A 3-year-old girl was diagnosed with constipation and treated with polyethylene glycol and dietary modification. Despite treatment, she had no bowel movements for more than 20 days and developed abdominal pain and distension. Two visits to the pediatrician and one local emergency department (ED) visit resulted in no management change. At follow-up, she was instructed to go to a children’s ED if symptoms persisted, with expected disimpaction.
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ACEP Now: April 2026 (Digital)Two days later, at the children’s ED, she was evaluated by a visiting female emergency clinician. The supervising male pediatric emergency physician attending documented: “I declined performing this procedure myself because of the size of my hands.” A female colleague was asked to supervise. Nursing and Child Life [services] were not available to assist, so the female attending clinician and parents restrained the patient while the resident performed the procedure. Using a lubricated finger and patient assistance bearing down, the resident removed multiple stool balls. After many repetitions, the father expressed concern that the resident’s finger entered the patient’s vagina. The resident believed she was in the rectum but acknowledged the vagina appeared irritated and that it was possible her finger entered the vagina. The attending finished the procedure. Parents remained upset, filed a police report, and a child abuse exam was limited by the child’s distress. Litigation followed. After depositions, the case was settled for a nominal amount.
Issues and Key Points in Care
1. Appropriateness of manual disimpaction in toddlers
In young children, fecal impaction is typically managed with oral, nasogastric, or rectal medical regimens. Manual disimpaction is rarely first-line. When required, it is commonly performed under sedation or anesthesia. In this case, the supervising male attending declined to perform the procedure because of hand size. This should have prompted reconsideration of whether an awake disimpaction was appropriate.
2. Supervision of intimate procedures requires full procedural capacity
Procedure supervision requires more than physical presence. The attending must be able to continuously visualize anatomy, monitor technique, and provide real-time guidance. In this case, the attending’s need to physically restrain the patient eliminated the ability to supervise. When parental concern arose, the attending should have spoken for the team to de-escalate and shield the trainee. This also serves as a learning opportunity for residents to observe de-escalation and boundary-setting.
3. Absence of pediatric multidisciplinary supports removed protective layers
Children’s EDs rely on pediatric nursing and Child Life services to prepare families, support positioning, reduce distress, and maintain procedural control. Their absence in this case removed key safety and trust-preserving layers that normally support pediatric care.
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26 Responses to “Manual Rectal Disimpaction in Toddler Results in Lawsuit”
April 12, 2026
Scott MankowitzIt is difficult for me to express how deeply troubled I am by this article. I understand that this is a relatively distasteful procedure, but if it must be done, it must be done. From the history, it appears that multiple non-invasive methods were attempted, and they had all failed. Every procedure comes with known complications, and it seems obvious to me that manipulation of the rectum could possibly result in an inadvertent touch of the vagina. There is no way a reasonable person would not be able to forsee this as a risk.
I disagree with the author’s claim that this is a procedure best done under anesthesia. Clearly, the pediatrician as well as the ER Doctor who saw this patient did not feel that the risks of anesthesia were out weighed by the risk of inadvertent touching. How do you think the family should respond if the patient had an airway issue during anesthesia? Could you argue that the risks in that case outweigh the benefits?
April 18, 2026
Kathryn MarpleAgree with Scott!
April 22, 2026
Kurtis A MayzAbsolutely not! This is rarely if ever a true emergency in pediatrics and is not worth the risk of rectal trauma when there are other ways to initiate clean out in pediatric patients. This is unlike our elderly adult patients who with a larger anus, less susceptible to trauma, can often go home after disimpaction. These kids should be monitored and evaluated for motility anyway if it is that severe and manual or instrumented disimpaction should be done in a controlled setting under sedation.
April 28, 2026
ArielI appreciate the opportunity to discuss differences in practice. Having worked in both general and pediatric ERs, there are meaningful differences in how these situations are approached — context, patient population, and practice environment matter.
My goal in writing was to learn from the lawsuit. I may have taken away different teaching points than others, and I’m always open to hearing what you think can be gleaned from this case.
April 30, 2026
M Mullins100%. This case, the lawsuit, the settlement and the expert opinion are so irritating to the extreme to this PGY28 EM doc. The world has gone mad. Good luck to future docs working in this future world of medicine
May 3, 2026
Brian Levy MD FACEPPGY16 EM Here. I wholeheartedly agree with you. For exactly this reason, I would NEVER agree to do a fecal disimpaction on a child and ESPECIALLY a female child. I would refer to a pediatric surgeon. It’s hard to believe 20 days without a bowel movement and PEG or enema not working in the context of a child without something like Hirschsprung’s. That’s why I wouldn’t touch it. We live in a nasty world today and you’ve got to think twice before agreeing to do a procedure.
May 4, 2026
Larry J Miller MDAgree with Scott. Manual Dis-impaction is not a high risk procedure. General anesthesia for such a procedure is excessive and the risks outweigh the benefits.
What was the settlement? $1,000 would be too much.
April 18, 2026
Karen Ailsworth KinzerI was troubled, too, but for the opposite reason. Holding a person down and then forcibly entering their rectum multiple times would clearly be assault if it wasn’t done in the ED. I believe the child should have been sedated.
April 28, 2026
ArielThank you for sharing your thoughts.
April 19, 2026
Joe Riffe, MDWe’re seriously holding down and penetrating little kids’ anuses without anesthesia or even anxiolytics? It doesn’t matter what’s been done traditionally. There is no way these kids experience this any differently than assault. They simply can’t comprehend the difference.
Also, if the PCP and other doctors truly didn’t augment a regimen of MiraLAX with other laxatives, fiber gummies, etc. after such a protracted period of constipation, and a GI doctor was not involved (if available), then they bear some responsibility for this situation, ethically and morally, if not medicolegally.
April 28, 2026
ArielThank you for sharing your thoughts.
April 19, 2026
Brent TamamotoAre we supposed to administer anxiolytics rather than restrain every 4 year old who is stressed out about getting their MMR vaccines? I do think that we need to weigh the relative risk / cost of these two choices and it seems to me that reasonable efforts were made to resolve this patients constipation medically before attempting manual disimpaction. Finally, I disagree that this situation represents a “invasive procedure” resulting in “disproportionate medicolegal and emotional risk”. How are they supposed to learn besides through experience? Yes, they should study and observe, but eventually, they do need to ATTEMPT a procedure under appropriate supervision. There was a first time for all of us and I fear for a generation of inept clinicians whose preceptors were unwilling to let them try.
April 19, 2026
deepaI do believe that ER docs did not intend to harm the child.
If this was getting a urine sample via cath. from a non potty trained child, is an anxiolytic needed? That procedure is also traumatic. Most Peds offices do not have restraints and anxiolytics.
April 21, 2026
NThankfully, I have never had to do this procedure on a child in the ED. This case certainly illustrates some of the reasons why constipation is one of the worst presenting complaints. It is rare that anyone leaves happy—staff included.
April 22, 2026
V DharbhamullaWhen parents are clearly informed that the procedure may be uncomfortable and could cause the child to cry, and they still consent, I do not believe the physician is acting inappropriately. Given the close proximity of the genital area and the possibility of a resisting child, inadvertent contact and minor local irritation can occur despite appropriate technique. If we were to require sedation or anxiolytics for all minor procedures, most pediatric office-based care would become impractical and many necessary interventions would be deferred, which is a form of defensive medicine. A clear explanation of the indication, steps, potential discomforts, and alternatives, followed by informed parental consent, is what is ethically and legally required, and I intend to continue performing appropriate minor procedures in the office without routine sedation.
April 23, 2026
Sean Sullivan1. No mention of whether or not an enema was attempted in the ED, that should have been attempted prior to manual disimpaction.
2. This 3-year-old should not have undergone an unsedated manual disimpaction. This procedure is traumatic for any patient, particularly a 3-year-old. At a minimim anxiolysis should have been provided. Even if child life personnel were present, she should not undergo this procedure without sedation. You can be certain, that this toddler with chronic constipation with never allow or tolerate any rectal therapy in the future.
3. If vaginal digital penetration occurred, it was likely a result of the panic stricken child moving about during the procedure.
4. If the rectal stool burden was so great as to require disimpaction, there should be consideration for hospital admission and inpatient laxative therapy.
5. A trainee should never have been the one performing this invasive, unsedated traumatic procedure even with supervision.
Sullivan, MD
Pediatric Gastroenterology
April 28, 2026
ArielThank you for chiming in.
April 25, 2026
VincentI offer manual disimpaction at will in adults when indicated. I have found the post-disimpaction experience to be very rewarding for my patients. I am very concerned about normalizing sedation as a standard practice in fecal disimpaction in our pediatric population. I believe this should be reserved for a small population of children. The sedation and anxiolysis mindset will gradually lead us to sedation and anxiolysis for rectal temp and enema. Who says these are not uncomfortable procedures. We should also advocate for these in triage, since some of our pediatric patients get very distressed by the SPO2 light.
April 26, 2026
Franc MD Senior PEDS EDDuring my clinical practice, I have done so many rectal disimpactions to count in children of all ages and some with chronic conditions. The procedure is done with the appropriate medical history and physical exam. It is simple and most of the time with parents support. No need for sedation or anesthesia, you might need some help from the patient for a successful procedure. Has to be Done by somebody with experience and known of the procedure as well as the anatomy. Consent is recommended. Observation after the procedure and knowledge of expected within normal physical findings and parents support and advice for followup. The relief of the problem not necessarily means that there is not an underlying problem.
April 30, 2026
Michael PEMI am more than a little shocked by the cavalier attitude that I see in these responses to what is a very traumatic procedure in a child of this age. Manual disimpaction is not a “minor procedure” for a 3-4 year old and is very traumatic and intrusive. Given that we can and should be attempting some form of anxiolysis, pain control, or sedation for ALL painful procedures in this age group, why would we not do the same for a manual disimpaction? We do not even do rectal exams routinely in pediatric trauma any more and what was done to this child is far, far worse.
Second point, it’s definitely not considered the standard of care in pediatric constipation and the AAP in fact states it should only be used in very rare case and not routinely. How much miralax was this child taking? Once a day….that is not even close to the max outpatient treatment. You should increase up to at least twice a day and if that doesn’t work then encourage parents to do a cleanout (Seattle Children’s has one availed for free online) at home. If that fails or the parents can’t do it, then you admit for impatient cleanout.
Final point, patients are sent in all the time by their primary care providers with requests for “MRI” or “neurosurgical evaluation” and other such request, this doesn’t mean anything. It’s still on us to determine if this is the appropriate next level of care and then do what is appropriate. If what they are asking for isn’t appropriate and medically indicated, then we should not be doing it.
Just my 2 cents.
May 3, 2026
DeI agree with the comments that express that the staff’s performance was reasonable. And I disagree with those that suggest sedation or imply admission or operating rooms and on necessary. I wonder if after consolation, did the child go home comfortable, the unfortunate experience soon forgotten? Future patients will have a worse and riskier time as a result, staff involved will forever be anxious and hesitant to treat.
What an awful experience resulting in protracted anxiety for all, and intrusion by untrained, entirely inexperienced people, not to mention overthinking ?colleagues-who weren’t there and should no better second guessing.
Empathy, sympathy, reassurance were reasonable consolation. We explain procedures and ask permission for a reason. You sign a consent. We were all students at first and frankly always are-first in class, then clinic, then solo, but always evaluating and striving to improve.
May 3, 2026
PaulThe author of this article feels more like a legal consultant than a practicing clinician. Few ED are lucky enough to have child life or appropriate staffing. Two other clinicians may have avoided the disimpaction. Additionaly while you may make the argument for anxiolytics with intra nasal versed anesthesia seems like both an unnecessary risk, cost and use of manpower. Lastly, if a resident does not do simple procedures they will never be able to do them as an attending.
May 4, 2026
ArielI appreciate your perspective. I do want to clarify that I am actively practicing in both adult and pediatric emergency departments—not speaking from a purely legal lens.
What I’ve seen firsthand is that pediatric care often differs significantly from adult care. In many children’s EDs, child life and additional support are standard, and there is a lower threshold to offer analgesia or anxiolysis for younger patients, particularly in the age range discussed here.
Regarding training, this resident had experience with disimpactions—but, as is typical, that experience is almost entirely in adults. Performing this procedure in a young child is far less common and carries different considerations, which is why many pediatric-focused clinicians approach it differently.
I agree resources vary across settings, but part of my goal in discussing this case was to highlight how approach and expectations can shift depending on the patient population and practice environment.
May 8, 2026
Michael PEMCould you please tell me what are the “risks” of IN versed? It’s used routinely in pediatric ER’s for anxiolysis in the setting oif a painful procedure and I have not seen a bad outcome when used at the appropriate dose?
Manual disimpaction is not a “simple” procedure in a child this age. As I mentioned in my other comment we do NOT recommend routine rectal exams in trauma any more because of the discomfort and pain it causes to the child and this procedure is far, far worse.
Final point, there is NO pediatric constipation protocols from any children’s hospital or Pediatric organization that recommends going immediately to a manual disimpaction, especially in the setting of suboptimal outpatient management of this child’s constipation….and yes, simply using miralax and dietary modification is suboptimal and there are multiple other interventions that could have tried before this one.
May 3, 2026
Coffee BrownI never had to do this with a child.
1. Of course each resident will need a first time with each procedure. “See one, do one, teach one” is a little cavalier, but directionally right. ALL of us had a first time for EVERY procedure we’ve ever done. NOT always after an adequate demonstration, either, which is a problem. But not this problem.
2. I would probably NOT have thought this required procedural anesthesia, though I’d have some threshold in mind for transitioning to that. Now, based on this, I think I would open with that, or transition sooner.But these letters make clear that everyone knows, “of course” the right answer. And it is not the same answer for every thoughtful, experienced physician. Standard of care would thus support either approach, as tailored to the clinicians and resources available.
3. Multiple comments criticized going right to disimpaction, but the article was quite clear about multiple prior less invasive attempts and, “Despite treatment, she had no bowel movements for more than 20 days and developed abdominal pain and distension.” This had clearly become an emergency. Maybe more things could have been tried earlier, and seeing a specialist should have occurred earlier, but none of that was under the control of this visit’s clinicians.
4. I would have said this was a learning/discussion opportunity, one which HAS changed my thinking, to a degree. But far from egregious malpractice. And the price of making every re-consideration reputationally and financially threatening is the polar opposite of Safety Engineering. We jumped right over inquiry to shame and blame. Past questions to answers. This should have been an opportunity, but we opened with hardened positions.
May 4, 2026
PKS20 days without a BM is a bit outrageous especially if other bowel cathartics failed. Not clear if a glycerin or dulcolax supp or a fleet’s enema was tried but, never the less, waiting 20 days to finally come to the ED seems not at all beneficial for the child who probably had other secondary symptoms related the bowel obstruction. A sooner referral to a pediatric gastroenterologist or earlier ED visit and admission with GI consult and KUB study with bowel clean out under a more controlled and well planned procedure would likely have been beneficial for the child and family especially in our very litigious environment.