Transanal irrigation (TAI) is an invasive procedure that involves instilling tepid water into the rectum via the anus, in varying agreed quantities, using either a rectal catheter or cone device. It is usually used to treat bowel dysfunction. Once the water is instilled, the catheter/cone is removed and the water is expelled, along with the contents of the rectum and/or sigmoid colon.
TAI may be a relatively new intervention for the treatment of bowel dysfunction, but anal irrigation itself is an old concept recognised by the Roman writer Pliny the Elder (AD 23-79). He wrote that the ancient Egyptians are said to have watched and learnt from the sacred ibis who used its long beak to insert water into its anus to wash out decaying material (Doyle, 2005). The sacred ibis was associated with their god of wisdom, Thoth, who was said to have devised the use of enemas to relieve bowel problems.
Over the centuries, TAI has been used to treat a long list of symptoms, including nausea, fatigue, depression, headache, anxiety, rheumatism and constipation and has been used as a ritual and part of the modern social phenomenon of colonic irrigation.
More recent descriptions of TAI by Henderson et al (2018) identify it as a treatment for bowel dysfunction which has been approved by the National Institute for Health and Care Excellence (NICE) (2018).
Chronic constipation is a prevalent condition and is defined as ‘passing infrequent stools or difficult stool passage or both for at least 3 months’ (Emmett et al, 2015). Faecal incontinence is ‘the recurrent uncontrolled passage of solid or liquid faecal material’ (Duelund–Jakobsen et al, 2016) and, although not as common as constipation, its prevalence increases with age.
Both these conditions can have a profound effect on the individual's quality of life, and can affect them physically, psychologically and socially. Many present to health professionals expressing feelings of isolation, embarrassment and loss of self esteem. They can also lead to restrictions in social activities, employment and relationships with partners, family and friends.
First-line treatments
First-line treatments for bowel problems should be conservative and usually include dietary adjustments, fibre supplements, lifestyle changes, laxatives (including specialist initiated medication such as prucalopride, lubiprostone, linaclotide or naloxegol), constipating agents, pelvic floor rehabilitation, digital stimulation and/or evacuation, suppositories, or mini enemas (Emmanuel et al, 2013). However, studies indicate that more than 50% of these individuals will have exhausted these treatments with little or no improvement (Christensen 2006; Kim et al 2013).
Transanal irrigation
The next stage of intervention would be TAI, which has, in the last decade, been widely used by professionals and has begun to find its place in the hierarchy of treatments. This is especially true for patients with neurogenic bowel dysfunction, such as those with spinal cord injury, spina bifida, and multiple sclerosis, as well as chronic constipation, including both evacuation difficulties and slow transit constipation and chronic faecal incontinence. NICE has reviewed several studies of TAI (NICE, 2018).
TAI can be self-administered or administered by a carer or health professional.
Contraindications
The following contraindications to TAI have been identified. These include:
There are also conditions when it should be used with caution, eg, faecal impaction, congestive cardiac failure, low blood sodium, previous anal, colorectal or pelvic surgery, and severe autonomic dysreflexia (Emmanuel et al, 2013).
Although TAI is a simple, reversible and minimally invasive intervention, it is not without complications. It can worsen faecal incontinence in some individuals, and leakage of irrigation fluid, minor discomfort, abdominal cramps, expulsion of rectal catheter (when used) and minor rectal or anal bleeding can occur. Perforation of the bowel is also a possible complication, although it is rare.
To initiate TAI an individual needs to have a bowel assessment by a competent professional who is trained in anal irrigation. Henderson et al (2018) recommended that all red flags, such as blood in faeces, weight loss, abdominal pain and changes in bowel habit should be excluded before commencing treatment, and all individuals should have a rectal examination to rule out loaded rectum, anal fissures or anal stenosis.
Devices available
Different devices are available for TAI but most of the published evidence relates to the Coloplast Peristeen device. It is the health professional's responsibility to be aware of all devices and discuss with the individual which would be most beneficial for that person. Devices are usually for personal use at home but instruction for use should be undertaken by health professional.
The increasing number of TAI devices available may cause confusion, but they can be divided into low- (<250 ml) or high- (>250 ml) volume devices, using cone or balloon inflating devices and pump and gravity-fed systems (Henderson et al, 2018). Low-volume cone devices include the Quofora IrriSedo Mini and Aquaflush Compact systems, which usually clean out the rectum only, and are used for individuals with passive soiling or post-defaecation soiling or rectoceles/posterior prolapse.
High-volume devices include the Quofora IrriSedo Cone system, Aquaflush Quick cone system and the B. Braun IryPump system, using either a cone or electric pump. Balloon high-volume devices include the Peristeen system, the Quofora IrriSedo Balloon system, and Wellspect HealthCare's Navina Classic and Navina Smart (electric pump). These clean out the rectum, descending colon and part of the transverse colon.
There is some controversy over the composition of irrigating fluid used, with most using tepid water and different volumes of irrigating fluid, varying between 250 ml and 4000 ml.
The decision on which device to use will be based on the individual's bowel problem and preferences, but mobility and whether the person has enough dexterity to be able to hold the cone device in place should also be taken into account.
Research findings
NICE (2018) stated that if patients are instructed correctly there is a multitude of benefits that individuals undertaking TAI can achieve. These include that TAI:
Studies, such as Christensen et al's (2009), have shown that, when TAI is first instigated, statistical efficacy is apparent in certain population groups. For example, there is higher success rates in spinal injury patients, neurogenic bowel patients, some success in faecal incontinence and leakage, but not so much in faecal soiling.
This effect, however, was not replicated in one long-term study, with more than half the study population discontinuing TAI (Kim et al, 2013). The main reasons included unsatisfactory effect, personal reasons, withdrew consent/lost to follow up, expulsion of rectal catheter, rectal balloon bursting, water leakage, disliked treatment, bowel perforation, abdominal pain, minor rectal bleeding, fatigue, peri-anal discomfort, nausea, shivers, and headaches.
Conclusion
Research findings show that TAI is not suitable for every patient with bowel dysfunction. There should always be a trial of conservative therapies before considering TAI, and only when they have been exhausted should TAI be contemplated. Assessment should exclude any conditions that would contraindicate treatment and identify the most suitable device for the individual's needs and abilities. Instruction and follow-up should be via a competent professional trained in TAI.
If these issues are not taken into account there will be a high probability of discontinuation but, if implemented correctly, TAI can improve quality of life substantially for individuals with bowel dysfunction.