We have demonstrated in previous publications the consistent association of the dilated rectum and overactive bladder in children. The pioneering work on this topic, first published by Sean O'Regan, described an enema regimen ideally suited to resolve megaretcum and voiding compliants in these children. As our experience has grown with this population, we have gained more insight into the function of the dilated rectum, its role in dysfunctional elimination syndrome, and the methods required for its most effective resolution. In this review, we will describe the Modified O'Regan protocol, which we have developed to treat patients resistant to Dr. O'Regan's originally described regimen, and we will introduce the concept of "rectal failure," which we feel fully describes the onset and progression of dysfunctional elimination syndrome.