Clinical Considerations Of Rectal Balloon Training In Pediatric Patients

In pediatric pelvic floor therapy, some cases push beyond the limits of your standard tools and techniques. As this field of therapy evolves and you see increasingly complex medical cases, you need to be prepared for interventions that go beyond your typical toolbox. One of those interventions is rectal balloon training, which is not commonly used. And rightly so. But in the right context, with the appropriate child, it can make a profound difference.

One concern that may come up—especially for therapists newer to the field—are the questions of rectal balloon training. Should we be doing this with kids? Is it ethical? Safe? Helpful?

I do not recommend rectal balloon training as a routine part of pediatric pelvic floor therapy. This is not a training tool to be used lightly or often. It should only be considered in very rare and very specific situations. But rare doesn’t mean never.

In my Peds Level 2 course, we cover rectal balloon training in depth because I believe those working with medically complex patients need to understand when, why, and how it may be appropriate. This blog post is a chance to unpack some of those complexities and help you make informed, ethical, and compassionate decisions in your own practice.

My own training in rectal balloon training started when one of my trusted referring pediatric gastroenterologists approached me about a few patients. His kids who had undergone major bowel surgeries were continuing to struggle despite the best medical and therapeutic care. He asked if I’d consider rectal balloon training for a select group of post-operative patients, and I began diving into the literature and specialized training.

These weren’t typical kids with functional constipation. These were children recovering from surgeries like anorectal malformation repair, Hirschsprung’s disease resection, and colostomy reversal. Many had been through years of struggle and were living with non-retentive fecal incontinence, dyssynergic defecation, or chronic abdominal pain due to visceral hypersensitivity.

Traditional therapy just wasn’t enough.

In these cases, rectal balloon training became a crucial part of their recovery, helping them improve rectal awareness, coordination, and desensitization of the hypersensitive bowel. Let’s look at which children this training might be indicated for in your clinic.

To be clear, most children will never need rectal balloon training. But for a very small population, it may be the one thing that works when nothing else has.

It’s typically considered in cases that haven’t responded to conservative treatment like:

• Post-operative anorectal malformations
• Hirschsprung’s disease post pull-through
• Colostomy reversals
• Complex non-retentive fecal incontinence
• Refractory dyssynergic defecation
• Chronic abdominal pain from visceral hypersensitivity

These are the kids who’ve already done everything—diet changes, toileting programs, pelvic floor exercises, behavior therapy—and are still struggling.

When you’ve tried all the conservative tools in your toolbox and you’re working alongside a committed medical team, rectal balloon training might be the next step. But there’s a lot that has to happen first.

Before considering balloon training, you must understand the underlying issues you’re addressing. These case challenges involve dysfunctional neuromuscular coordination and sensory processing, which affects how the body perceives and responds to rectal sensation.

Children with rectal hypersensitivity experience exaggerated responses to normal levels of rectal filling, sometimes interpreting even small volumes as painful or urgent. The nervous system becomes overly reactive, leading to withholding, abdominal pain, or frequent, unproductive trips to the toilet. For these kids, rectal balloon training acts as a graded desensitization tool, helping the rectum and brain recalibrate what’s “normal.”

In contrast, children with rectal hyposensitivity are the kids who don’t sense fullness until it’s too late, or not at all. They may be entirely unaware they need to go, resulting in bowel leakage or complete avoidance. Balloon training in these cases, especially in kids with megarectum,  serves as a sensory re-education technique to help the brain build a more accurate picture of internal signals.

Balloon expulsion testing offers valuable insight into a child’s defecatory coordination. The balloon is inflated and the child is asked to expel it, ideally using appropriate abdominal pressure and relaxation of the pelvic floor. If the child strains and contracts instead of relaxing the pelvic floor, or is unable to evacuate the balloon, it reveals important information about neuromuscular function. This is an opportunity for you to provide real-time cues, modify strategies, and actively retrain the defecation mechanics.

If you’re considering rectal balloon training for a child, several things need to be in place.

First, you must have a physician’s written prescription. This isn’t just about legal protection—it ensures this treatment is seen as part of a coordinated medical plan. Informed parental consent is also necessary. Parents and the child need to fully understand what the procedure involves, what the goals are, and what the child may experience.

You also need to look at the emotional and cognitive readiness of the child. Questions to consider:

• How much medical trauma have they already endured?
• Are they fearful or avoidant of medical procedures?
• Do they have the communication skills to express discomfort or ask for a break?
• Do they need a Child Life Specialist to work with them to prepare?

These factors must weigh heavily in your decision-making process.

If the child is not willing or able, this modality should not be used. For some children, a less invasive option, like Botox under anesthesia, might be more appropriate.

Remember, guidelines are not absolute rules—they’re frameworks designed to inform care, not limit it. When working with complex patients, clinical reasoning is key. Exceptions will arise, and in these situations, proper training, collaborative care, and informed consent ensure that interventions like rectal balloon training are both ethical and effective.

You must have verified training in both internal rectal examination and rectal balloon technique. Rectal balloon training is included in Peds Level 2—not to promote it as a go-to treatment, but to ensure that when the need arises, therapists are equipped to offer it safely and ethically.

By the time these children get to you, many have seen multiple specialists, undergone surgeries, and experienced years of frustration. When done with proper training, rectal balloon training can be a life-changing intervention.

If you’re encountering more complex cases in your practice and want to be prepared, I encourage you to consider enrolling in Pediatrics Level 2: Advanced Pediatric Bowel and Bladder Disorders . Because sometimes, it’s not about having all the answers. It’s about knowing when and how to help, even when the path isn’t straightforward.

Join me live for Peds 2 – May 31 to June 1, 2025!