Pediatric Rectal Prolapse In Children With Autism: Clinical Considerations For Pediatric Pelvic Floor Therapists

One of the most challenging parts of pediatric pelvic floor therapy is knowing how to navigate situations when a family’s expectations don’t align with what the child is ready for. These conversations require clinical reasoning, confidence, and sometimes the willingness to explain why delaying an intervention is actually the best treatment decision.

While chronic constipation and excessive straining are common contributors to pediatric rectal prolapse, it can also be influenced by hypotonia, neurodevelopmental conditions, sensory processing differences, and behavioral factors.

In our KBB Professional Village meeting, we discussed a case that serves as an important reminder that successful pediatric pelvic floor therapy isn’t always about choosing the right intervention. Sometimes the most important clinical decision is recognizing when a child is not yet ready for that intervention and shifting the focus toward regulation, caregiver education, and interdisciplinary care.

Rectal prolapse occurs when part or all of the rectal wall protrudes through the anus. Although the condition can be alarming for both families and healthcare providers, it is often the result of another underlying issue rather than the primary diagnosis.

Children who develop rectal prolapse frequently have a history of:

• chronic constipation or diarrhea
• prolonged straining
• poor pressure system management
• poor postural control
• connective tissue disorders
• neurologic conditions

In some children, poor pelvic floor coordination further complicates evacuation, creating a cycle of incomplete emptying, increased straining, and worsening prolapse. When developmental disabilities or communication differences are present, therapists should also consider how sensory processing, anxiety, and behavioral responses may be contributing to bowel dysfunction.

The patient discussed during our mentorship meeting was Jared*, a 12-year-old boy with autism who was mostly nonverbal. Jared was unable to describe his symptoms, requiring his therapist to rely heavily on facial expressions, body language, and behavioral responses to understand his level of comfort throughout treatment.

His history was significant for suspected abuse while living with his mother. After transitioning into his father’s care, the longstanding toileting difficulties progressed to a rectal prolapse, measuring more than an inch. Jared’s father, an OB-GYN physician, sought pelvic floor therapy in hopes of avoiding surgery for his son.

Perhaps the most concerning behavior was the child’s repeated attempts to manually remove stool from his rectum. Jared’s father reported that whenever Jared sensed fullness or incomplete evacuation, he would pull on the prolapsed tissue in an attempt to help himself empty his bowels. Stool consistency had already been optimized with laxatives, making constipation a less likely contributor. Despite soft stools, he continued to demonstrate dyssynergic defecation and persistent prolapse.

One of the biggest lessons from this case was recognizing how many different systems were contributing to this child’s presentation. While dyssynergic defecation was certainly part of the problem, it quickly became apparent that autism, trauma, communication difficulties, and sensory processing were also influencing his symptoms.

Rather than asking, “How do we fix the pelvic floor?” our discussion shifted toward a more important question: “What barriers are preventing this child from successfully participating in treatment?” That change in perspective ultimately will shape every treatment recommendation that follows.

Jared’s father specifically requested pelvic floor biofeedback after reviewing the literature supporting its effectiveness and seeing his postpartum women have success. While biofeedback can be an excellent intervention for women and appropriately selected children, successful treatment requires much more than simply placing sensors on the pelvic floor. Children must be able to tolerate sensor placement, follow directions, and understand cause and effect.

During the initial evaluation, the child became significantly dysregulated and demonstrated obvious distress whenever treatment focused on his perineal region. Rather than viewing these behaviors as noncompliance, the mentorship group recognized them as indicators that he was not yet ready for pelvic floor biofeedback.

One practical recommendation was to begin with surface EMG on the biceps rather than the pelvic floor. This would allow the therapist to determine whether the child understood the concepts of muscle contraction and relaxation without introducing additional stress. If he could not complete this task using his arm, expecting him to learn pelvic floor coordination would be unrealistic. Demonstrating this objectively could also help his father understand why delaying biofeedback was in his son’s best interest.

A major theme that emerged during our discussion was the importance of trauma-informed care. This child had experienced suspected abuse, repeated medical encounters, chronic bowel dysfunction, and significant communication barriers. Minimally verbal children often communicate through behavior rather than language, making it essential for therapists to recognize grimacing, avoidance, and dysregulation as meaningful forms of communication rather than noncompliance.

One statement from the discussion captured this perfectly: “We don’t want to create medical trauma.” Even evidence-based interventions can become harmful if introduced before a child is emotionally and cognitively ready to participate. Protecting the therapeutic relationship is often just as important as the intervention itself.

Another valuable discussion centered on why the child repeatedly attempted to remove stool manually. Was he trying to empty his bowels? Was he seeking sensory input? Or were both contributing to the behavior?

Children with autism often experience altered sensory processing and may have difficulty interpreting internal sensations such as rectal fullness or pressure. The prolapse itself may have further changed his sensory experience, reinforcing repetitive touching or pulling behaviors.

The group discussed strategies to support sensory regulation, including tactile activities, appropriate fidgets, and a behavioral assessment. These interventions acknowledge that successful toileting often depends on regulating the nervous system as much as coordinating the pelvic floor.

Families are understandably eager to avoid surgery whenever possible, and many children improve with conservative management that includes optimizing stool consistency, reducing straining, and improving bowel habits. However, a persistent rectal prolapse despite appropriate treatment may warrant referral to pediatric colorectal surgery.

Referral for surgery should not be viewed as a failure of therapy, but rather as one component of comprehensive care when conservative management alone is insufficient.

Jared’s case highlights the importance of an interdisciplinary team that includes pediatric colorectal, the pediatrician, and behavioral health. Coordinated care is essential not only for managing the prolapse, but also for supporting emotional regulation, consistent routines, and caregiver education.  must recognize when other professionals can help address barriers that fall outside your scope of pelvic floor rehabilitation.

The discussion also emphasizes the importance of supporting the child’s father. Like many caregivers facing overwhelming medical and behavioral challenges, he was understandably focused on finding the intervention that would “fix” the problem. Helping him understand his son’s readiness for treatment is just as important as the treatment itself.

Sometimes the most effective treatment plan begins not with advanced techniques, but with creating safety, building trust, and assembling the right team around the child. By treating the whole child rather than focusing solely on the pelvic floor, you create the best opportunity for meaningful, lasting improvements in both bowel function and overall quality of life.

If you’d like to learn more about treating these kinds of cases, I invite you to sign up for Pediatrics Level 2 – Advanced Pediatric Bowel and Bladder Disorders. You’ll gain advanced knowledge in the evaluation and treatment of complex pediatric pelvic floor cases. If you’ve already taken Peds Level 1, join me in Level 2!

Additionally, these case presentations are the sole purpose of the KBB Professional Village, which is our private Facebook networking group. This group of dedicated pelvic floor therapists meets every other week to discuss and learn from tough cases like this. We’d love to have you in our Village!

*patient name changed for privacy