access to physical therapists, though some states still attach conditions to treatment without a referral.⁠¹⁰ Your insurer may have its own rules, so ask. Our direct access guide explains the details.

Questions to ask your plan: whether pelvic floor physical therapy is covered for a child, whether a referral or prior authorization is needed, how many visits a year are covered, and which in-network clinics treat children. If coverage falls short, see our guide to therapy without insurance.

When should a child see a doctor first?

See your child's doctor before starting therapy, and promptly if any of these signs appear, because they can point to an infection, a problem in the urinary tract, nerves or spine, or another illness that needs medical treatment first.⁠^6,13,25

How do I find a pediatric pelvic floor therapist?

APTA Pelvic Health's PT Locator has a Pediatric Pelvic Health category, listed with autism spectrum disorder, ADD/ADHD and sensory processing under Pediatric & Neurodiversity.⁠³⁹ When you call a clinic, ask how many children it treats, what any exam or sensor involves, whether you can stay in the room, and how it shares progress with your child's doctor.

Our physical therapist directory and occupational therapist directory list clinics by city, and the pelvic floor therapy hub covers care at every age.

Clinics that list pediatric pelvic floor therapy

12 clinics in the DrSensory directory name pediatric pelvic health, bedwetting or encopresis among their services (7 PT, 5 OT), across 12 states.

Each clinic appears here because its own listing names this among what it offers. A listing is not an endorsement, and inclusion does not mean we have verified a clinic’s credentials, licensure or insurance. Browse all physical therapy clinics.

Frequently Asked Questions

Sources

1. APTA Pelvic Health. Evidence Highlight: Pediatric Pelvic Health. Author: Molly Self, PT, DPT. aptapelvichealth.org. Accessed November 1, 2026. aptapelvichealth.org. Checked November 1, 2026.
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   “Pediatric pelvic health physical therapy supports children from infancy through early adulthood to manage bladder, bowel, and pelvic pain disorders.” “Pediatric pelvic health physical therapy (PHPT) addresses a spectrum of bladder, bowel, and pelvic pain disorders from infancy through late adolescence and emerging adulthood (birth to 18 years old). Developmentally, dysfunction may arise from delayed toilet training, constipation, withholding behaviors, or sensory-motor discoordination, all of which disrupt maturation of the pelvic floor and continence mechanisms” “Physical therapists therefore individualize assessment and education to each child’s cognitive, motor, and emotional stage, integrating play, family routines, and school participation goals” “For infants and toddlers, caregiver-centered instruction in optimal toileting posture, abdominal massage, diaphragmatic-breathing games, and early voiding schedules establishes neuromotor foundations for continence” “Preschool and early-school children benefit from play-based pelvic floor muscle training, surface EMG or ultrasound imaging biofeedback, and structured bowel regimens that combine fiber, hydration, and physical activity” “During adolescence, hormonal shifts and evolving body image coincide with higher rates of dysmenorrhea, persistent constipation, urgency, or pelvic pain. Evidence supports multimodal programs” “Across all ages, clinicians must account for pediatric anatomy (smaller pelvic outlet, unfused coccyx), developing neuromuscular control, and psychosocial factors such as autonomy, privacy, trauma history, and gender identity” “Trauma-informed, inclusive communication improves adherence and outcomes and should extend to caregiver coaching to reinforce home strategies”
2. Gordon M, de Geus A, Boruta M, Banasiuk M, Benninga M, Borrelli O, et al. European Society for Paediatric Gastroenterology, Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines for treatment of functional constipation in children aged 0-18 years. J Pediatr Gastroenterol Nutr. 2026;83(2):335-366. doi:10.1002/jpn3.70447. PMID: 42159193. PMCID: PMC13446596. europepmc.org. Checked November 1, 2026.
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   “Functional constipation (FC) is a common problem in childhood, with a worldwide prevalence of 9.5%.” “Polyethylene glycol (PEG) is the only treatment with a strong recommendation in the current guideline.” “A total of 102 original randomized controlled trials (RCTs) assessing treatment of FC in children aged 0–18 years were identified.” “Pelvic floor physiotherapy is suggested as an adjunct treatment option for FC in children (conditional recommendation, overall low certainty evidence, effect size large)” “Pelvic floor physiotherapy assumes that FC can be partly caused by incorrect use of the pelvic floor and abdominal muscles (dyssynergic defecation), as well as the interaction between breathing, posture, and movement.” “Treatment by a qualified pediatric pelvic floor physiotherapist will include providing information and general advice, along with toilet training, relaxation exercises, breathing exercises, and defecation‐promoting exercises on the toilet. The exercises aim to improve the function of the diaphragm, abdominal, and pelvic floor muscles, teach the correct straining and relaxation technique and toilet posture, and enhance body awareness, helping the child recognize the urge to defecate and respond appropriately.” “GRADE assessment showed pelvic physiotherapy as an addition to standard medical care may lead to more treatment success compared to standard medical care alone (92% vs. 44%; RR: 2.08 [1.34–3.21]; NNT 2 [1–6]; large magnitude of effect; low certainty).” “Adverse events were not reported in the included trials.” “The recommendation could only be based on one study, including a small number of children. No conclusions could be drawn for pelvic floor physiotherapy as a stand‐alone treatment, and therefore, the use of pelvic floor physiotherapy can only be suggested as adjunct therapy. The GDG suggests referring children with suspected dyssynergic defecation and with a developmental age of 6 years or older to a pelvic floor physiotherapist specialized in children.” “PFE was performed using an electromyography biofeedback method, in which an electrode is inserted through the anus.” “It is recommended to implement a toilet training program with a reward system, encouraging the child to attempt defecation after meals.” “The GDG suggests referring children with constipation and behavioral problems to a child psychologist with expertise in FC if there is poor adherence to the medical regimen, significant child/family stress inhibiting progress, and/or concern about comorbid behavioral diagnoses” “The GDG suggests not to use biofeedback alone, but to consider it as part of a wider strategy of pelvic floor physiotherapy.” “Available evidence on biofeedback was of very low certainty, therefore no GRADE recommendations could be made. There was a GDG experience with the use of biofeedback, and the GDG acknowledges biofeedback may be useful as part of a wider strategy of pelvic floor physiotherapy in select patients. There is no role for biofeedback as a standalone treatment.”
3. van Engelenburg-van Lonkhuyzen ML, Bols EM, Benninga MA, Verwijs WA, de Bie RA. Effectiveness of Pelvic Physiotherapy in Children With Functional Constipation Compared With Standard Medical Care. Gastroenterology. 2017;152(1):82-91. doi:10.1053/j.gastro.2016.09.015. PMID: 27650174. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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   “We performed a multicenter randomized controlled trial of 53 children (age, 5-16 y) with FC according to the Rome III criteria, at hospitals in The Netherlands from December 2009 to May 2014.” “SMC consisted of education, toilet training, and laxatives (n = 26), whereas PPT included SMC plus specific physiotherapeutic interventions (n = 27).” “The primary outcome was absence of FC, according to Rome III criteria, after a 6-month follow-up period.” “Treatment was effective for 92.3% of the children receiving PPT and for 63.0% of the children receiving SMC (adjusted odds ratio for success of PPT, 11.7; 95% confidence interval, 1.8-78.3) (P = .011). Significantly more children undergoing PPT stopped using laxatives (adjusted odds ratio, 6.5; 95% confidence interval, 1.6-26.4) (P = .009).” “PPT also produced larger adjusted mean differences, before vs after treatment, in numeric rating scales to assess quality of life: an increase of 1.8 points for parents (P = .047) and 2.0 points for children (P = .028).”
4. National Institute of Diabetes and Digestive and Kidney Diseases. Definition & Facts for Bladder Control Problems & Bedwetting in Children. Last reviewed September 2017. Accessed November 1, 2026. niddk.nih.gov. Checked November 1, 2026.
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   “Children normally gain control over their bladders somewhere between ages 2 and 4—each in their own time. Occasional wetting is common even in 4- to 6-year-old children.” “By age 4, when most children stay dry during the day, daytime wetting can be very upsetting and embarrassing.” “Loss of urine is almost never due to laziness, a strong will, emotional problems, or poor toilet training. Parents and caregivers should always approach this problem with understanding and patience.” “Holding urine too long.” “Overactive bladder.” “Underactive bladder.” “Disordered urination.” “About 1 in 10 children has trouble with daytime wetting at age 5.” “Daytime wetting is more common in girls than boys.” “Most children with bladder control problems are physically and emotionally normal.” “However, accidental wetting can cause emotional distress and poor self-esteem for a child as well as frustration for families.”
5. National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for Bladder Control Problems & Bedwetting in Children. Last reviewed September 2017. Accessed November 1, 2026. niddk.nih.gov. Checked November 1, 2026.
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   “You should reward your child for following a program, rather than for staying dry—because a child often cannot control wetting.” “If your child wets both day and night, the doctor is likely to treat daytime wetting first. Children usually stay dry during the day before they gain bladder control at night.” “Your child’s doctor will treat any constipation, so that hard stools don’t press against the bladder and lead to wetting.” “urinating on schedule every 2 to 3 hours, called timed voiding.” “urinating twice during one visit, called double voiding. This method may help the bladder empty completely in children who have an underactive or “lazy” bladder or vesicoureteral reflux (VUR)” “relaxing the pelvic floor muscles so children can empty the bladder fully. A few sessions of biofeedback can retrain muscles that don’t work together in the right order.” “Oxybutynin (Ditropan) is often the first choice of medicine to calm an overactive bladder” “If your child often has bladder infections, the doctor may prescribe an antibiotic” “drink more liquid, mainly water, if the doctor suggests doing so.” “take extra time in the bathroom to relax and empty the bladder completely.” “avoid drinks with caffeine or bubbles, citrus juices, and sports drinks. These drinks may irritate the bladder or produce extra urine.” “Taking back rewards, shaming, penalties, and punishments don’t work; your child is not wetting the bed on purpose.” “A wristwatch alarm set to vibrate can privately remind your child to visit the toilet, without help from a teacher or parent.”
6. National Institute for Health and Care Excellence. Bedwetting in under 19s. Clinical guideline CG111. Published October 27, 2010. Accessed November 1, 2026. nice.org.uk. Checked November 1, 2026.
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   “Ask whether the bedwetting started in the last few days or weeks. If so, consider whether this is a presentation of a systemic illness.” “Consider assessment, investigation and/or referral when bedwetting is associated with:” “severe daytime symptoms” “a history of recurrent urinary infections” “Refer children and young people with suspected type 1 diabetes immediately (on the same day) to a multidisciplinary paediatric diabetes team” “Consider investigating and treating daytime symptoms before bedwetting if daytime symptoms predominate.” “A common comorbidity that can cause bedwetting and requires treatment” “Offer an alarm as the first‑line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system” “Offer desmopressin to children and young people over 7 years, if:” “an alarm is inappropriate or undesirable” “However, do not use desmopressin in the treatment of children and young people who only have daytime wetting.” “Do not exclude desmopressin as an option for the treatment of bedwetting in children and young people with emotional, attention or behavioural problems or developmental and learning difficulties if an alarm is inappropriate or undesirable and they can comply with night‑time fluid restriction.”
7. Li F, Feng L, Yang Y, Ma X, Kang T, Huang W. The effect of biofeedback on nonneurological dysfunctional voiding in children: A meta-analysis and systematic review. J Pediatr Urol. 2024;20(4):565-580. doi:10.1016/j.jpurol.2024.06.042. PMID: 38997937. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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   “Meta-analysis revealed that BF increased the maximum urinary flow rate (SMD = 3.78, 95% CI 1.33∼6.22), improved urination time (SMD = 5.88, 95% CI 3.75∼8.01), and reduced the postvoid residual (SMD = -19.18, 95% CI -27.03∼-11.33) and urinary tract infection incidence (RR = 0.43, 95% CI 0.21∼0.87). Electromyogram activity (RR = 0.46, 95% CI 0.25∼0.84) and abnormal urination patterns (RR = 0.51, 95% CI 0.35∼0.74) improved, with effects persisting for more than 1 year.” “Existing evidence indicates that BF can enhance urinary parameters and patterns in children with NDV. However, its effectiveness in addressing constipation, daytime urinary incontinence, and nocturnal urinary incontinence is not substantial.”
8. Fazeli MS, Lin Y, Nikoo N, Jaggumantri S, Collet JP, Afshar K. Biofeedback for nonneuropathic daytime voiding disorders in children: a systematic review and meta-analysis of randomized controlled trials. J Urol. 2015;193(1):274-279. doi:10.1016/j.juro.2014.07.097. PMID: 25072179. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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   “Five eligible studies were included in the systematic review, of which 4 (382 participants) were pooled in the meta-analysis based on available outcomes data. The overall proportion of cases with resolved incontinence at month 6 was similar in the biofeedback and control groups (OR 1.37 [95% CI 0.64 to 2.93], RD 0.07 [-0.09, 0.23]).” “Current evidence does not support the effectiveness of biofeedback in the management of children with nonneuropathic voiding disorders.”
9. Passos CL, Mendes Souza MB, Corrêa Leite MT, Carvalho BCN, Saconato H, Freitas Filho LG. Efficacy of Electromyographic Biofeedback for Dysfunctional Voiding in Children and Adolescents: A Systematic Review and Meta-analysis of Randomized Trials. Urology. 2025;206:114-120. doi:10.1016/j.urology.2025.08.046. PMID: 40865572. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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   “Four randomized controlled trials were included, totaling 244 patients. The meta-analysis showed that EMGBF therapy significantly increased maximum urinary flow rate (MD: 4.69; 95% CI: 1.06-8.31), normalized voiding flow patterns (RR: 2.70; 95% CI: 1.43-5.10), reduced postvoid residual urine (MD: 11.11; 95% CI: 2.38-19.84)” “EMGBF is an effective and well-tolerated intervention for treating dysfunctional voiding in children and adolescents.”
10. American Physical Therapy Association. Direct Access Advocacy. apta.org. Accessed November 1, 2026. apta.org. Checked November 1, 2026.
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    “As of July 1, 2025, all 50 states, the District of Columbia, and the U.S. Virgin Islands have either provisional or unrestricted direct access to physical therapist services for evaluation and treatment. Even though patients may go directly to a physical therapist without a referral, some provisions tied to treatment absent a referral still persist in a number of states”
11. Centers for Medicare & Medicaid Services. Early and Periodic Screening, Diagnostic, and Treatment. Medicaid.gov. Accessed November 1, 2026. medicaid.gov. Checked November 1, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.” “States are required to furnish all 1905(a) Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines.” “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state's Medicaid plan.”
12. Nieuwhof-Leppink AJ, Hussong J, Chase J, Larsson J, Renson C, Hoebeke P, Yang S, von Gontard A. Definitions, indications and practice of urotherapy in children and adolescents: a standardization document of the International Children's Continence Society (ICCS). J Pediatr Urol. 2021;17(2):172-181. doi:10.1016/j.jpurol.2020.11.006. PMID: 33478902. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “Urotherapy is an umbrella term for all non-surgical, non-pharmacological interventions for lower urinary tract disorders (LUTD) in children and adolescents. Urotherapy is a specialized practice, which has become mainstay therapy not only for daytime urinary incontinence, but also for nocturnal enuresis, functional constipation and fecal incontinence. The aim of urotherapy is to achieve the normalization of the micturition and bowel pattern and to prevent further functional disturbances by repeated training. It is well known that in the treatment of adult and childhood incontinence a team approach is best, where there are shared areas of expertise and also discipline-specific expertise available.” “Standard urotherapy comprises components such as provision of information, instructions, life-style advice, counselling and registration of symptoms. Specific urotherapy is tailored towards specific disorders and includes alarm treatment, biofeedback training, pelvic floor training, neurostimulation and other interventions.” “Therefore urotherapy is recommended by the ICCS as the first-line treatment for most types of LUTD.”
13. National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms & Causes of Bladder Control Problems & Bedwetting in Children. Last reviewed September 2017. Accessed November 1, 2026. niddk.nih.gov. Checked November 1, 2026.
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    “the urgent need to urinate, often with urine leaks” “urinating 8 or more times a day, called frequency” “infrequent urination—emptying the bladder only 2 to 3 times a day, rather the usual 4 to 7 times a day” “squatting, squirming, leg crossing, or heel sitting to avoid leaking urine” “If you or your child are worried about accidental wetting, talk with a health care professional. He or she can check for medical problems and offer treatment, or reassure you that your child is developing normally.” “pain or burning when urinating” “cloudy, dark, bloody, or foul-smelling urine” “pain in the lower belly area or back” “your child dribbles urine or has a weak urine stream, which can be signs of a birth defect in the urinary tract” “your child was dry, but started wetting again” “If your child has symptoms of a bladder or kidney infection, or has a fever without a clear cause, see a health care professional within 24 hours.” “As the bladder empties, sphincter or pelvic floor muscles may cut off urine flow too soon, before the bladder empties all the way. Urine left in the bladder may leak.”
14. National Institute of Diabetes and Digestive and Kidney Diseases. Definition & Facts for Constipation in Children. Last reviewed May 2018. Accessed November 1, 2026. niddk.nih.gov. Checked November 1, 2026.
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    “fewer than two bowel movements a week” “stools that are hard, dry, or lumpy” “stools that are difficult or painful to pass” “Almost 1 of every 20 visits children make to a doctor are because of constipation.”
15. National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms & Causes of Constipation in Children. Last reviewed May 2018. Accessed November 1, 2026. niddk.nih.gov. Checked November 1, 2026.
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    “standing on tiptoes and then rocking back on his or her heels” “clenching his or her buttocks” “doing unusual, dancelike movements” “having stool in his or her underwear that looks like diarrhea” “Your child should see a doctor if his or her symptoms last for more than 2 weeks or do not go away with at-home treatment.” “Take your child to a doctor right away if he or she has constipation and any of the following symptoms” “bleeding from his or her rectum” “blood in his or her stool” “constant pain in his or her abdomen” “vomiting” “weight loss” “Children most often get constipated from holding in their stool to avoid or delay having a bowel movement.”
16. MedlinePlus Medical Encyclopedia. Encopresis. Review date July 16, 2024. Accessed November 1, 2026. medlineplus.gov. Checked November 1, 2026.
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    “If a child over 4 years of age has been toilet trained, and still passes stool and soils clothes, it is called encopresis.” “The child may have constipation. The stool is hard, dry, and stuck in the colon (called fecal impaction). The child then passes only wet or almost liquid stool that flows around the hard stool.” “Seeing a pediatric gastroenterologist when these treatments are not enough. Your gastroenterologist may use biofeedback, or teach the parents and child how to manage encopresis.” “Most children respond well to treatment. Encopresis often recurs, so some children need ongoing treatment.” “If not treated, the child may have low self-esteem and problems making and keeping friends.” “Contact your provider for an appointment if a child is over 4 years old and has encopresis.”
17. Axelgaard S, Kamperis K, Hagstrøm S, Dossche L, Svendsen AM, Mikkelsen LF, Isidor S, Brodersen B, Borch L. Bowel Management and Standard Urotherapy in Pediatric Bladder and Bowel Dysfunction: A Randomized Clinical Trial. JAMA Netw Open. 2026;9(4):e268836. doi:10.1001/jamanetworkopen.2026.8836. PMID: 42043819. europepmc.org. Checked November 1, 2026.
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    “Bladder and bowel dysfunction is a common pediatric condition characterized by functional constipation and lower urinary tract symptoms, including daytime urinary incontinence. It increases the risk of urinary tract infections and kidney damage” “Bladder and bowel dysfunction (BBD) is defined by the coexistence of functional constipation and lower urinary tract symptoms, including urgency, altered voiding frequency, daytime urinary incontinence (DUI), and nocturnal enuresis in children 5 years or older.” “with 12-week follow-up at 5 outpatient pediatric clinics in Denmark. Children aged 5 to 14 years with treatment-naive bladder and bowel dysfunction” “Urotherapy included education, timed voiding, optimal toilet posture, and fluid intake guidance.” “Ninety-four children (median [IQR] age, 6.9 [6.1-8.2] years; 57 [60.6%] male) were randomized” “Constipation resolution was associated with larger reductions” “In this randomized clinical trial of children with bladder and bowel dysfunction, bowel management reduced daytime urinary incontinence; concurrent urotherapy provided no additional benefit.” “adequate fluid intake (1200-1500 mL/d), and timed voiding supported by a timer watch, usually every 2 hours.”
18. Koppen IJN, Benninga MA. Functional Constipation and Dyssynergic Defecation in Children. Front Pediatr. 2022;10:832877. doi:10.3389/fped.2022.832877. PMID: 35252068. europepmc.org. Checked November 1, 2026.
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    “Nowadays, toilet training is usually initiated between 21 and 36 months of age” “Interestingly, the age of onset of FC peaks around 1 year of age and decreases after the age of 4 years, with a median age of onset of 2.3 years” “Withholding behavior often occurs after a negative experience such as a hard, painful or frightening bowel movement.” “Stool withholding behavior allows fecal matter to remain in the colon and rectum longer, where water is absorbed and the fecal mass becomes harder and more difficult to evacuate. This can eventually lead to the accumulation of a large fecal mass in the rectum, known as fecal impaction. If, after a period of withholding, a child needs to evacuate a hard, large diameter stool, this frequently results in painful defecation. This painful experience again prompts withholding behavior resulting in a vicious circle that can prove hard to break. In addition, fecal impaction may lead to overflow fecal incontinence which is the involuntary loss of soft stools that leak around the solid, obstructing, fecal mass. Fecal incontinence has been reported to be present in 75–90% of children presenting with FC” “A relaxed posture, with proper foot support and the knees lifted at or above hip level, helps to reduce the anorectal angle.” “A recent meta-analysis, including the three studies comparing add-on treatment with biofeedback to conventional treatment, detected considerable levels of heterogeneity and found no evidence for benefit of the addition of biofeedback in children with FC” “However, a large study in a primary care setting, including 134 children, did not find additional benefit of pelvic physiotherapy”
19. de Wall LL, Nieuwhof-Leppink AJ, Schappin R. Alarm-assisted urotherapy for daytime urinary incontinence in children: A meta-analysis. PLoS One. 2023;18(2):e0275958. doi:10.1371/journal.pone.0275958. PMID: 36735674. europepmc.org. Checked November 1, 2026.
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    “In 7-year-old children, the prevalence varies between 3.9 and 9.0% with approximately 0.5 to 0.8% suffering from severe DUI” “Meta-analysis revealed a nonsignificant risk ratio of 1.4 (95% CI: 0.8–2.6) for the use of alarm systems. Urotherapy with alarm systems resulted in a 48% (95% CI: 33–62%) continence rate after treatment.”
20. Lauters RA, Garcia KW, Arnold JJ. Enuresis in Children: Common Questions and Answers. Am Fam Physician. 2022;106(5):549-556. PMID: 36379501. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “Approximately 14% of children have spontaneous resolution each year without treatment.” “Children with nonmonosymptomatic enuresis have daytime and nighttime symptoms resulting from a variety of underlying etiologies.” “Treatment should begin with behavioral modification, which then progresses to enuresis alarm therapy and oral desmopressin. Enuresis alarm therapy is more likely to produce long-term success; desmopressin yields earlier symptom improvement. Treatment of secondary monosymptomatic nocturnal enuresis and nonmonosymptomatic enuresis should primarily focus on the underlying etiology. Pediatric urology referral should be made for refractory cases in which underlying genitourinary anomalies or neurologic disorders are more likely.”
21. Burgers RE, Mugie SM, Chase J, Cooper CS, von Gontard A, Rittig CS, Homsy Y, Bauer SB, Benninga MA. Management of functional constipation in children with lower urinary tract symptoms: report from the Standardization Committee of the International Children's Continence Society. J Urol. 2013;190(1):29-36. doi:10.1016/j.juro.2013.01.001. PMID: 23313210. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “We present a consensus view of members of the International Children's Continence Society (ICCS) together with pediatric gastroenterologists, experts in the field of functional gastrointestinal disorders, on the management of functional constipation in children with lower urinary tract symptoms.”
22. National Institute of Diabetes and Digestive and Kidney Diseases. Diagnosis of Bladder Control Problems & Bedwetting in Children. Last reviewed September 2017. Accessed November 1, 2026. niddk.nih.gov. Checked November 1, 2026.
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    “medical history” “In addition, doctors will ask questions about” “when and how often the wetting happens” “dry periods” “family history of bedwetting” “Write down when your child uses the toilet, the amount of urine passed, and when your child leaks urine. Record the timing and amount of liquid your child drinks, too, including whether your child drinks fluids before bedtime.” “Because constipation can cause wetting or make it worse, your child’s doctor may ask you to record how often your child passes stool and whether it’s hard or soft.” “An ultrasound uses sound waves to look at structures inside the body without exposing your child to radiation. During this painless test, your child lies on a padded table. A technician gently moves a wand called a transducer over your child’s belly and back.”
23. National Institute of Diabetes and Digestive and Kidney Diseases. Diagnosis of Constipation in Children. Last reviewed May 2018. Accessed November 1, 2026. niddk.nih.gov. Checked November 1, 2026.
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    “How often does your child have a bowel movement?” “What do your child’s stools look like?” “Are there streaks of blood on the toilet paper when he or she wipes?” “What is your child’s daily routine, including potty training, physical activity, and day care?” “What are your child’s eating habits?” “What medicines does he or she take?” “You may want to track your child’s bowel movements and what his or her stools look like for several days or weeks before the doctor’s visit.” “perform a rectal exam”
24. von Gontard A, Nieuwhof-Leppink A, Barroso U, Joinson C. Psychological and Psychiatric Issues in Functional Constipation, Fecal Incontinence and Bladder and Bowel Dysfunction: A Revised and Updated Document of the International Children's Continence Society (ICCS). Neurourol Urodyn. 2026;45(6):1035-1045. doi:10.1002/nau.70291. PMID: 42021557. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “30%-50% with FI, FC, and NRFI fulfill the criteria for clinically relevant psychiatric disorders.” “Because the comorbidity rate is high, screening for psychological symptoms is recommended for all children in all settings with FI, FC, FNRFI and BBD.”
25. National Institute for Health and Care Excellence. Constipation in children and young people: diagnosis and management. Clinical guideline CG99. Published May 26, 2010; last updated July 13, 2017. Accessed November 1, 2026. nice.org.uk. Checked November 1, 2026.
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    “If a child or young person has any 'red flag' symptoms, do not treat them for constipation. Instead, refer them urgently to a healthcare professional with experience in the specific aspect of child health that is causing concern.” “Evidence of retentive posturing: typical straight legged, tiptoed, back arching posture” “Reported from birth or first few weeks of life” “Failure to pass meconium/delay (more than 48 hours after birth [in term baby])” “'Ribbon stools' (more likely in a child younger than 1 year)” “Previously unknown or undiagnosed weakness in legs, locomotor delay” “Abdominal distension with vomiting” “Gross abdominal distension” “Abnormal: asymmetry or flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi or sinus, hairy patch, lipoma, central pit (dimple that you can't see the bottom of), scoliosis” “If the history-taking and/or physical examination show evidence of faltering growth treat for constipation and test for coeliac disease (see the NICE guideline on coeliac disease) and hypothyroidism.” “For a digital rectal examination ensure:” “privacy” “informed consent is given by the child or young person, or the parent or legal guardian if the child is not able to give it, and is documented” “a chaperone is present” “the child or young person's individual preferences about degree of body exposure and gender of the examiner are taken into account” “Do not use biofeedback for ongoing treatment in children and young people with idiopathic constipation.” “Refer children and young people with idiopathic constipation who do not respond to initial treatment within 3 months to a practitioner with expertise in the problem.”
26. National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for Constipation in Children. Last reviewed May 2018. Accessed November 1, 2026. niddk.nih.gov. Checked November 1, 2026.
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    “Ask your potty-trained child to use the toilet after meals to build a routine.” “Use a reward system when your child uses the bathroom regularly.” “Take a break from potty training until the constipation stops.” “Your child’s doctor may recommend giving your child an enema or laxative to help treat his or her constipation.” “Talk with your child’s doctor before stopping any medicines.”
27. Ladi-Seyedian S, Kajbafzadeh AM, Sharifi-Rad L, Shadgan B, Fan E. Management of non-neuropathic underactive bladder in children with voiding dysfunction by animated biofeedback: a randomized clinical trial. Urology. 2015;85(1):205-210. doi:10.1016/j.urology.2014.09.025. PMID: 25444633. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “A total of 50 children with UB without underlying neuropathic disease, aged 5-16 years, were included in this study. They were randomly divided into 2 equal treatment groups comprising standard urotherapy (hydration, scheduled voiding, toilet training, and diet) with (group A) or without (group B) animated biofeedback and PFM exercise. The follow-up period for each participant was 1 year.” “Mean number of voiding episodes was significantly increased in group A after biofeedback therapy compared with group B with only standard urotherapy (6.6 ± 1.6 vs 4.5 ± 1 times a day; P <.000). Urinary tract infection did not relapse in 9 of 11 (81%) and 8 of 15 (38%) patients in groups A and B, respectively (P <.02).”
28. Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, Gomes S, et al. Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a randomized study. Pediatr Nephrol. 2006;21(12):1858-1864. doi:10.1007/s00467-006-0277-1. PMID: 16967285. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “Fifty-six patients 5.9-15.2 years old with dysfunctional elimination syndrome (DES) unimproved by previous therapies were randomly distributed into two voiding training programs: group 1 contained 26 patients submitted to 24 training sessions over a 3-month period; group 2 contained 30 patients submitted to 16 sessions over a 2-month period.” “Clinical evaluation was carried out before each program's initiation and 1, 6, and 12 months after each program's termination.” “Urinary continence was improved after completion of either training program. Only those patients who received biofeedback training showed a significant decrease in postvoiding residual (PVR) urine as detected by dynamic ultrasonography.”
29. van Gool JD, de Jong TP, Winkler-Seinstra P, Tamminen-Möbius T, Lax H, Hirche H, et al.; European Bladder Dysfunction Study. Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence. Neurourol Urodyn. 2014;33(5):482-487. doi:10.1002/nau.22446. PMID: 23775924. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “All children received standardized cognitive treatment, to which these interventions were added. The main outcome variable was daytime incontinence with/without urinary tract infections.” “In branch I, the 15% full response evolved to cure rates of 39% for placebo, 43% for oxybutynin, and 44% for bladder training. In branch II, the 25% full response evolved to cure rates of 52% for controls and 49% for pelvic floor training.” “The mismatch between urodynamic patterns and clinical symptoms explains why cognitive treatment was the key to success, not the added interventions.”
30. Russo M, Strisciuglio C, Scarpato E, Bruzzese D, Casertano M, Staiano A. Functional Chronic Constipation: Rome III Criteria Versus Rome IV Criteria. J Neurogastroenterol Motil. 2019;25(1):123-128. doi:10.5056/jnm18035. PMID: 30646483. europepmc.org. Checked November 1, 2026.
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    “In the group of neonate/toddlers, considering that the majority of toddlers aged less than 2.5 years are not toilet trained, a differentiation between toilet-trained and not toilet-trained children has been included.”
31. Muhardi L, Aw MM, Hasosah M, Ng RT, Chong SY, Hegar B, et al. A Narrative Review on the Update in the Prevalence of Infantile Colic, Regurgitation, and Constipation in Young Children: Implications of the ROME IV Criteria. Front Pediatr. 2021;9:778747. doi:10.3389/fped.2021.778747. PMID: 35071132. (Table 1 reproduces the Rome IV criteria.). europepmc.org. Checked November 1, 2026.
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    “Diagnostic criteria must include one month of at least 2 of the following in infants up to 4 years of age:” “Two or fewer defecations per week” “History of excessive stool retention” “History of painful or hard bowel movements” “History of large diameter stools” “Presence of a large faecal mass in the rectum” “For toilet-trained children:” “At least one episode per week of incontinence after the acquisition of toileting skills” “History of large diameter stools which may obstruct the toilet”
32. Niemczyk J, Wagner C, von Gontard A. Incontinence in autism spectrum disorder: a systematic review. Eur Child Adolesc Psychiatry. 2018;27(12):1523-1537. doi:10.1007/s00787-017-1062-3. PMID: 29019014. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “After eligibility assessment, 33 publications were included in the review. The published literature implies a higher prevalence of incontinence in children with ASD compared to typically developing children. Limitations and biases as inappropriate diagnostic criteria for ASD and incontinence, selected samples, or lack of control groups are reported.”
33. von Gontard A, Pirrung M, Niemczyk J, Equit M. Incontinence in children with autism spectrum disorder. J Pediatr Urol. 2015;11(5):264.e1-7. doi:10.1016/j.jpurol.2015.04.015. PMID: 26052001. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “Forty children with ASD (12 children with infantile or childhood autism, 15 with atypical autism and 13 with Asperger's syndrome) (mean age 11.3 years) and 43 age-matched control children (mean age 10.7 years) were assessed.” “Children with ASD showed increased rates of NE (30.0% vs 0%) and DUI (25.0% vs 4.7%) compared to controls. Among children with ASD, daytime bladder control (≥5 years of age: 20.5% vs 0%) and bowel control (≥4 years of age: 42.5% vs 7.5%) were delayed compared to controls.” “they needed a longer time to become dry and continent”
34. Wiggins LD, Nadler C, Hepburn S, Rosenberg S, Reynolds A, Zubler J. Toileting Resistance Among Preschool-Age Children with and Without Autism Spectrum Disorder. J Dev Behav Pediatr. 2022;43(4):216-223. doi:10.1097/DBP.0000000000001036. PMID: 35170572. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “Families and children aged 24 to 68 months were enrolled in the Study to Explore Early Development, a multisite case-control study on ASD. Children with ASD (N = 743) and DD (N = 766) and those from the POP (N = 693) who were 48 months or older were included in this study. Parents reported toileting resistance” “Toileting resistance was more common among children with ASD (49.1%) than children with DD (23.6%) and those from the POP (8.0%).” “Constipation, expressive language delays, and low social motivation were significantly associated with toileting resistance only in children with ASD”
35. Clark E, Brown T, Yu ML. Interoception and its application to paediatric occupational therapy: A scoping review. Aust Occup Ther J. 2025;72(1):e12997. doi:10.1111/1440-1630.12997. PMID: 39505563. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “Paediatric occupational therapists assess and provide intervention for children presenting with sensory processing challenges that impact their daily occupational performance. Interoception, the ability to sense internal body signals, is an emerging practice area” “Findings indicated that paediatric occupational therapists are integrating interoception concepts alongside occupational therapy principles to inform assessment and intervention processes. Several assessments and interventions are utilised to support children; however, evidence to strengthen use is lacking.”
36. Little LM, Wallisch A, Dunn W, Tomchek S. A Telehealth Delivered Toilet Training Intervention for Children with Autism. OTJR (Thorofare N J). 2023;43(3):390-398. doi:10.1177/15394492231159903. PMID: 36942902. pubmed.ncbi.nlm.nih.gov. Checked November 1, 2026.
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    “Participants included 34 families of children with autism ages 2 to 8 years. Measures were administered at pre- and postintervention (10-12 weeks)” “Parents found the intervention highly acceptable and reported significant improvements in child toileting behaviors”
37. APTA Pelvic Health. Pediatric Pelvic Health. aptapelvichealth.org. Accessed November 1, 2026. aptapelvichealth.org. Checked November 1, 2026. “Pelvic Health Physical Therapy Level 3 Pediatric Pelvic Health” “Meet the Pediatric Pelvic Health Special Interest Group Directors”
38. Centers for Medicare & Medicaid Services. Mandatory & Optional Medicaid Benefits. Medicaid.gov. Accessed November 1, 2026. medicaid.gov. Checked November 1, 2026. “Physical therapy (1905(a)(11), 42 CFR 440.110(a))” “Occupational therapy (1905(a)(11), 42 CFR 440.110(b))” “Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services (1905(a)(4)(B), 1905(r), 42 CFR 440.40, 42 CFR 441 Subpart B)”
39. APTA Pelvic Health. PT Locator: Pediatric Pelvic Health. aptapelvichealth.org. Accessed November 1, 2026. aptapelvichealth.org. Checked November 1, 2026. “Explore pelvic health specialties and find a physical therapist who may be able to help.” “Pediatric & Neurodiversity” “ADD / ADHD Autism Spectrum Disorder (ASD) Neurodiversity Pediatric Pelvic Health Sensory Processing”

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