Transanal irrigation

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Transanal irrigation
Other namesretrograde irrigation, [nb 1] anal irrigation, [1] rectal irrigation, [1] bowel irrigation, [2] transanal colonic irrigation, [3] bowel washouts. [4]
Specialty gastroenterology

Transanal irrigation is medical procedure in which water is used to evacuate feces from the rectum and descending colon via the anus. [5] [1]

Contents

Transanal irrigation uses a large volume water enema system. [2] It is carried out every day (or every 2 days) by the patient or carer as a long term management for bowel dysfunction, including fecal incontinence and/or constipation (especially obstructed defecation).

Although the procedure and general goals may be similar, transanal irrigation is different from colon cleansing (colon hydrotherapy), which is a term used in alternative medicine. Transanal irrigation is used for medical conditions which affect defecation, such as spinal cord injury or multiple sclerosis. Colon cleansing is used outside of mainstream medical supervision, and may be used in the belief that the procedure removes toxins from the body.

The impact of transanal irrigation varies considerably. Some individuals experience complete control of incontinence, and other report little or no benefit. [5] Evidence shows this treatment can be considered for children as well. [6] [7] When diet and medication has proven ineffective, transanal irrigation may be used. [5] [8]

Procedure

Transanal irrigation systems may use either a rectal balloon catheter or a cone-shaped colostomy tip. [9]

The catheter tip is inserted into the anal canal. Systems with balloon catheters require inflation of the balloon once the tip is in position. [9] Cone shaped colostomy tip systems must be supported manually. [9]

Lukewarm tapwater (36-38°C) [4] is used if it is drinkable. [9] If tap water is not safe for drinking, a different source of clean water is needed. The irrigation bag is ideally placed or hung 1-1.5 m above the level of the toilet. The flow is switched on with a handheld valve. The flow rate of the water may be controlled by a manual pump or a battery pump. [9]

The volume of water used is normally about 1000 ml. [9] Some sources recommend repeat irrigation with a higher volume up to 2300 ml. [9]

Transanal irrigation may be performed every day or every other day in order to simulate a normal defecation routine. [9] Ideally, irrigation is performed at the same hour each day. [10]

The optimal volume and frequency may be determined by trail and error for each individual patient during the first few months of treatment. [9]

The time required for the procedure is in the range of 30–120 min. [9]

Some individuals take oral constipating medications or oral laxative medications in addition to transanal irrigation. [9]

It is unclear whether the mechanism of action of irrigation is by simple mechanical washing out of the bowel, or by triggering of colonic mass movements, or both. [9]

Disadvantages of the treatment may include:

Indications

Specific conditions for which transanal irrigatio has been used include:

Contraindications

Effectiveness

A Cochrane review found evidence that transanal irrigation was more effective compared to conservative management in the management of spinal cord injury. There were more positive benefits for constipation scores, neurogenic bowel dysfunction scores, and fecal incontinence scores. Patients spent less time in total on bowel care and were more satisfied with the treatment. [12]

Adverse effects

The treatment is generally considered safe. However, adverse effects are reported, including:

Bowel perforation

Bowel perforation is when the wall of the bowel ruptures. It is a potentially lethal complication [9] which requires emergency surgery. 49 bowel perforations caused by transanal irrigation were reported between 2005 and 2013. [19] This rate was used to calculate a risk of 2-6 perforations per 1 million procedures. [19] This risk of perforation is significantly lower compared to other common medical procedures such as flexible sigmoidoscopy (1 perforation per 40000 procedures), colonoscopy (1 per 1000) and barium enema (1 per 10000). [10] However, patients may need to conduct transanal irrigation daily or near-daily for many years, which increases their lifetime risk. [9] Perforation is more likely in the first weeks after starting treatment. [19] People who have had a surgical anastomosis (for example, after low anterior resection, stapled transanal rectal resection, ventral mesh rectopexy, or other types of surgery for rectal prolapse) are more at risk of bowel perforation during transanal irrigation. [10]

Long term effects on anorectal physiological function

One study reported before and after changes in anorectal physiology tests in patients with idiopathic faecal incontinence or chronic idiopathic constipation. The patients had all used transanal irrigation for at least 30 months. In the chronic idiopathic constipation group there was no reduction in anal sphincter function after long term use of transanal irrigation. In the idiopathic faecal incontinence group anal resting and squeeze pressures were lower after long term use of transanal irrigation. The researchers suggested that this was due to age related changes in sphincter function and the deterioration of the disease over time rather than due to the use of transanal irrigation. In both groups rectal urge volume increased after long term use of transanal irrigation. The researchers suggested that patients get accustomed to larger rectal volumes, and without the irrigation their everyday sensation of urge from the presence of stool in the rectum is decreased. This may encourage patients to continue using the irrigation. However, rectal compliance (how well the rectum can stretch and accommodate increasing volumes without triggering discomfort or pain) and biomechanical properties of the rectal wall were unchanged. [3]

Notes

  1. ↑ The term retrograde irrigation distinguishes this procedure from the Malone antegrade continence enema, where irrigation fluid is introduced into the colon proximal to the anus via a surgically created irrigation port

Related Research Articles

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An enema, also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum. The word enema can also refer to the liquid injected, as well as to a device for administering such an injection.

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents — including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Rectal prolapse</span> Protrusion of the walls of the rectum outside the body

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<span class="mw-page-title-main">Colorectal surgery</span> Field in medicine for disabilities in the rectum

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<span class="mw-page-title-main">Fecal impaction</span> Solid buildup of feces in the rectum due to chronic constipation

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<span class="mw-page-title-main">Anal plug</span> Medical device sometimes used to treat fecal incontinence

An anal plug is a medical device that is often used to treat fecal incontinence, the accidental passing of bowel moments, by physically blocking involuntary loss of fecal material. Fecal material such as feces are solid remains of food that does not get digested in the small intestines; rather, it is broken down by bacteria in the large intestine. Anal plugs vary in design and composition, but they are typically single-use, intra-anal, disposable devices made out of soft materials to contain fecal material and prevent it from leaking out of the rectum. The idea of an anal insert for fecal incontinence was first evaluated in a study of 10 participants with three different designs of anal inserts.

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<span class="mw-page-title-main">Defecography</span> Visualisation of the mechanics of a patients defecation

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<span class="mw-page-title-main">Colon cleansing</span> Pseudoscience procedure to cleanse human colon

Colon cleansing, also known as colon therapy, colon hydrotherapy, a colonic, or colonic irrigation, encompasses a number of alternative medical therapies claimed to remove toxins from the colon and intestinal tract by removing accumulations of feces. Colon cleansing in this context should not be confused with an enema which introduces fluid into the colon, often under mainstream medical supervision, for a limited number of purposes including severe constipation and medical imaging.

<span class="mw-page-title-main">Rectum</span> Final portion of the large intestine

The rectum is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. The adult human rectum is about 12 centimetres (4.7 in) long, and begins at the rectosigmoid junction at the level of the third sacral vertebra or the sacral promontory depending upon what definition is used. Its diameter is similar to that of the sigmoid colon at its commencement, but it is dilated near its termination, forming the rectal ampulla. It terminates at the level of the anorectal ring or the dentate line, again depending upon which definition is used. In humans, the rectum is followed by the anal canal, which is about 4 centimetres (1.6 in) long, before the gastrointestinal tract terminates at the anal verge. The word rectum comes from the Latin rēctumintestīnum, meaning straight intestine.

<span class="mw-page-title-main">Anorectal manometry</span> Medical functional test of the anus and rectum

Anorectal manometry (ARM) is a medical test used to measure pressures in the anus and rectum and to assess their function. The test is performed by inserting a catheter, that contains a probe embedded with pressure sensors, through the anus and into the rectum. Patients may be asked to perform certain maneuvers, such as coughing or attempting to defecate, to assess for pressure changes. Anorectal manometry is a safe and low risk procedure.

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<span class="mw-page-title-main">Anismus</span> Failure to relax the pelvic floor muscles during defecation

Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

In fecal incontinence (FI), surgery may be carried out if conservative measures alone are not sufficient to control symptoms. There are many surgical options described for FI, and they can be considered in 4 general groups.

<span class="mw-page-title-main">Neurogenic bowel dysfunction</span> Human disease involving inability to control defecation

Neurogenic bowel dysfunction (NBD) is the inability to control defecation due to a deterioration of or injury to the nervous system, resulting in faecal incontinence or constipation. It is common in people with spinal cord injury (SCI), multiple sclerosis (MS) or spina bifida.

Low anterior resection syndrome is a complication of lower anterior resection, a type of surgery performed to remove the rectum, typically for rectal cancer. It is characterized by changes to bowel function that affect quality of life, and includes symptoms such as fecal incontinence, incomplete defecation or the sensation of incomplete defecation, changes in stool frequency or consistency, unpredictable bowel function, and painful defecation (dyschezia). Treatment options include symptom management, such as use of enemas, or surgical management, such as creation of a colostomy.

A rectal stricture is a chronic and abnormal narrowing or constriction of the lumen of the rectum which presents a partial or complete obstruction to the movement of bowel contents. A rectal stricture is located deeper inside the body compared to an anal stricture. Sometimes other terms with wider meaning are used, such as anorectal stricture, colorectal stricture or rectosigmoid stricture.

References

  1. 1 2 3 4 5 6 7 8 9 Woodward, S (14 December 2017). "Treating chronic constipation and faecal incontinence using transanal irrigation". British Journal of Nursing (Mark Allen Publishing). 26 (22): 1220–1222. doi:10.12968/bjon.2017.26.22.1220. PMID   29240487.
  2. 1 2 Cifu, DX, ed. (1 August 2020). Braddom's Physical Medicine and Rehabilitation E-Book. Elsevier Health Sciences. pp. 426, 427. ISBN   978-0-323-62540-1.
  3. 1 2 3 4 Faaborg, PM; Christensen, P; Buntzen, S; Laurberg, S; Krogh, K (October 2010). "Anorectal function after long-term transanal colonic irrigation". Colorectal Disease. 12 (10 Online): e314-9. doi:10.1111/j.1463-1318.2010.02198.x. PMID   20070334.
  4. 1 2 Yates, A (9 April 2020). "Transanal irrigation: is it the magic intervention for bowel management in individuals with bowel dysfunction?". British Journal of Nursing (Mark Allen Publishing). 29 (7): 393–398. doi:10.12968/bjon.2020.29.7.393. PMID   32279546.
  5. 1 2 3 4 Emmanuel, A V; Krogh, K; Bazzocchi, G; Leroi, A-M; Bremers, A; Leder, D; van Kuppevelt, D; Mosiello, G; Vogel, M; Perrouin-Verbe, B; Coggrave, M; Christensen, P (20 August 2013). "Consensus review of best practice of transanal irrigation in adults" (PDF). Spinal Cord. 51 (10): 732–738. doi: 10.1038/sc.2013.86 . PMID   23958927.
  6. ↑ Corbett, P V; Denny, A; Dick, K; Malone, PS; Griffin, S; Stanton, MP (April 2014). "Peristeen integrated transanal irrigation system treats feacel incontinence in children". Pediatric Urology. 10 (2): 219–22. doi:10.1016/j.jpurol.2013.08.006. PMID   24439630.
  7. ↑ Mosiello, Giovanni; Marshall, David; Rolle, Udo; Crétolle, Célia; Santacruz, Bruno G.; Frischer, Jason; Benninga, Marc A. (2017). "Consensus Review of Best Practice of Transanal Irrigation in Children". Journal of Pediatric Gastroenterology and Nutrition. 64 (3): 343–352. doi: 10.1097/mpg.0000000000001483 . PMID   27977546. S2CID   34911976.
  8. ↑ (UK), National Collaborating Centre for Acute Care (2007). Faecal incontinence the management of faecal incontinence in adults. London: National Collaborating Centre for Acute Care (UK). ISBN   978-0-9549760-4-0.
  9. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Christensen, P; Krogh, K (May 2010). "Transanal irrigation for disordered defecation: a systematic review". Scandinavian Journal of Gastroenterology. 45 (5): 517–27. doi:10.3109/00365520903583855. PMID   20199336.
  10. 1 2 3 4 5 Martellucci, J; Sturiale, A; Bergamini, C; Boni, L; Cianchi, F; Coratti, A; Valeri, A (July 2018). "Role of transanal irrigation in the treatment of anterior resection syndrome". Techniques in Coloproctology. 22 (7): 519–527. doi:10.1007/s10151-018-1829-7. PMID   30083782.
  11. ↑ Wolff, Bruce G.; et al., eds. (2007). The ASCRS textbook of colon and rectal surgery. New York: Springer. pp. 653–664. ISBN   978-0-387-24846-2.
  12. 1 2 Coggrave, M; Norton, C; Cody, JD (13 January 2014). "Management of faecal incontinence and constipation in adults with central neurological diseases". The Cochrane Database of Systematic Reviews. 2014 (1): CD002115. doi:10.1002/14651858.CD002115.pub5. PMC   10656572 . PMID   24420006.
  13. ↑ Emmanuel, Anton; Kumar, Gayathri; Christensen, Peter; Mealing, Stuart; Størling, Zenia M.; Andersen, Frederikke; Kirshblum, Steven (2016-08-24). "Long-Term Cost-Effectiveness of Transanal Irrigation in Patients with Neurogenic Bowel Dysfunction". PLOS ONE. 11 (8): e0159394. Bibcode:2016PLoSO..1159394E. doi: 10.1371/journal.pone.0159394 . ISSN   1932-6203. PMC   4996513 . PMID   27557052.
  14. ↑ Colonic emptying after transanal irrigation Bazzocchi G, Poletti E, Pillastrini
  15. ↑ Christensen, P; Krogh, K; Buntzen, S; Payandeh, F; Laurberg, S (Feb 2009). "Long-term outcome and safety of transanal irrigation for constipation and fecal incontinence". Diseases of the Colon and Rectum. 52 (2): 286–92. doi:10.1007/DCR.0b013e3181979341. PMID   19279425. S2CID   24381352.
  16. ↑ Christensen, P; Olsen, N; Krogh, K; Bacher, T; Laurberg, S (Jan 2003). "Scintigraphic assessment of retrograde colonic washout in fecal incontinence and constipation". Diseases of the Colon and Rectum. 46 (1): 68–76. doi:10.1007/s10350-004-6498-0. PMID   12544524. S2CID   32754686.
  17. ↑ Christensen, Peter; Bazzocchi, Gabriele; Coggrave, Maureen; Abel, Rainer; Hultling, Claes; Krogh, Klaus; Media, Shwan; Laurberg, Søren (2006). "A Randomized, Controlled Trial of Transanal Irrigation Versus Conservative Bowel Management in Spinal Cord–Injured Patients". Gastroenterology. 131 (3): 738–747. doi:10.1053/j.gastro.2006.06.004. PMID   16952543. S2CID   16917.
  18. ↑ Podzemny, V; Pescatori, LC; Pescatori, M (28 January 2015). "Management of obstructed defecation". World Journal of Gastroenterology. 21 (4): 1053–60. doi: 10.3748/wjg.v21.i4.1053 . PMC   4306148 . PMID   25632177.
  19. 1 2 3 Christensen, P; Krogh, K; Perrouin-Verbe, B; Leder, D; Bazzocchi, G; Petersen Jakobsen, B; Emmanuel, AV (February 2016). "Global audit on bowel perforations related to transanal irrigation". Techniques in Coloproctology. 20 (2): 109–15. doi:10.1007/s10151-015-1400-8. PMID   26573811.
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