Transanal irrigation (TAI) is a simple, safe, reversible treatment option and proven to be effective in treating neurogenic bowel dysfunction (in patients with multiple sclerosis, spina bifida or spinal cord injury), faecal incontinence and constipation (Christensen et al, 2009; Christensen and Krogh, 2010; Emmanuel; 2010; Emmett et al, 2015). TAI can be used to manage obstructed defecation, functional defecation disorder, chronic idiopathic constipation and constipation-predominant irritable bowel syndrome (IBS-C), as well as idiopathic post-traumatic constipation. It may also be considered in patients who have not responded to medical management.
TAI involves instilling tap water into the rectum via the anus using either a balloon catheter or a cone delivery system attached via a plastic tube to an irrigation bag holding up to 2 litres of water. Alternatively, a low-volume system consisting of a hand pump and a cone may be employed. By regularly emptying the bowel this way, TAI is intended to reduce leakage, help re-establish controlled bowel function, and enable the user to choose the time and place for rectal evacuation. The effect of TAI varies among patients; some report full satisfaction and improvements in quality of life, whereas others have poor efficacy and abandon treatment. Response to treatment depends not only on the correct indications but also on the patient's motivation and their degree of manual dexterity. A digital rectal examination is mandatory before using TAI to exclude localised anal disorders, and to assess for faecal impaction, as well as sphincter function and co-ordination. Comprehensive training of the patient is central to safe long-term use of TAI.
Hands-on training should be supported by locally written instructions, which may be supplemented by commercial information. Audio-visual resources may be helpful in preparing the patient and for their later reference. Information should also include explanation of risks and benefits; informed consent to TAI should be obtained prior to its use.
An individual should be taught how to self-administer the treatment when possible. Where an individual cannot undertake the procedure independently, a carer can be trained to perform all or part of the procedure. Most patients will be taught how to perform irrigation as outpatients. The first irrigation should be undertaken under clinical supervision—this allows the trainer to evaluate the patient/carer's understanding and abilities, to reinforce safety, and for the patient/carer to ask any questions.
Many individuals will empty their rectum with TAI without further intervention, which is the goal. However, some individuals will need to use additional interventions such as abdominal massage, bracing abdominal muscles, digital rectal stimulation, or digital evacuation of faeces. The need for these interventions may decrease as an effective routine is established. If the patient is using laxatives when starting TAI, these should be continued until TAI is well established; gradual reduction can then be attempted. Patients should understand that it may take 4-12 weeks and adjustments in technique to establish a reliable and effective routine to achieve their individualised goals.
The regular use of TAI allows bowel function to be re-established and controlled in patients with bowel dysfunction. This enables patients to develop a bowel routine by choosing the time and place of evacuation.
In patients with evacuatory dysfunction, regular evacuation of the rectosigmoid region can accelerate transit through the entire colon and therefore helps to prevent blockages. In patients with faecal incontinence TAI prevents faecal soiling, improving patients' confidence and quality of life. It is also an alterative to surgery. TAI is safe and its effectiveness is at least comparable with pharmacological therapies; in selective cases, it can be used in combination with them. A variety of systems are available that differ in design and use. These choices should be discussed by clinician and patient, and a number of systems may be tried before a preferred device is found.
In conclusion, the main points to bear in mind when TAI is considered as a treatment option would be:
- TAI is a beneficial and effective intervention for patients with lower bowel dysfunction
- Escalation of the appropriate treatment and an appropriate assessment (covering quality of life/symptoms) before TAI is essential in order to adhere to relevant clinical guidelines and governance
- Patient selection is the number one factor for a successful intervention
- Patient support is key for the success of the intervention in the short and the long term
- Ongoing liaison with the rest of the multidisciplinary team is essential for the ultimate benefit of the patient.