Pediatric Pelvic Floor Therapy: An Expert Q&A with Amanda Mathers
Before becoming a dad, I never considered pelvic floor therapy for kids. Working alongside a pelvic floor therapist in my own practice helped me understand how important it is, but I never realized children could have pelvic floor dysfunction too.
The more I learned, the more I recognized how many common childhood issues, including constipation, bedwetting, stool accidents, and recurrent urinary tract infections, may be connected to the pelvic floor. To help parents better understand this growing specialty, I reached out to an expert, Amanda Mathers, MS, OTR/L.
Amanda is a pediatric occupational therapist with seven years of experience helping infants, toddlers, and children build the foundational skills they need to thrive. Her speciality focuses on cases that involve pediatric pelvic floor, sensory processing, early intervention, and school-based OT.
She is passionate about translating evidence-based occupational therapy into practical, easy-to-understand strategies that empower parents and caregivers. She recently started working as an educator with Harkla (which is how I first discovered her), a company that creates sensory products and educational resources to support children, families, and pediatric therapists. Through her educational content on social media and as a co-host on the podcast All Things Sensory, she has built a fun community where she shares tips on child development, potty training, sensory regulation, and everyday parenting and OT challenges.
I threw a lot at her and her answers (and depth—look at that reference section!) did not disappoint.
Pediatric Pelvic Floor Therapy with Amanda Mathers
1. What is pediatric pelvic floor therapy?
Many parents are surprised to learn that kids can have pelvic floor dysfunction too.
When people hear "pelvic floor therapy," they usually think of preparing for pregnancy and/or postpartum recovery, or adults dealing with bladder issues. But children have pelvic floor muscles just like adults do, and those muscles play an important role in bladder control, bowel function, posture, breathing, and movement.
Pediatric pelvic floor therapy helps children learn how to coordinate those muscles effectively. Sometimes the muscles are too tight, sometimes they're not activating when they should, and sometimes kids develop habits that make bathroom problems worse over time (think withholding!).
A lot of what I do isn't actually focused on addressing the pelvic floor itself. Instead, we work on breathing patterns, posture, movement, healthy bathroom habits, hydration, and helping kids better understand what their bodies are telling them.
2. How do you make treatment feel comfortable and non-threatening for children?
The first thing I want parents to know is that pediatric pelvic floor therapy looks VERY different from adult pelvic floor therapy.
Kids learn best when they're comfortable and having fun. My goal is to create an environment where children feel safe. We use games and movement activities and age-appropriate education as well as lots of breaks!
Many children who come to therapy have already been struggling for months or even years. They may have been to multiple different therapists or doctors to address this problem. They may feel frustrated, ashamed, or worried or embarrassed about accidents. Building trust is often the most important part of the treatment plan.
When kids realize they aren't in trouble and that we're simply helping their body to work better, they're usually much more willing to participate.
3. What are the most common reasons kids are referred for pelvic floor therapy?
The most common reasons I see include:
Constipation
Bedwetting
Withholding behaviors
Stool accidents (encopresis)
Daytime urinary accidents
Recurrent urinary tract infections
Pain with urination or bowel movements
A child who struggles with constipation may also experience urinary symptoms because the bladder and bowel share space and communicate closely within the pelvis.
4. What is the relationship between urinary tract infections (UTIs) and the pelvic floor in kids?
Many people assume recurrent UTIs are purely a medical issue, but sometimes pelvic floor dysfunction plays a role.
When children have difficulty fully emptying their bladder, residual urine can remain behind after they pee. That leftover urine may increase the risk of bacterial growth and infection.
Children with pelvic floor dysfunction may also develop habits like holding their urine for long periods, rushing through bathroom trips, or tightening their pelvic floor muscles when they should be relaxing them (like when withholding stool).
While not every UTI is related to pelvic floor dysfunction, it's worth evaluating the bladder and bowel system as a whole when infections become recurrent.
Research has consistently shown that constipation and bladder dysfunction often occur together and can increase the risk of recurrent urinary tract infections in children (Dos Santos et al., 2017).
5. What are some "normal" bathroom habits that actually are not normal?
I first want to preface this information with this: many of the things we are discussing can be NORMAL for children that are not yet “toilet trained.” Toileting is a skill just like crawling, walking, eating solid foods, etc. Your child will NOT be “trained” in a weekend. That is normal. It will take time for them to be completely independent and confident with all of these skills.
Now, let's get into it! There are several habits parents often assume are normal because they've become routine in their child’s life.
Some examples include:
Straining to poop regularly
Pooping fewer than three times per week
Having pain with bowel movements
Peeing "just in case" every 30 minutes
Waiting until the last second to use the bathroom
Crossing legs, squatting, or doing a potty dance frequently to avoid going
Hovering over public toilets
Daily skid marks in underwear
Frequent stomach aches related to constipation
These behaviors often signal that the bladder, bowel, or pelvic floor isn't functioning as efficiently as it could.
6. When should parents become concerned about bedwetting?
Bedwetting is incredibly common, especially in younger children. That said, parents should consider seeking additional support if:
Bedwetting continues beyond age 5-6
A child who was previously dry starts wetting again
Bedwetting is causing emotional distress in the child's life
There are additional symptoms like constipation, daytime accidents, urgency, or recurrent UTIs
One of the biggest myths is that children simply need to outgrow bedwetting or that they are “just a heavy sleeper”. While that can be true, there are often contributing factors that can be addressed sooner.
7. What simple changes can make a surprisingly big difference?
Some of the most powerful interventions I use are also the simplest.
Making sure kids drink enough water throughout the day is huge.
Using a footstool during bowel movements to support proper positioning can be a game changer.
Establishing consistent toilet routines, especially sitting on the toilet after meals, often helps improve bowel regularity.
Teaching children how to relax and breathe rather than strain is another simple skill that can make a significant difference.
Parents are sometimes surprised when I don't start with complicated exercise programs. The basics often create the biggest improvements.
8. Are there any movements or exercises parents can do with their kids to promote a functional pelvic floor?
The pelvic floor doesn't work in isolation. It works together with breathing, the abdominal muscles, the diaphragm, and the hips.
Some of my favorite activities include:
Deep belly breathing & activities that address interoception
Low Squatting position during play
Crawling activities
Yoga poses like child's pose and happy baby
Animal walks (think bear crawls & crab walks)
General active play outdoors on a bike, swing, swimming, messy play.
The goal isn't necessarily to “strengthen” the pelvic floor but more to improve coordination, body awareness, motility, and regulation.
Kids usually don't need a strict or specific exercise program. Most kids need more opportunities to move in a variety of ways, a change in dietary habits, and a reduction of stress in their life.
9. What signs or symptoms make you think a child may need pelvic floor therapy?
Some signs that may warrant an evaluation include:
Constipation
Frequent urinary accidents after previously being “toilet trained”
Recurrent Bedwetting after age 5
Withholding behaviors
Recurrent UTIs
Pain with peeing or pooping
Frequent bathroom trips
Stool accidents
Chronic abdominal pain
Difficulty fully emptying the bladder
I always tell parents that if a bathroom-related issue is affecting a child's daily life, confidence, comfort, or participation in activities, it's worth having a conversation with a healthcare professional.
10. What are your favorite resources for patients and occupational therapists?
For parents, I love resources that simplify bladder and bowel health and make it approachable. The Bristol Stool Chart is one of my favorites because it gives families an easy way to understand what healthy stool should look like. I also love any books that talk about healthy eating and bowel habits such as the children’s book “Boo can’t poo.”
For therapists, I regularly reference continuing education courses focused on pediatric bowel and bladder dysfunction, pelvic health, sensory processing, and nervous system regulation. The more we understand how these systems interact, the better we can support children and families. Some of my favorite sites and clinicians include Herman & Wallace, Kids Bowel & Bladder, Dawn Sandalcidi, Quiara Smith, and Kelly Mahler.
Most importantly, I encourage both parents and therapists to remember that bathroom issues are rarely just bathroom issues. They often involve movement, habits, hydration, breathing, sensory processing, and emotional/regulation factors as well.
Rapid Fire Questions:
One bathroom habit kids should avoid?
Withholding stool or dangling feet
What does healthy poop look like?
Think smooth banana. We don’t want rabbit pellets or watery stool.
The ideal sitting position on the potty?
Feet supported above 90-degree angle at knees/hips with knees slightly higher than hips, slight lean forward with forearms on thighs.
Do this for better pelvic floor health.
Practice deep belly breathing throughout the day and while toileting.
Avoid this for better pelvic floor health.
Straining!
Biggest misconception when it comes to pelvic floor health and kids?
That just because your child is having daily bowel movements that means they are no longer constipated. Constipated until proven clear.
My Final Thoughts:
Parents often worry they've done something wrong when their child struggles with bladder or bowel issues. In my experience, that's almost never the case. Most children aren't lazy and defiant. The good news is that with the right education, habits, and support, many kids experience significant improvements as well as an increase in their confidence following treatment.
Some Sources I Reference often:
Axelgaard, J., Jensen, M. B., & Hagstroem, S. (2023). Functional constipation as a risk factor for pyelonephritis and recurrent urinary tract infection in children. Acta Paediatrica, 112(3), 540–546. https://doi.org/10.1111/apa.16621
Aydogdu, O., Burgu, B., & Gurocak, S. (2024). Pediatric lower urinary tract dysfunction: A comprehensive exploration of clinical implications and diagnostic strategies. Biomedicines, 12(5), 945. https://doi.org/10.3390/biomedicines12050945
Blum, N. J., Taubman, B., & Nemeth, N. (2003). Relationship between age at initiation of toilet training and duration of training: A prospective study. Pediatrics, 111(4), 810-814.
Dos Santos J, Lopes RI, Koyle MA, Barroso U. Bladder and bowel dysfunction in children: An update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem. Canadian Urological Association Journal. 2017.
https://pmc.ncbi.nlm.nih.gov/articles/PMC5332240/
Hodges, P. W., Sapsford, R., & Pengel, L. H. M. (2007). Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynamics, 26(3), 362-371.
Joinson, C., Heron, J., & von Gontard, A. (2009). Psychological problems in children with daytime wetting and combined day and night wetting. Journal of Pediatric Psychology, 31(5), 491-497.
Meena, J., Sinha, A., Sethi, S. K., & Hari, P. (2020). Prevalence of bladder and bowel dysfunction in toilet-trained children with urinary tract infection and/or primary vesicoureteral reflux: A systematic review and meta-analysis. Frontiers in Pediatrics, 8, 84. https://doi.org/10.3389/fped.2020.00084
Shaikh, N., Hoberman, A., Keren, R., Ivanova, A., Gotman, N., Chesney, R. W., Mathews, R., Bhatnagar, S., Greenfield, S. P., Carpenter, M. A., Moxey-Mims, M., & Wald, E. R. (2016). Recurrent urinary tract infections in children with bladder and bowel dysfunction. Pediatrics, 137(1), e20152982. https://doi.org/10.1542/peds.2015-2982
Sikirov, D. (2003). Comparison of straining during defecation in three positions: Results and implications for human health. Digestive Diseases and Sciences, 48(7), 1201-1205
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