Pelvic floor physiotherapy improves quality of life and reduces painful defecation in pediatric functional constipation

This systematic review and meta-analysis evaluated the efficacy of pelvic floor physiotherapy in managing functional constipation among pediatric and adolescent populations aged 18 years or younger. The analysis synthesized data from seven randomized controlled trials, encompassing a total sample size of 775 participants. Study settings and specific protocols varied significantly across the included trials, with sample sizes ranging from 45 to 400 participants per trial. The intervention comprised various physiotherapeutic modalities, including pelvic floor exercises, biofeedback, telerehabilitation, visceral mobilization, and electrostimulation. The comparator arm consisted of conventional medical treatment, which frequently involved co-intervention with polyethylene glycol (PEG). Follow-up periods across the studies were generally shorter than 12 months.

Regarding the primary outcome of defecatory frequency, the meta-analysis reported less consistent results. The mean difference was 1.00 with a 95% confidence interval ranging from 0.35 to 1.65. While the direction of the effect was generally positive, the heterogeneity in protocols and assessment instruments contributed to this variability. In contrast, secondary outcomes demonstrated more robust positive trends. Improvements were observed in fecal consistency and quality of life. Additionally, painful defecation showed significant improvement with the physiotherapeutic interventions compared to conventional management alone.

Safety and tolerability data were not reported in the included trials, nor were rates of adverse events, serious adverse events, or discontinuations documented. Consequently, the tolerability profile of the physiotherapeutic interventions remains unknown based on this specific evidence base. The absence of blinding for both participants and therapists in the original trials introduces potential performance and detection biases that could influence the reported outcomes.

When compared to prior landmark studies in pediatric functional constipation, this meta-analysis reinforces the role of non-pharmacologic interventions. However, the frequent co-intervention with PEG in the comparator groups complicates the interpretation of whether improvements are solely due to physiotherapy or the combined effect of standard medical care. The large effect size noted for reducing painful defecation and enhancing quality of life aligns with the broader therapeutic goal of improving patient comfort and daily functioning.

Key methodological limitations include marked heterogeneity in physiotherapy protocols regarding type, intensity, and duration. Variability in the instruments used to assess outcomes further complicates direct comparisons. The frequent use of PEG as a co-intervention limits the ability to isolate the specific contribution of physiotherapy. Furthermore, the short duration of follow-up raises questions regarding the long-term sustainability of the observed benefits. These factors collectively suggest that while the current evidence is encouraging, it is not yet definitive for long-term clinical adoption without further validation.

Clinically, these results support considering pelvic floor physiotherapy as a promising adjuvant intervention for pediatric functional constipation, particularly for addressing painful defecation and quality of life. However, practitioners must interpret these findings with caution due to the lack of long-term data and the heterogeneity of the intervention protocols. The evidence does not yet support a definitive recommendation for universal adoption without further high-quality trials. Questions remain unanswered regarding the optimal duration of therapy, the most effective specific modality among the various techniques tested, and the long-term maintenance of benefits after cessation of therapy.

Future research should prioritize multicenter trials with standardized protocols and larger sample sizes to reduce heterogeneity. Studies must also aim for longer follow-up periods to assess the sustainability of improvements. Additionally, efforts to blind participants and therapists, and to standardize assessment instruments, are necessary to minimize bias. Until such data are available, clinicians should integrate these findings into practice while remaining aware of the current evidence's limitations regarding efficacy confirmation and long-term outcomes.