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267 Transanal irrigation 13 INTRODUCTION Intractable constipation in children is a frustrating and difficult problem for affected children, their families, andmedical caregivers involved. Finding thebest tailored therapeuticapproach for these children can be challenging, especially after various conventional pharmacological options have been exhausted. Transanal irrigation with specifically designed equipment is a treatment modality that is not widely used yet, but that is potentially beneficial for a subset of these children. Unfortunately, published data on this treatment modality in children are scarce. In this survey study, the use of transanal irrigation is evaluated in children with intractable functional constipation (FC) in a single medical center. Pediatric constipation is a commonly encountered problem in primary, secondary, and tertiary pediatric healthcare and accounts for substantial healthcare costs. 1,2 The vast majority of children with constipation experiences FC as defined by the Rome III criteria (Table 1). 3,4 The prevalence of FC ranges from 0.7% to 29.6%. 2 Organic causes of constipation are rare and include anorectal malformations, spina bifida, and Hirschsprung’s disease. 5 Table 1. Rome III criteria functional constipation 4 Children <4 years a Children with a developmental age of ≥4 years b Rome III criteria 1. <3 defecations per week 2. ≥1 episode of fecal incontinence per week after the acquisition of toileting skills 3. History of excessive stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which may obstruct the toilet 1. <3 defecations in the toilet per week 2. ≥1 episode of fecal incontinence per week 3. History of retentive posturing or excessive volitional stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which may obstruct the toilet a Must fulfill ≥2 criteria for ≥1 month prior to diagnosis. b Must fulfill ≥2 criteria at least once per week for ≥2 months prior to diagnosis with insufficient criteria for the diagnosis of IBS. FC symptoms such as fecal incontinence and painful defecation are bothersome, may impede children in their daily activities, and have a significant effect on the health- related quality of life. 6,7 Conventional treatment of FC in children comprises education, a toilet training program, and pharmacological treatment with oral and/or rectal laxatives. 8 Approximately 50% of children with FC treated with conventional therapy will recover and be taken off laxatives within 6 to 12 months 9 ; however, even after 5 years of intensive treatment, approximately 50% of children referred to a pediatric gastroenterologist still experience infrequent painful defecation and fecal incontinence. 3 FC unresponsive to optimal conventional treatment for at least three months is referred to as intractable FC. 3 In