Bowel Irrigation Techniques
Transanal irrigation 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 & 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 abominal 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 recently 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 individuals with chronic SCI. 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 individuals with SCI for whom transanal irrigation is ineffective or inappropriate, the Malone antegrade continence enema (MACE) can eliminate fecal incontinence (Worsøe et al. 2008; Teichman et al. 2003; Christensen et al. 2000; Teichman et al. 1998), reduce time spent on bowel care (Worsøe et al. 2008; Teichman et al. 2003; Teichman et al. 1998), improve quality of life (Teichman et al. 2003; Christensen et al. 2000), resolve autonomic dysreflexia secondary to the neurogenic bowel (Teichman et al. 1998), and successfully treat constipation (Christensen et al. 2000; Teichman et al. 2003).
Christensen et al. (2000) compared the efficacy of Malone antegrade continence enema with the enema continence catheter and reported successful treatment of fecal incontinence, slow transit or constipation, and obstructed defecation in persons with SCI.
Conclusion
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 1b 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 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 four retrospective reviews: Teichman et al. 1998; Christensen et al. 2000; Teichman et al. 2003; Worsøe et al. 2008) that the Malone Antegrade Continence Enema successfully treats neurogenic bowel dysfunction.
There is level 4 evidence (from one retrospective review: Christensen et al. 2000) that the enema continence catheter can be used to treat neurogenic bowel dysfunction.
Authors; Country
Date included in the review Total Sample Size Types of Articles Score |
Methods
Databases Level of Evidence |
Conclusions |
Christensen & Krogh 2010
Denmark Systematically reviewed articles up until August 2009 N=27 studies (4 studies with SCI patients) Level of evidence: Methodological quality not assessed Type of study: 1 multi-centre, RCT (SCI); all others had no control AMSTAR: 3 |
Method: Systematic literature search for published reports on transanal irrigation was conducted. Participants of interest were self-administered transanal irrigation, indications, techniques, outcomes, modes of action, complications, quality of life and quality of methods used.
Databases: Medline, Embase, CINAHL, Cochrane Library, completed studies from the internet-based trial register (www.clinicaltrials.gov) |
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Emmanuel 2010
UK Systematically reviewed articles (no dates specified) N=23 studies (6 SCI) Level of evidence: Strengths and limitations were assessed for each study Type of study: 1 RCT, the rest were retrospective or observational AMSTAR: 2 |
Method: Systematic literature search for published reports on TAI in NBD participants. No restrictions on articles by size or design.
Databases: Pubmed |
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Authors; Country
Total Sample Size Types of Articles Score |
Methods
Databases Level of Evidence |
Conclusions |
Emmanuel et al. 2013;
UK (international panel of experts) N=20 non-pediatric articles |
Methods: a consensus group of specialists from a range of nations (Denmark, France, Germany, Italy, the Netherlands, UK) and disciplines (physicians, surgeons, physiology experts, rehab specialists) who have experience in prescribing and monitoring patients using TAI assimilated emerging literature and clinical experience, reaching consensus through a round table discussion process.
Databases: PubMed, Athens
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Author Year; Country
Score Research Design Total Sample Size |
Methods |
Outcome |
Christensen et al. 2006;
Denmark PEDro = 7 RCT N=87 |
Population:
1) TAI group: ≥T9: 3 complete, 5 incomplete; T10-L2: 1 complete, 1 incomplete; L3-S1: 1 incomplete); Age: mean 47.5 yrs; 29M 13F. 2) Conservative bowel management (CBM) group: ≥T9: 22 complete,11 incomplete; T10-L2: 1 complete, 3 incomplete; L3-S1, 8 incomplete Age: mean 50.6yrs; 33M 12F Treatment: TAI (Peristeen Anal Irrigation system) or conservative bowel management (Paralyzed Veterans of America clinical practice guidelines) for 10 weeks. Outcome Measures: Cleveland Clinic constipation scoring system (CCCSS), St. Mark’s fecal incontinence grading scale (FIGS), American Society of Colon and Rectal Surgeons fecal incontinence score (symptom-related QOL scale), NBD score. |
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Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
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Kim et al. 2013;
Korea Longitudinal N=52 |
Population: Level of injury: 28 tetraplegics, 24 paraplegics; 41M 11F; Mean (SD) age: 44.5 (11.0) yrs; mean (SD) DOI: 92.9 (118.4) months
Treatment: Transanal irrigation (TAI) Outcome Measures: Compliance rate, questionnaire on demographics, bowel care habits, frequency and time needed to defecate, intestinal symptoms, need for assistance during bowel management, participant satisfaction and quality of life, adverse events |
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Smith & Decter 2015
USA Prospective Cohort N=17 |
Population: N=17 (12M, 5F)
Mean (range) age at surgery 33 (6-49) Mean (range) time post SCI at surgery 10 (1-30) years Mean time from surgery to follow-up 56 (4-102) months 10 paraplegia, 7 tetraplegia 9 thoracic, 8 cervical N=5 excluded due to completing pre-operative survey after surgery (N=12 remain for final analysis) Treatment: Anterograde continence enema (ACE) Outcome Measures: Fecal incontinence quality of life (FIQL) instrument |
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Faaborg et al. 2009;
Denmark Post-test N = 211 |
Population: neurogenic bowel dysfunction 96M 115F; age: median 49yrs, range 7-81 yrs, who were introduced to transanal irrigation between 1994-2007. 74 traumatic SCI participants; 10 high complete, 12 high incomplete, 14 low complete, 38 low incomplete.
Treatment: TAI (Enema continence catheter; same as that used in Christensen et al. 2000) Outcome Measures: Rate of success (treatment was considered successful if the patient is currently using TAI, if the patient used TAI until he/she died, or if the patient’s symptoms resolved while using TAI) as evaluated by a questionnaire, as well as the patient’s medical records; incidence of bowel perforation and other side effects |
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Worsoe et al. 2008
Denmark Case series N = 80 |
Population: 64F 16M; Age: mean (range) 51 (17-84) yrs. Main symptom was constipation for 48 participants, fecal incontinence for 20 and a combination of both in 12.
Treatment: Antegrade colonic enema (ACE), or ACE combined with colostomy Outcome Measures: A 44-item questionnaire, including whether the patient is still using ACE and if not, why; functional results and side effects of ACE; overall satisfaction with bowel function and quality of life; success of treatment, defined as participants still using ACE or bowel symptoms resolved because of ACE |
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Christensen et al. 2008;
Europe Pre-post N = 62 |
Population: 45M 17F; mean (SD) age: 47.5 (15.5) yrs; level of injury: supraconal for 61, conal/cauda equina (S2-S4) for 1. 55/62 completed the studyTreatment: TAI (Peristeen Anal Irrigation) for a 10-week periodOutcome Measures: Cleveland Clinic constipation scoring system (CCCSS), St Mark’s fecal incontinence grading system (FIGS), Neurogenic bowel dysfunction (NBD) score (higher scores = worse outcomes) |
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Del Popolo et al. 2008;
Italy Pre-post N = 36 |
Population: SCI patients with severe NBD and unsatisfactory bowel management; 32/36 completed the study. Cause of SCI: 42.4% trauma, 36.4% spina bifida, 6.1% MS, 3% surgery, 9.1% other, 3% not recorded. 39.4% sensory complete, 42.4% sensory incomplete, 18.2% not specified.
Treatment: TAI (Peristeen Anal Irrigation) for three weeks Outcome Measures: Quality of life questionnaire (scale and nominal variables), participants’ opinions on their intestinal functionality, use of pharmaceuticals, dependence on caregivers, incidence of incontinence and constipation, abdominal pain or discomfort |
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Teichman et al. 2003; USA
Retrospective chart review N=6; 3 SCI |
Population: (for N=3 SCI) Level of injury: T5 complete, C6 complete, C7 incomplete; all males; Age: mean (range) 36 (29-47) yrs;
Treatment: Malone antegrade continence enema (MACE) with mean follow-up 4.5 years Outcome Measures: Bowel incontinence; subjective patient satisfaction (patients were asked: “do you consider the surgical procedure beneficial to you” and “if you could do the ACE procedure again, would you?”) |
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Christensen et al. 2000;
Denmark Retrospective interviews and case series N=29; 19 SCI |
Population:
1) TAI (enema continence catheter): N=21 participants (15/21 were SCI); 10M 11F; Age: mean (range) 39.9 (7-72) yrs; for SCI participants: Level of injury: 3 supraconal (T2 incomplete, T4 complete, T11 complete), 12 incomplete conal or cauda equina injuries; follow-up: mean (range) 16 (1-51) months 2) MACE: 8 patients, (4/8 were SCI); 3M 5F; Age: mean 32.8 years, range 15-66; 2 supraconal SCIs (C5-6 and T2, incomplete); mean follow-up 38 months, range 4-77 Treatment: TAI (enema continence catheter) vs. MACE (out of 8 MACE patients, 3 had tried ECC previously) Outcome Measures: questionnaire on colorectal function, practical procedure, impact on daily living and quality of life, general satisfaction of the patient with the treatment |
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Teichman et al. 1998; USA
Retrospective chart review N=7; 4 SCI |
Population: (for N=4 SCI participants) Level of injury: 2 C6, 1 C7, 1 T5; all males; Age: mean (range) 32.5 22-47yrs; Mean follow-up: 11 months
Treatment: MACE Outcome Measures: Number of fecal incontinence episodes per week, time for evacuation, bowel management episodes attempted |
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Puet et al. 1997;
USA Case series N=173 |
Population: 15 complete tetraplegia, 28 incomplete tetraplegia, 35 complete paraplegia, 95 incomplete paraplegia; 31 patients with pulsed irrigation evacuation (PIE).
Treatment: Pulsed TAI:. intermittent, rapid pulses of warm water to break up stool impactions and stimulate peristalsis. Outcome Measures: Efficacy of technique (percentage success in removing stool), outpatient use |
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