Toilet Refusal in Pediatric Pelvic Floor Therapy: A Case-Based Perspective

Toilet refusal is an emotionally fraught and clinically challenging condition for pediatric pelvic floor therapists. It does not involve a single system and does not respond to schedules or rewards. By the time families arrive at pelvic floor therapy, they have likely endured a long history of conflict, anxiety, withholding and shame on all sides.

In this blog post, we will take a look at toilet refusal in the context of a real case presentation from the Kids Bowel and Bladder Professional Village, my private professional network for pediatric pelvic floor therapists. This case will serve as a framework to explore the many intersections that impact toilet refusal, and why sequencing matters more than speed.

Lily* was a 4-year-old girl referred to pediatric pelvic floor therapy for toilet refusal. She would only wear pull-ups and refused to pee or poop on the toilet. Her parents had attempted potty training multiple times, each attempt ending in a significant power struggle. Over time, toileting became a source of stress for the entire family.

At the time of evaluation, Lily was constipated and had a bowel movement only every four to five days, exclusively in her pull-up. Despite stool softening strategies, she continued to withhold. When she needed to poop, Lily would lie on the floor in visible discomfort, resisting the urge for as long as possible.

After six weeks of preschool, Lily’s anxiety escalated. Through parent education, it became clear that Lily was likely worried about peers discovering she still used pull-ups. Around this time, she began peeing on the toilet, but only under particular conditions. Because she was distressed by the sound of urine hitting the toilet water, her parents gave her headphones to block the noise so she could tolerate voiding.

Despite the progress with urinating, Lily continued to refuse pooping on the toilet.

In cases like Lily’s, it is tempting to focus immediately on the refusal itself. However, one of the most important clinical decisions is determining what actually needs to be addressed first.

In this case, the answer was clear: constipation had to be addressed before the toilet refusal could be meaningfully addressed.

A child who is constipated, pooping infrequently, and experiencing discomfort cannot be expected to feel safe or successful on the toilet. Attempting to push toilet use in the presence of unresolved constipation often intensifies withholding, increases fear, and reinforces the child’s belief that toileting is painful or threatening.

For pediatric pelvic floor therapists, this underscores a foundational principle: regularity and regulation must come first.

One of the most consistent themes in toilet refusal is the escalation that occurs when adults push for change before the child is ready. Lily’s history reflected this clearly. Each attempt to control where and how she eliminated resulted in increased resistance.

At the heart of this case was the need to meet Lily where she was, rather than where adults felt she should be.

That meant asking really specific questions to get to the bottom of Lily’s behavior.

For Lily, bowel movements occurred in a particular way. She would go into a closet, stand on her tiptoes, squeeze her gluteal muscles, and actively try not to poop, yet this was where her bowel movements occurred.

This pattern is critical information, not misbehavior.

From a pediatric pelvic floor therapy perspective, Lily’s toileting pattern raised immediate questions about pressure management and abdominal control.

It’s imperative as a pediatric pelvic floor therapist that you’re able to discern exactly why Lily stood on her tiptoes, gripped through her posterior chain, and actively resisted elimination. You might assume it’s simply a protective strategy developed in response to past negative experiences with elimination. However, there is more to uncover, and the answer becomes much more clear after joining me in my live Pediatrics Level 1 course, coming up soon!

For many children demonstrating toilet refusal, the issue is not unwillingness; rather, it is that their bodies have learned compensatory or protective strategies to manage pressure. If we ignore this and focus solely on behavior or motivation, we miss the root of the problem.

This is where a thorough musculoskeletal assessment becomes essential.

Pediatric pelvic floor therapists are uniquely trained to identify these patterns. When children lack efficient pressure strategies, the toilet can feel like an impossible demand. Refusal, in this context, becomes a logical response rather than a defiant or strictly behavioral one.

Lily’s case also highlights the role of sensory processing and anxiety in toilet refusal.

Her distress over the sound of urine hitting the toilet water is a clear example of auditory sensitivity influencing toileting behavior. The use of headphones was not a “crutch”. It was a regulatory support that allowed her nervous system to tolerate the task.

Similarly, her anxiety after starting preschool added another layer. Fear of peers discovering her pull-up use likely intensified her withholding and need for control.

Toilet refusal often reflects a nervous system that no longer feels safe in the bathroom. Addressing this requires more than reassurance; it requires thoughtful environmental and emotional support.

A common instinct in toilet refusal is to try to control where the child eliminates. However, this often reinforces shame and escalates withholding.

In Lily’s case, attempts to dictate location increased her need to control the process. The more pressure she felt, the more tightly she held on, both physically and emotionally. This created a cycle:

1. Pressure to perform
2. Increased fear and guarding
3. More withholding
4. Greater parental concern
5. Even more pressure

Breaking this cycle requires stepping back rather than pushing forward.

“Don’t push the progressions. Wait until they are ready.”

This principle does not mean doing nothing. It means actively supporting the systems that need to change while allowing the child to retain a sense of control. Lily needed most:

• bowel regularity
• pressure management
• movement capacity
• emotional safety

Progress in toilet refusal is often subtle at first. Reduced distress, increased comfort with body sensations, or improved movement mechanics may precede any visible change in toileting behavior. These shifts matter.

Potty training is not about making children comply. Our goal is to help their bodies and nervous systems feel safe enough to participate.

Cases like Lily’s are rarely solved with protocols alone. They require nuanced clinical reasoning, flexibility, and pattern recognition developed over time. With over 40 years of experience working through complex pediatric bowel and bladder cases, I have seen repeatedly that toilet refusal is not a single problem, it is a convergence of systems.

Experience teaches us when to pause and when not to intervene directly. It allows us to guide families away from urgency and toward understanding.

Lily’s case reinforces several critical principles:

• Treat constipation before addressing toilet refusal
• Prioritize pressure management and abdominal control
• Consider musculoskeletal, sensory, and emotional contributors
• Avoid controlling location when shame and withholding are present
• Meet the child where they’re at and wait for readiness

If cases like Lily’s feel familiar (or overwhelming!), this is exactly the type of clinical reasoning we dive into in Peds Level 1–Treatment of Bowel and Bladder Disorders.

Peds Level 1 provides pediatric pelvic floor therapists with:

• Foundational assessment frameworks
• Clinical reasoning for bowel and bladder dysfunction
• A deeper understanding of pressure management and movement
• Case-based learning grounded in real world practice

The next live Peds Level 1 course will be held February 28 to March 1, 2026.

If you are looking to build confidence in treating pediatric pelvic floor cases and want tools that go beyond protocols, I would love to have you join us!

*patient name changed for privacy