Bowel Irrigation Techniques

Transanal irrigation (TAI) is a process of facilitating evacuation of stool from the bowel by passing water (or other liquids) in via the anus in a quantity sufficient to reach beyond the rectum into the colon. Pulsed water irrigation uses an electrical pump to deliver intermittent, rapid pulses of warm water into the rectum/colon to break up stool and to stimulate peristalsis (Puet et al. 1997). The enema continence catheter was a specially designed catheter with an inflatable balloon, originally developed by Shandling and Gilmour (1987) for bowel management in individuals with spina bifida. The catheter was inserted into the rectum and the balloon inflated to hold the catheter in place. After the irrigation was administered under gravity, the balloon was deflated, the catheter removed, and the bowel contents emptied. In 2006 Christensen et al. assessed the use of the newly developed Peristeen Anal Irrigation system (Coloplast A/S, Kokkedal, Denmark). This system consists of a rectal balloon catheter, a manual pump, and a water container. The catheter is inserted into the rectum and the balloon inflated to hold the catheter in place while tap water is administered using the manual pump (Christensen et al. 2006).

Antegrade irrigation introduces water to the colon (caecum) via a surgically formed non-reflux stoma. Irrigation may be delivered via the stoma using a manual or powered pump, or by gravity. The Malone antegrade continence enema (MACE or ACE) is a continent catheterizable stoma, connecting from the external abdominal wall to the caecum, through which a catheter is inserted. An enema can then be given via the catheter.

During both transanal and antegrade irrigation a rectal balloon catheter or rectal cone without a balloon is placed into the rectum and removed once irrigation is completed for controlled voiding of the rectum.

Discussion

Two review papers published in 2010 looked at transanal irrigation in the neurogenic population (Emmanuel 2010) and both the neurogenic and wider population (Christensen & Krogh 2010) respectively.

Both reviews concluded that the use of transanal irrigation resulted in significant improvements in incontinence, constipation, time spent on bowel care, autonomic symptoms around bowel management and quality of life, in comparison to conservative management in individuals with SCI. Irrigation was found to be a safe procedure, as the risk of bowel perforation was approximated as 1/50,000 irrigations. No adverse changes in rectal or colonic function were associated with irrigation use. However, in the long term a significant proportion of users stop using irrigation. The cause of this is not clear but thorough preparation and training for irrigation and continuing support whilst establishing a new regimen are thought to improve compliance.

An international group of specialists from a range of disciplines, experienced in transanal irrigation, have published a consensus review (Emmanuel et al. 2013) that provides guidance regarding patient selection, indications and contraindications for transanal irrigation and a step-by-step approach to treatment and follow-up. Absolute contraindications include anal or rectal stenosis, active inflammatory bowel disease, acute diverticulitis, colorectal cancer, ischaemic colitis, rectal surgery within the previous 3 months or endoscopic polylectomy within the previous 4 weeks. Relative contraindications include severe diverticulosis, long term steroid medication, painful anal conditions, planned or current pregnancy, and severe autonomic dysreflexia. Fecal loading/impaction should be treated before irrigation is instigated. No clear patient selection criteria have been identified; any individual whose bowel management is ineffective, lacks contraindications above, and who is suitably motivated may benefit from transanal irrigation. The importance of training the patient and their caregiver, as well as providing follow up support, while establishing an individualized program is emphasized.

The evidence for irrigation is mostly in people with chronic SCI with upper motor neuron bowel dysfunction. However, in a small study Ethans et al. (2022) found improvements in all measures of incontinence scores, constipation severity, improved transit times, and satisfaction, including in people with LMN bowel dysfunction.

There is a need to explore its potential in the subacute rehabilitation phase. Further research is also required to determine the cause of the reduction in use of irrigation over time and how this can be improved, and to develop clear patient selection criteria.

In people with SCI for whom transanal irrigation is ineffective or inappropriate, the Malone antegrade continence enema (MACE) can eliminate fecal incontinence (Worsoe et al. 2008; Teichman et al. 2003; Christensen et al. 2000; Teichman et al. 1998), reduce time spent on bowel care (Worsoe et al. 2008; Teichman et al. 2003; Teichman et al. 1998), improve quality of life (Teichman et al. 2003; Christensen et al. 2000; Smith & Decter 2015), resolve autonomic dysreflexia secondary to the neurogenic bowel (Teichman et al. 1998), and successfully treat constipation (Christensen et al. 2000).Smith & Decter (2015) found three of the twelve patients (25%) in their cohort study (mean follow-up 56 months) developed stomal stenosis and one developed delayed small bowel obstruction.

Christensen et al. (2000) compared the efficacy of MACE with the enema continence catheter in people with SCI and reported successful treatment of fecal incontinence, slow transit or constipation, and obstructed defecation.

Conclusion

There is level 1 evidence (from one RCT; Christensen et al. 2006) that supports the use of transanal irrigation (Peristeen Anal Irrigation system) over conservative bowel treatment (as outlined by the Paralyzed Veterans of America clinical practice guidelines) in individuals with chronic SCI and bowel management problems.

There is level 2, 3, and 4 evidence (from four retrospective reviews and one longitudinal cohort; Teichman et al. 1998; Christensen et al. 2000; Teichman et al. 2003; Worsoe et al. 2008; Smith & Decter, 2015) that the Malone Antegrade Continence Enema successfully treats neurogenic bowel dysfunction.

There is level 3 evidence (from one retrospective review; Christensen et al. 2000) that the enema continence catheter can be used to treat neurogenic bowel dysfunction.

There is level 4 evidence (from one case series, one cross-sectional, and three non-randomized cohort studies) (Del Popolo et al. 2008, Christensen et al. 2008, Faaborg et al. 2009, Kim et al. 2013) that supports the use of transanal irrigation to manage neurogenic bowel dysfunction.

There is level 4 evidence (from one case series; Puet et al. 1997) that supports using pulsed water irrigation (intermittent rapid pulses) to remove stool in individuals with SCI.

There is level 4 evidence (Ethans et al. 2022) that PAISTM, as a non-pharmaceutical method of bowel management is effective and has the potential to improve symptoms of bowel dysfunction in people with CES.