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273 Transanal irrigation 13 and refusal of further treatment. 20 Furthermore, in patients with poor treatment adherence, transanal irrigation is likely to fail because it is time consuming, which requires commitment and effort from both patients and parents. We described that a proportion of patients added laxatives, especially bisacodyl, to the irrigation fluid, in an attempt to achieve better efficacy of transanal irrigation. The effect of stimulant laxatives on colonic motility has been described in colonic manometry studies, in which it has been shown to induce high-amplitude propagated contractions. 21–23 High- amplitudepropagated contractions are considered to enable the transfer of colonic contents over long distances and they are known to be involved in the process of defecation. By that mechanism, inducing high-amplitude propagated contractions during rectal irrigation may help to optimize the irrigation process. Similarly, stimulants have been successfully used in patients with antegrade continence enemas, without reported complications. 24,25 Future studies should assess the safety and efficacy of using additives such as stimulant laxatives during transanal irrigation. There are several limitations to the present study. There is a risk of selection bias; some patients or their parents may have been reluctant to participate because they had stopped using Peristeen® due to ineffectiveness of treatment or due to adverse effects. However, the response rate in our study was high (74%). Moreover, we also received questionnaires from children who had ceased using Peristeen® due to ineffectiveness. This type of survey study always carries the risk of social desirability bias, to minimize this risk the questionnaires in the present study were anonymous. Children included in the present study often used concomitant medication, which may have influenced our results. In all children, transanal irrigation had been initiated only after unsuccessful pharmacological treatment, indicating that pharmacological treatment alone is unlikely to account for these results in thesepatients. Furthermore, the present study was based on a self-developed nonvalidated questionnaire, not taking into account validated measurements before and after treatment. To further assess the usefulness of Peristeen® in the management of children with constipation, prospective studies should be conducted, preferably with validated measurements (e.g., quality of life questionnaires) and standardized symptom-based outcome measures (e.g., bowel diary and fecal incontinence scores) so that patient and parent reported satisfaction can be matched with clinical information. A randomized controlled trial comparing the efficacy, side effects, and patient/parental satisfaction of rectal enemas and Peristeen® would be of great interest.