Transanal irrigation is medical procedure in which water is used to evacuate feces from the

rectum The rectum (: rectums or recta) is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. Before expulsion through the anus or cloaca, the rectum stores the feces temporarily. The adult ...

and

descending colon In the anatomy of humans and homologous primates, the descending colon is the part of the colon extending from the left colic flexure to the level of the iliac crest (whereupon it transitions into the sigmoid colon). The function of the descen ...

via the

anus In mammals, invertebrates and most fish, the anus (: anuses or ani; from Latin, 'ring' or 'circle') is the external body orifice at the ''exit'' end of the digestive tract (bowel), i.e. the opposite end from the mouth. Its function is to facil ...

. Transanal irrigation uses a large volume water

enema An enema, also known as a clyster, is the rectal administration of a fluid by injection into the Large intestine, lower bowel via the anus.Cullingworth, ''A Manual of Nursing, Medical and Surgical'':155 The word ''enema'' can also refer to the ...

system. 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 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 ...

and/or

constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The Human feces, stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the ...

(especially

obstructed defecation Obstructed defecation syndrome (abbreviated as ODS, with many synonymous terms) is a major cause of functional constipation (primary constipation), of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying ...

). Although the procedure and general goals may be similar, transanal irrigation is different from

colon cleansing 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 o ...

(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 A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. It is a destructive neurological and pathological state that causes major motor, sensory and autonomic dysfunctions. Symptoms of ...

multiple sclerosis Multiple sclerosis (MS) is an autoimmune disease resulting in damage to myelinthe insulating covers of nerve cellsin the brain and spinal cord. As a demyelinating disease, MS disrupts the nervous system's ability to Action potential, transmit ...

. 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. Evidence shows this treatment can be considered for children as well. When diet and medication has proven ineffective, transanal irrigation may be used.

Procedure

Transanal irrigation systems may use either a rectal balloon catheter or a cone-shaped colostomy tip. The catheter tip is inserted into the anal canal. Systems with balloon catheters require inflation of the balloon once the tip is in position. Cone shaped colostomy tip systems must be supported manually. Lukewarm tapwater (36-38°C) is used if it is drinkable. 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. The volume of water used is normally about 1000 ml. Some sources recommend repeat irrigation with a higher volume up to 2300 ml. Transanal irrigation may be performed every day or every other day in order to simulate a normal defecation routine. Ideally, irrigation is performed at the same hour each day. The optimal volume and frequency may be determined by trail and error for each individual patient during the first few months of treatment. The time required for the procedure is in the range of 30–120 min. Some individuals take oral constipating medications or oral laxative medications in addition to transanal irrigation. 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. Disadvantages of the treatment may include: * Social stigma causing problems with cohabitation, travel, and work/study or leisure activities. * Requires training by a healthcare professional so individual understands how to use the equipment * A degree of dexterity is required to perform transanal irrigation at home. If the individual cannot perform the irrigation themselves, a carer may be required * Periodic sterilization and replacement of the equipment is needed, or microbial

biofilm A biofilm is a Syntrophy, syntrophic Microbial consortium, community of microorganisms in which cell (biology), cells cell adhesion, stick to each other and often also to a surface. These adherent cells become embedded within a slimy ext ...

s may start grow inside the tubing, contaminating the irrigation fluid. Current TAI devices offer single-use rectal catheters or cones. * Requires a lot of time to administer and wait for full evacuation (30–120 min). This evacuation time may be increased in those with obstructed defecation. * Persistent leaking of residual irrigation fluid after the irrigation may occur and make this option unhelpful as liquids are more difficult to retain than solids in persons with fecal incontinence.

Indications

* Functional constipation * Obstructed defecation syndrome (functional evacuation disorders) * Unsuccessful treatment with biofeedback, medicines, surgery. Specific conditions for which transanal irrigation has been used include: *

Spina bifida Spina bifida (SB; ; Latin for 'split spine') is a birth defect in which there is incomplete closing of the vertebral column, spine and the meninges, membranes around the spinal cord during embryonic development, early development in pregnancy. T ...

. *

Anorectal malformations An imperforate anus or anorectal malformations (ARMs) are birth defects in which the rectum is malformed. ARMs are a spectrum of different congenital anomalies which vary from fairly minor lesions to complex anomalies. The cause of ARMs is unknow ...

. *

Multiple sclerosis Multiple sclerosis (MS) is an autoimmune disease resulting in damage to myelinthe insulating covers of nerve cellsin the brain and spinal cord. As a demyelinating disease, MS disrupts the nervous system's ability to Action potential, transmit ...

. * After surgery such as low anterior resection,

dynamic graciloplasty 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. * Restoration and impro ...

Contraindications

* TAI may be successfully used only if there is normal formation of solid feces in the colon. * Active

inflammatory bowel disease Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine, with Crohn's disease and ulcerative colitis (UC) being the principal types. Crohn's disease affects the small intestine and large intestine ...

. * Mass in rectum or colon causing

bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...

. *

Surgical anastomosis A surgical anastomosis is a surgical technique used to make a new connection between two body structures that carry fluid, such as blood vessels or bowel. For example, an Artery, arterial anastomosis is used in vascular bypass and a Colon (anatom ...

in the rectum or colon carried out with in the last 6 months.

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. * Avoids surgery, medications, or other procedures * By regularly emptying the bowel using transanal irrigation, controlled bowel function is often re-established to a high degree in patients with bowel dysfunction. This enables the users to develop a consistent bowel routine by choosing the time and place of evacuation. * In patients with constipation, regular evacuation of the lower part of colon and rectum can accelerate transit through the entire colon.Colonic emptying after transanal irrigation Bazzocchi G, Poletti E, Pillastrini There has, perhaps unsurprisingly, been a rapid uptake of transanal irrigation methods in highly symptomatic patient groups with anorectal symptoms. * In individuals with fecal incontinence, efficient emptying of the lower part of colon and rectum means that new feces may not reach the rectum for up to 2 days, which may prevent leakage between irrigations. * May decrease the incidence of urinary tract infections in patients with neurogenic bowel and bladder problems

Adverse effects

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

abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...

or rectal pain/discomfort, or

cramp A cramp is a sudden, involuntary, painful skeletal muscle contraction or overshortening associated with electrical activity. While generally temporary and non-damaging, they can cause significant pain and a paralysis-like immobility of the aff ...

s. *

Chills Chills is a feeling of coldness occurring during a high fever, but sometimes is also a common symptom which occurs alone in specific people. It occurs during fever due to the release of cytokines and prostaglandins as part of the inflammatory ...

. *

Nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...

. * Minor

rectal bleeding Rectal bleeding refers to bleeding in the rectum, thus a form of lower gastrointestinal bleeding. There are many causes of rectal hemorrhage, including inflamed hemorrhoids (which are dilated vessels in the perianal fat pads), rectal varices, pr ...

. *

Electrolyte imbalance Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function ...

(not demonstrated when using either tap water or saline solution). * Leakage of water around the catheter tip during procedure. * Anal stricture or

rectal stricture A rectal stricture (rectal stenosis) 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 th ...

/ fibrosis. One publication stated that "it is well known that the abuse of self- administered enemas may cause anorectal fibrosis and stricture, due to repeated microtrauma."

Bowel perforation

Bowel perforation Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastroi ...

is when the wall of the bowel ruptures. It is a potentially lethal complication which requires emergency surgery. 49 bowel perforations caused by transanal irrigation were reported between 2005 and 2013. This rate was used to calculate a risk of 2-6 perforations per 1 million procedures. 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). However, patients may need to conduct transanal irrigation daily or near-daily for many years, which increases their lifetime risk. Perforation is more likely in the first weeks after starting treatment. People who have had a surgical anastomosis (for example, after low anterior resection,

stapled transanal rectal resection Stapled trans-anal rectal resection (STARR) is a Minimally invasive procedure, minimally invasive surgical procedure for conditions such as obstructed defecation syndrome, internal rectal prolapse, and rectocele. Circular surgical staplers are use ...

ventral mesh rectopexy Ventral rectopexy is a surgical procedure for external rectal prolapse, internal rectal prolapse (rectal intussusception), and sometimes other conditions such as rectocele, obstructed defecation syndrome, or solitary rectal ulcer syndrome. The re ...

, or other types of surgery for

rectal prolapse A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depen ...

) are more at risk of bowel perforation during transanal irrigation.

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.

Notes

References

{{Reflist, 30em Gastroenterology Colorectal surgery