Approximately 6.5 million adults in the UK suffer from a bowel problem and over half a million adults suffer from faecal incontinence (NHS England, 2018). Transanal irrigation (TAI) is widely used to manage neurogenic bowel dysfunction (NBD) and has been approved by the National Institute for Health and Care Excellence (NICE) (2018) as a treatment for constipation and faecal incontinence. It is a maintenance therapy, rather than a cure (Emmett et al, 2017).
TAI involves instilling water into the lower bowel via the anus using either a rectal catheter or a cone, and is usually performed over a toilet. When the catheter or cone is removed, the water is expelled along with the contents of the rectum, sigmoid colon and possibly the descending colon (Nursing Times, 2007). Following sufficient training, TAI can be performed by the patient, a carer or a health professional (Yates, 2020).
Henderson et al (2018) previously noted that warm tap water (36–38°C) is typically used; however, the frequency of TAI and the volume of water used can vary depending on the patient's tolerance, response and requirements. Where drinkable tap water is unavailable, bottled water should be used (Emmanuel et al, 2013). Individuals are advised to irrigate daily initially for the first 2–3 months (Emmanuel et al, 2019a), and then alternate days thereafter (Yates, 2020). Patients should set realistic expectations when beginning TAI, as it can take up to 12 weeks to establish an effective and suitable routine (Wilson, 2017).
Efficacy, safety and patient benefits
Before considering TAI, less invasive advice and treatment options must be explored. Only then and once these have proven inadequate should TAI be used (Wilson, 2017). However, Woodward (2017) suggests that there are some people for whom more conservative measures will not work and, in these instances, TAI should be introduced sooner.
TAI is generally regarded as a safe treatment, but there are risks involved. Perforation of the bowel can occur, but it is very rare (Sheffield Teaching Hospitals, 2020). Latest data report the risk of bowel perforation due to TAI is two per one million irrigations (Christensen et al, 2016). It is advised that patients weigh up the risks against the potential benefits (Sheffield Teaching Hospitals, 2020). Further, forewarning patients about potential common side effects of TAI, including abdominal cramping, dizziness, nausea and minor rectal or anal bleeding (University Hospitals Birmingham, 2017), is vital to prevent them from stopping TAI prematurely.
Despite this, if patients are instructed correctly, TAI can provide myriad benefits for both patients and health professionals. These include (Emmanuel et al, 2013; NICE, 2018):
- Consistent bowel routine, with regular bowel movements
- Individuals can select time/place of evacuation
- Reduction in time to achieve bowel care
- Improvement of symptoms and reduction in the severity of chronic constipation
- Potential prevention and reduction of frequency of faecal incontinence
- Psychological improvement and enhanced quality of life for patients
- Reduction in stoma surgery rates
- Reduction in incidence, frequency and cost of urinary tract infections
- Reduction in hospital admissions in people with NBD and associated treatment costs.
The nursing role
Nurses should undertake a full assessment before beginning TAI, to determine patient suitability (Shaw, 2018). Points for consideration during the assessment include (Emmanuel et al, 2020):
- Toilet position/evacuation technique
- Stability/balance on toilet
- Manual function/dexterity/strength/wrist flexibility
- Body habitus/buttock contour/size
- Skin integrity
- Psychological condition (eg cognitive and visual function, language/speech)
- Examination features/perianal sensation/anal tone
- Medical/surgical history
- Home environment
- Availability of care provision (if carers are required to assist).
The assessment should also include a digital rectal examination prior to initiating TAI, preferably within 48 hours of the first irrigation in order for safe performance of the procedure (Emmanuel et al, 2020). If there is any doubt regarding suitability, nurses should seek further medical advice before commencing treatment (Shaw, 2018).
There are numerous TAI devices available, which may cause confusion. It is the nurse's responsibility to be aware of all devices and discuss which would be most beneficial for the patient (Yates, 2019). As devices are typically used by the individual at home, following individual manufacturers' instructions and providing adequate training to the patient is crucial for safe and efficient long-term use (Emmanuel et al, 2013). There is evidence that TAI has a high discontinuation rate: between 19–57% after 1 year (Mekhael et al, 2021). Therefore, just as communicating potential side effects to and training patients is vital in encouraging continuation of TAI, a nurse's ability to effectively communicate the proven improvement in quality-adjusted life years (Emmanuel et al, 2016) and encourage adherence during follow-up is also critical.
Selecting the most appropriate device
Patients' capabilities and patient/carer preferences should remain at the forefront when selecting the most suitable TAI equipment (Shaw, 2018) (Figure 1), but there are additional, important factors to consider. A good starting point would be to determine whether a low or high volume of water is required (Henderson et al, 2018). Collins and Norton (2013) note that low-volume irrigation is typically used successfully in patients with passive faecal incontinence or post-defaecation soiling. Meanwhile, high-volume irrigation may be more appropriate for patients with neurogenic dysfunction, constipation-predominant irritable bowel syndrome, idiopathic constipation, obstructive defaecation syndrome or faecal incontinence. Portability and cost of the device are also important factors to consider (Bardsley, 2020).
A patient should also choose whether they would prefer to use a rectal catheter or cone. While most patients can use any system, a person with reduced mobility may be more suited to a rectal catheter, and patients with anal pain may also find these more comfortable. A catheter-based system may be more convenient for those who have TAI delivered via carers (Henderson et al, 2018). Sometimes, the use of more than one system may be appropriate (Bardsley, 2020). In addition, health professionals should consider whether a patient has a latex allergy and avoid prescribing equipment that could trigger this (Emmanuel et al, 2013).
Types of systems
Despite the wide choice, TAI devices can be categorised into low (less than 250 ml) or high (more than 250 ml) volume; cones, catheters or balloon inflating devices; manual, electric pump or gravity-fed systems (Bardsley, 2020); and bed systems (Shaw, 2018).
Low- and high-volume systems
The maximum volume of fluid that a TAI system can deliver varies, depending on the system. For instance, low-volume systems can typically deliver up to 250 ml of fluid per irrigation (Shaw, 2018). Meanwhile, high-volume systems can deliver between 250 ml and 4000 ml (Yates, 2019). Shaw (2018) recommends a starting volume of 500 ml, gradually increasing by 100 ml until successful evacuation is achieved without leakage between irrigations.
Low-volume systems (Figure 2), which usually clean out the rectum only, consist of a small reservoir attached to a cone. Therefore, they are a compact system that can be easier to transport (Wilson, 2017), making these a more convenient option than a high-volume system should they provide sufficient symptom relief. Henderson et al (2018) stated that low-volume systems can be a good introduction for patients who are nervous about TAI.
High-volume devices empty the rectum, descending colon and part of the transverse colon (Yates, 2020), and consist of a larger irrigation bag connected to a tube (Emmett et al, 2017) (Figure 3). It is worth noting that high-volume systems can also be used for low-volume irrigation (Yates, 2020). In a systematic review of TAI as a treatment for chronic functional constipation, Emmett et al (2015) identified seven small studies using high-volume irrigation, with patient-reported satisfaction (subjective or visual-analogue scale) being the most reported outcome. Meanwhile, an audit of 15 patients who were using TAI to manage symptoms of low anterior resection syndrome (LARS), found that the use of higher volumes of water seemed to be more beneficial for patients than the use of lower volumes. Although, research into the optimum level of water is lacking (Embleton and Henderson, 2021).
While it appears that high-volume devices are more effective in managing/providing symptom relief in patients with certain conditions, it remains unclear whether high-or low-volume devices are generally better. As was the case in 2020 (Bardsley, 2020), the results from the only randomised controlled trial protocol to directly compare low- and high-volume systems used by adults with chronic constipation had not been published (Emmett et al, 2017).
Cones, catheters and balloons
TAI using a cone (Figure 2) involves the user holding the cone manually in place. The flexibility and dexterity of the patient should be assessed to determine their capability. The requirement of the patient to possess adequate core strength to help them balance sufficiently while completing the installation process and maintaining the position of the cone (Holroyd, 2017) should be considered. Some low-volume cone systems can be used with an extension tube to make the installation process easier (Bardsley, 2020). Catheter systems usually include a balloon that creates a seal and helps retain irrigation fluid by inflating inside the rectum. Therefore, patients are not required to hold the catheter in place (Holroyd, 2017).
While this can make catheters a more convenient option, the inflation process can cause reflex rectal contractions that expel the catheter (Yates, 2020). The balloon can be filled with either air or water, but Henderson et al (2018) have previously suggested that water may be more suitable for patients who experience either leakage during instillation or expulsion of the catheter after the balloon has been inflated. On the other hand, cones may have an advantage over catheters in terms of ease of setting up, procedure time and low risk of complications (Emmanuel et al, 2019b). Cone systems also have a conical tip, which can be less invasive than a catheter (Bardsley, 2020). Further, an audit of 48 female and two male patients with evacuation difficulties and/or passive faecal incontinence, who used the Qufora Mini Irrigation System (now known as Qufora IrriSedo Mini system), demonstrated that 70% of participants found the cone comfortable, while 74% rated its performance as ‘good’ or ‘acceptable’. Two-thirds of participants experienced improved symptoms and wanted to continue using it (Collins and Norton, 2013). The latest products within this range are the QuforaIrriSedo MiniGo and QuforaIrriSedo MiniGo Flex (Figure 2). However, as they are fairly new, wide research surrounding the efficacy and performance of these products remains to be seen. Despite this, there is insufficient evidence to suggest whether one system outperforms another.
Manual, electric and gravity-fed
During TAI, the water is propelled by an electric or manual pump or a gravity-fed system. To determine which is best suited to a patient, it is important to consider whether they have sufficient hand strength to pump up the device (Yates, 2020).
In manual pumps, water instillation is delivered by manual squeezing. Low-volume systems use manual pumps that double up as the reservoir. Many high-volume systems also feature manual pumps, but these are usually connected to a separate reservoir bag (Bardsley, 2020). Peristeen (Figure 3) is an example of this: it uses a constant-flow pump that does not rely on gravity to maintain regular pressure during instillation. Much of the published evidence on TAI focuses on this device and indicates that it improves bowel-related outcomes (NICE, 2018). Some high-volume systems are designed to be suspended above the user at a distance sufficient to exert enough gravitational force to propel the water into the colon without the use of a pump. Alternatively, some high-volume systems use an electric pump to propel the water. These systems usually have either an integrated reservoir or are connected to a floor bag; they can be placed on the ground and require minimal manual effort from the user (Bardsley, 2020).
One of the latest TAI systems on the market is the Navina Smart (Figure 4), which consists of a catheter with an in/deflatable balloon, a water container and an electric pump, and is designed to be used with an app that can be downloaded onto a smartphone to track progress. Emmanuel et al (2021) recently investigated the short-term efficacy of the electronic system in patients with NBD; the first-ever study of its kind identified the Navina Smart as an effective treatment option for individuals with NBD, including those with severe symptoms, during the initial three months. Further, after using it for this time period, the device significantly reduced the time participants spent on their daily bowel management from mean 73.5 minutes to 46.4 minutes. More long-term studies of the Navina Smart would be beneficial.
Anecdotal evidence shows that electric pumps can be more cumbersome, but easier to use (Yates, 2021). Currently, there is no evidence to suggest whether manual, electric or gravity-fed systems are more effective, so patient assessment and preference, along with specialist nurse advice, availability of funding and local formularies, are most likely to influence device selection (Woodward, 2017).
Bed system
The only bed system – the Qufora IrriSedo Bed System – enables bed-bound patients to receive irrigation. It is recommended for those receiving terminal care or who are bedbound for other reasons (MacGregor Healthcare Ltd, 2016 in Wilson, 2017). This is a closed system, where water is pumped from a suspended water bag into the rectum through a non-ballooned rectal catheter, and waste is collected in a drainage bag (Wilson, 2017).
Conclusion
TAI is considered a safe and effective treatment, but should only be carried out after less invasive treatment options have been explored. Nurses should be aware of the range of available devices and consult the Bladder, Bowel and Stoma Handbook (MA Healthcare, 2021), an annually updated product selection guide, alongside NICE (2018) guidance, to stay up to date with the latest developments. Longer-term and larger studies into newer devices on the market are necessary to provide evidence-based efficacy for nurses to draw upon during decision-making. A thorough assessment of the patient and consideration of their preferences and tolerance should primarily influence system choice.
Nurses not only need to help patients select a suitable device, but also adequately train them in its usage and provide ongoing follow-up support, so patients can successfully implement and continue with TAI. Emmanuel et al's (2020) Decision Guide is also a useful tool to consult throughout the TAI process.
KEY POINTS
- Transanal irrigation (TAI) is a safe and effective treatment for constipation and faecal incontinence
- TAI should only be carried out after less invasive treatment options have been explored
- Nurses should help patients select a suitable device, as well as train them in its usage and provide ongoing follow-up support, so patients can successfully implement and continue with TAI
CPD reflective questions
- If performed correctly, what benefits can patients and health professionals expect from transanal irrigation (TAI)?
- What is the maximum volume of water low- and high-volume TAI devices can deliver?
- Consider which type of device might be most suitable for a patient with reduced flexibility and dexterity
- Reflect on the advantages and disadvantages of catheters compared with cones