Transanal irrigation (TAI) is the insertion of tepid tap water (36-38°C) (Henderson et al, 2018) into the lower bowel using either a rectal catheter or a cone device. It is usually self-administered by the individual or performed by a carer or health professional. The procedure has also been referred to as rectal irrigation or as bowel washouts. It has recently been approved by the National Institute for Health and Care Excellence (NICE) (2018) as a form of bowel treatment in individuals who suffer bowel dysfunction of either constipation or faecal incontinence.
Although it may be a relatively new intervention for bowel dysfunction, anal irrigation itself is an old concept. The Roman writer Pliny the Elder (AD23-79) recorded that the ancient Egyptians are believed to have watched and learnt from the sacred ibis who used its long beak to insert water into its anus to wash out decaying material (Doyle, 2005; Yates, 2019). The sacred ibis was associated with their god of wisdom, Thoth, who was said to have devised the use of enemas to relieve bowel problems. TAI has been used over the centuries to treat a long list of symptoms, including nausea, fatigue, depression, headache, anxiety, rheumatism and constipation, and it has been used as a ritual and part of the modern social phenomenon of colonic irrigation (Doyle, 2005; Yates 2019). Individuals who may present with bowel dysfunction would include people with neuropathic bowel disorders, such as multiple sclerosis, spinal injuries, spina bifida, Parkinson's and other conditions that affect sphincter control or bowel motility disorders. Bowel dysfunction can also include injury to the rectum, sphincter or bowel, slow transit times, evacuation difficulties or prolapse due to a weak/damaged pelvic floor (Emmanuel et al, 2013), and chronic faecal incontinence (NICE, 2018). However, there are numerous factors that may influence an individual's ability to use the device as a clinical treatment option. These factors are discussed in this article.
Bowel assessment and initial treatment options for bowel dysfunction
Bowel dysfunction includes both constipation and faecal incontinence. Although faecal incontinence is not as common as constipation, its incidence increases with age; it is defined as the recurrent uncontrolled passage of solid or liquid faecal material (Duelund–Jakobsen et al, 2016). Chronic constipation is a prevalent condition that is defined as ‘passing infrequent stools or difficult stool passage or both for at least 3 months' (Emmett et al, 2015). Both these conditions will have a profound effect on an individual's quality of life and they can affect them physically, psychologically and socially (Yates, 2019).
The patient should have an individual bowel assessment undertaken by a professional who is trained in TAI (Table 1). The assessment should rule out all red flag indicators, ie blood in faeces, weight loss, abdominal pain and any changes in bowel habits. This should also include a digital rectal examination to rule out loaded rectum, anal fissures or anal stenosis. Once these factors have been ruled out, the assessment should include recording things such as symptoms, onset of bowel problem, medical and/or surgical history, medication, mobility, dexterity, proximity to toilet, and social need, for example whether carers are required, and their availability (Emmanuel et al, 2019).
| Undertake an holistic assessment of patient including: |
| To undertake TAI the health professional should be able to: |
| The health professional should identify suitable equipment to carry out TAI and consider the following: |
Emmanuel et al (2013) has also identified that the patient's psychological profile and demonstrated compliance with regard to other hospital follow-up is highly likely to influence their safe and long-term use of TAI, and these factors should be included as part of baseline assessment.
Initial treatment options for bowel dysfunction should take the form of conservative therapies (Figure 1), which include:
However, some studies have indicated (Kim et al, 2013) that more than 50% of individuals who undertake conservative treatments will have exhausted these treatments with little or no improvement. This failure to achieve good bowel care with the individual's current bowel programme should alert clinicians to consider TAI (Emmanuel et al, 2013).
How the procedure works
TAI is designed to empty the rectum and up to the descending colon (according to which device is used). By regularly emptying the bowel in this way, TAI is intended to help re-establish controlled bowel function and enable the user to choose the time, frequency and place of evacuation. In patients who have faecal incontinence, efficient emptying of the distal colon and rectum means that new faeces do not reach the rectum for an average of 2 days, preventing leakage between irrigations. In patients who have constipation, regular evacuation of the rectosigmoid region can accelerate transit through the entire colon, preventing impaction (Emmanuel, 2010, Henderson et al, 2018). However, prior to initiating TAI, a risk assessment of any contraindications or cautions should be undertaken for the individual (Table 2).
| Contraindications/or discontinue | Cautions |
|---|---|
| Active inflammatory bowel disease | Cognitive impairment |
| Acute diverticulitis | Congestive cardiac failure |
| Anal or colorectal stenosis | Faecal impaction |
| Change in bowel habits (until cancer excluded) | Inactive inflammatory disease |
| Colorectal cancer | Low blood sodium |
| During chemotherapy | Long-term steroid therapy |
| Ischaemic colitis | Painful anal conditions, including fissure, fistula, haemorrhoids, rectal ulcers |
| Pregnancy (even established users) | Pelvic radiotherapy |
| Within 12 months after radical prostatectomy | Pregnancy (planned) |
| Within 3 months of rectal/colorectal surgery | Previous anal, colorectal or pelvic surgery |
| Within 4 months of polypectomy | Previous diverticulitis or diverticular/severe diverticulitis |
| Prone to rectal bleeding or on anticoagulant therapy (excluding aspirin or clopidogrel) | |
| Renal disease | |
| When rectal medications are used for other conditions | |
| Within 3 months of colonic biopsy | |
| Within 6 months of rectal or colorectal surgery |
Complications and benefits
Although TAI is a simple, reversible and minimally invasive intervention, it is not without complications. Henderson et al (2018) identified that it can worsen faecal incontinence in some individuals, and there is also the possibility of leakage of irrigation fluid, minor discomfort, abdominal cramps, expulsion of rectal catheter (when used); minor rectal or anal bleeding can also occur. Other side effects or consequences that have been noted are sweating, chills and general discomfort.
Inserting a rectal catheter into the rectum, inflating a balloon and instilling water carries the potential risk of bowel perforation. Christensen et al (2016) stated the average risk is 6 in every million irrigations. Perforation may occur due to one of three mechanisms: direct impaling trauma, overinflation of the balloon or exaggerated hydrostatic pressure during water instillation (Emmanuel et al, 2013). Although perforation of the bowel is a potential complication, it is rare.
Despite the potential complications associated with TAI, the benefits of the procedure for most individuals are likely to outweigh the risks. These include (Emmanuel et al, 2013, NICE, 2018):
Type of device
There is now a growing range of equipment available for TAI, but currently most of the published evidence relates to one device (Coloplast Peristeen). It is the health professional's responsibility to be aware of all available devices, which should be used as per manufacturer's instructions. It is important to discuss with each individual which device would be most beneficial for a particular person and their preferences. Devices are usually for personal use at home by either the individual or their carer, but instructions for use should be conveyed by the health professional.
The increasing number of TAI devices available may cause confusion, but they can be divided into low (less than 250 ml) or high (more than 250 ml) volume devices, using cone or balloon inflating devices, and pump and gravity-fed systems (Henderson et al, 2018) (Figure 2).
Systems delivering high-volume irrigation can be used for low-volume irrigation
The Qufora IrriSedo Bed is a system that allows a bed-bound patient to receive irrigation. Water is pumped from a suspended bag into the rectum through a non-ballooned rectal catheter. It is a closed system, and waste is collected in a drainage bag. It is recommended for use in those who are receiving terminal care or are bed-bound for other reasons, including neurogenic bowel dysfunction (Wilson, 2017). There are three sizes available.
The balloon on the rectal catheter utilised in some systems is intended to allow the catheter to be self-retaining, while a cone is held in place manually throughout instillation. The cone is held firmly against the anus to help retain the water and the slim cone tip is unlikely to provoke reflex contractions of the rectum. The rectal balloon is also intended to create a seal within the rectum to facilitate retention of water. However, it should be borne in mind that the process of inflating a rectal balloon can provoke reflex rectal contractions. Prior to the patient deciding which device to use, it is important to establish whether they need high-volume or low-volume/rectal only irrigations. In addition, it should be considered whether they have the dexterity to hold a cone device in place or whether they require a self-retaining balloon; if the choice is to use a balloon it is important to consider whether they have enough hand strength to pump up the device or whether they would require an electric device.
Low-volume cone devices include the Qufora IrriSedo Mini and Aquaflush Compact systems, which usually clean out the rectum only. They are used for individuals with passive soiling, post-defaecation soiling or with those who have rectocele/posterior prolapse.
High-volume devices include the Qufora IrriSedo Cone system, the Aquaflush Quick cone system and the B. Braun IryPump S system, which use either a cone or electric pump. Balloon high-volume devices include the Qufora IrriSedo Balloon system, the Peristeen TAI system and Wellspect's Navina Classic and Navina Smart (electronic pump). High volume devices clean out the rectum, descending colon and part of the transverse colon.
Instruction of an individual
Following individual manufacturers' instructions and providing comprehensive training to the patient is central for the safe and efficient long-term use of TAI (Emmanuel et al, 2013). It is therefore vital that the individual is instructed by a professional competent in TAI and bowel care, and is able to advise with regards to the appropriate device on a case-by-case basis. Consent should be obtained and recorded in patients' notes, and patients provided with relevant written information/DVDs about the agreed device. This information should include explanation of the risks, as well as the benefits, for the patient. Some patients may require support and training over several episodes of TAI before they will be confident to undertake the procedure independently. Training should provide the patient and/or carer with an understanding of how TAI works, why they are using it and how they can benefit from the procedure. This is important in encouraging patients to persist with TAI until they establish an effective routine (Emmanuel et al, 2013).
There is some controversy over the composition of irrigating fluid used, with most patients using tepid tap water (however, if there is any doubt bottled water can be used). Different volumes of irrigating fluid have been recommended and range from 250 ml to 4000 ml (Emmanuel et al, 2019). Large volumes are usually used for patients with conditions such as constipation due to slow transit times or opioid-induced or neuropathic conditions. Low volumes may be used for passive faecal incontinence, post-defaecation seepage, posterior prolapsed or evacuation difficulties (Emmanuel et al, 2019). Individuals are usually advised to irrigate daily initially for the first 2-3 months (Emmanuel et al, 2019), then usually high-volume irrigation can be carried out on alternate days and low-volume irrigation daily. However, this will vary depending on individual requirements. As part of the education and instruction, patients should be advised about potential complications, on troubleshooting and appropriate interventions (Table 3). It is important that, if TAI is successful, the professional informs the patient/carer how to obtain future supplies.
| Problem/complication | Intervention |
|---|---|
| Bleeding | A small amount of bleeding is to be expected. More copious or regular bleeding requires further investigation. Haemorrhage with or without pain suggests a probable perforation, which should be treated as a medical emergency |
| Pain | If cramps, discomfort or pain occur while instilling the irrigation, pause instillation for a few moments and continue more slowly once the discomfort has subsided. Ensure that irrigation fluid is warm enough—at body temperature, around 36°–38°C. |
| Autonomic dysreflexia (AD) and autonomic symptoms during irrigation (sweating, palpitations and dizziness) |
|
| Leakage of water around the catheter/cone |
|
| Difficulty inserting catheter/cone or instilling irrigation |
|
| Irrigation not expelled |
|
| No stool evacuated after irrigation |
|
| Faecal incontinence between uses of transanal irrigation |
|
| Leakage of water between irrigations |
|
Studies, such as Christensen et al's (2009), have shown that, when TAI is first instigated, statistical efficacy is apparent in certain population groups. For example, there are higher success rates in improving faecal incontinence and leakage, but not so much faecal soiling, in patients with spinal injury and neurogenic bowel.
This effect, however, was not replicated in one long-term study, with more than half the study population discontinuing TAI (Kim et al, 2013). The main reasons included unsatisfactory outcome with regards to emptying bowel contents, personal reasons, patient withdrew consent/lost to follow-up, expulsion of rectal catheter, rectal balloon bursting, water leakage, patient disliked treatment, bowel perforation, abdominal pain, minor rectal bleeding, fatigue, peri-anal discomfort, nausea, shivers, and headaches. These findings have also been identified and supported by Yates (2019).
Conclusion
Although TAI is a valuable asset in the treatment of bowel dysfunction, it is not suitable for all patients. It is imperative that the individual is appropriately assessed and, if suitable, discussion takes place with regards to the most appropriate device to have the best clinical outcomes. To achieve this, patients must be instructed and supported in the initial phase by a competent professional to make sure that they attain the best efficacy from the device and so improve their quality of life and bowel function. This process is summarised in Figure 3.
It is the duty of the health professional to keep up to date with developments in TAI and the new devices becoming available to provide best possible care and outcomes to patients who suffer with bowel dysfunction.