(Healthcare Professionals) - Mythic Beasts - Control Panel

1 GuidelinesfortheuseofRectalIrrigation(He althcareProfessionals)CV 412N professional :Layout 1 03/03/2009 10:57 Page 1CV 412N professional :Layout 1 03/03/2009 10:57 Page 2 PrefaceDear ColleagueIt is always a little daunting introducing a new procedure into your clinicalpractice. There are always questions and some uncertainties. For thisreason the bowel continence team at St Mark's Hospital have decided toshare their guidelines on rectal irrigation with others. There is too muchre-inventing of wheels in today's health service. We are not claiming thatthis is the last word on irrigation: there is always room for flexibility andadaptation.

2 With experience, our practice may well change and developover years to come. But for now, this is our clinical practice, which we arehappy for you to use and adapt. Feedback or comments would be Professor of Gastrointestinal NursingSt Marks Hospital, LondonMarch 2009 StMark'sHospitalContinenceService2009 SUPPORTEDBYCV 412N professional :Layout 1 03/03/2009 10:57 Page 3 BackgroundFaecal incontinence is a common health problem, affecting over 1% ofcommunity-dwelling adults (1;2). Chronic constipation may affect 3-5% ofthe population depending on the definition used (3). Most patients willrespond to lifestyle modifications (such as dietary modifications),medication (constipating or laxatives as appropriate) and behaviouralmethods such as pelvic floor muscle training or biofeedback (3;4).

3 But forthe minority who do not respond, symptoms may impose severe ongoingrestrictions on quality of irrigation is a well-established technique for controlling stomaoutput. Trans-anal irrigation is reported to benefit some patients with faecalincontinence, rectocele and constipation (5;6). It is possibly more effectivein patients with passive soiling than those with urge incontinencesecondary to loose stool (7). It has been more widely reported in childrenwith spina bifida than in adults (8-10).Trans-anal irrigation has been found in a randomised controlled trial to beeffective for both constipation and faecal incontinence in people with spinalcord injury (11).

4 In scintigraphic studies anal irrigation has been found toempty stool as far up as the splenic flexure (12).Trans-anal irrigation is widely used in Europe but until recently seldom inthe United Kingdom (UK). More widespread implementation has beenlimited until recently because no purpose-designed equipment was easilyavailable in the UK, necessitating the use of often unsuitable colostomyirrigation equipment. The advent of the first purpose-designed and CEmarked rectal irrigation kit (Peristeen Anal Irrigation, Coloplast Limited) onprescription in the UK, means that this procedure can now beimplemented much more widely in clinical practice.

5 StMark'sHospitalContinenceService2009CV 412N professional :Layout 1 03/03/2009 10:57 Page 4 StMark'sHospitalContinenceService2009CV 412N professional :Layout 1 03/03/2009 10:57 Page 5 IntroductionRectal irrigation will usually only be tried if other less invasive methods ofbowel management have failed to adequately Control constipation and/orfaecal incontinence. Depending on each individual's assessed symptomsand need (13), this will often include dietary measures, adjusting fluidintake, bowel habit, ensuring toilet access, evacuation techniques,medication and pelvic floor muscle training (14)(15). There is a relativelysmall evidence base for this procedure at present (5;7.)

6 11), and so much ofthe advice given here is based on expert opinion and practical for use Neurogenic bowel spinal cord injury, spina bifida, multiple sclerosis Chronic constipation, including both evacuation difficulties and slowtransit constipation Chronic faecal incontinence StMark'sHospitalContinenceService2009CV 412N professional :Layout 1 03/03/2009 10:57 Page 6 Use with care and close monitoringSome types of patient may require additional supervision or monitoring, atleast until it is clear that irrigation is not producing any problems. This willdepend on the judgement of the assessing professional , but may include: Spinal cord injury at or above T6, monitor for autonomic dysreflexia,until it is clear that the technique is well tolerated and does not provokeautonomic dysreflexia Unstable metabolic conditions (frail, known renal disease or liverdisease.

7 May need to monitor electrolytes and possibly use salinerather than water for irrigation) Under 18 years old (consult paediatric consultant and use saline foryounger children) Inability to perform the procedure independently or comply with theprotocol in the absence of close involvement of carers ( due tophysical disability, cognitive impairment, major mental/emotionaldisorder). Experience to date with irrigation by a carer suggests that itis no more problematic than self irrigation for physically disabledindividuals Anorectal conditions that could cause pain or bleeding during theprocedure ( third degree haemorrhoids, anal fissure)Relative contra-indications (use only after careful discussionwith relevant medical practitioner) Pregnant or planning pregnancy (women) Active perianal sepsis Diarrhoea Anal fissure Large haemorrhoids that bleed easily Faecal impaction (clear, if possible before starting irrigation.

8 Digital rectalexamination if unsure) Past pelvic radiotherapy which has caused bowel symptoms Known severe diverticular disease Use of rectal medications for other diseases Congestive cardiac failure Anal surgery within the past 6 months Children under 3 years old StMark'sHospitalContinenceService2009CV 412N professional :Layout 1 03/03/2009 10:57 Page 7 Absolute contra-indications (irrigation should not be used) Acute active inflammatory bowel disease Known obstructing rectal or colonic mass Rectal or colonic surgical anastomosis within the last 6 months Severe cognitive impairment (unless carer available tosupervise/administer)AssessmentIt is essential to carry out a full individual assessment of patient suitabilityprior to commencing irrigation.

9 This will consider the aboveinclusion/exclusion criteria, assess patient motivation and acceptability ofthe procedure, and whether other possible alternatives have beenconsidered or tried. This assessment should be in the format approvedlocally for bowel care, for an example see (13). Digital rectal examinationshould be performed before the first irrigation and documented in all casesto check that there is no obstruction, that the anus is not stenosed andthat there are not any painful anorectal conditions (such as anal fissure).Informed consentIrrigation is an invasive procedure and as such informed consent must beobtained from the patient prior to commencing the procedure.

10 This shouldfollow local policy on whether this needs to be written or verbal way, the discussion should be documented and the patient'sconsent required Irrigation bag, Control unit and single-use rectal catheter (Peristeen AnalIrrigation, Coloplast Ltd: available on prescription and via CharterHealthcare 0800 132 787). Most patients irrigate every other day and they will need a new catheterfor each irrigation and a new water bag after every 15 irrigations(Accessory unit order number 29122, contains 15 catheters andreplacement water bag). The irrigation system lasts for 90 uses soneeds replacement every 6 months (order number 29121), if the patientirrigates every other day.