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Transanal irrigation after spinal cord injury

author Maureen Coggrave, PhD, MSc, RGN, is research fellow, the National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury and senior lecturer, Burdett Institute of Gastrointestinal Nursing, King’s College, London.

ABSTRACT Coggrave, M. (2007) Transanal irrigation after spinal cord injury. Nursing Times; 103: 47, 44–46.

Maureen Coggrave explains why and how transanal irrigation is used for bowel management following spinal cord injury.

author Maureen Coggrave, PhD, MSc, RGN, is research fellow, the National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury and senior lecturer, Burdett Institute of Gastrointestinal Nursing, King’s College, London.

ABSTRACT Coggrave, M. (2007) Transanal irrigation after spinal cord injury. Nursing Times; 103: 47, 44–46.

Maureen Coggrave explains why and how transanal irrigation is used for bowel management following spinal cord injury.


Spinal cord injury (SCI) has a significant impact on bowel function (Krogh et al, 1997; Stiens et al, 1997; Camilleri and Bharucha, 1996; Banwell et al, 1993). Awareness of the need for a bowel movement and voluntary motor control over bowel function are lost or reduced (Stiens et al, 1997) and autonomic input to the colon and rectum is altered, producing prolonged transit times (Leduc et al, 1997). These changes result in a high risk of faecal incontinence and constipation.

Bowel function must be managed regularly and pre-emptively to achieve continence and to avoid constipation and impaction of faeces.

Bowel problems are the second most common trigger for autonomic dysreflexia (Colachis, 1992), a dangerous condition associated with injuries at or above the sixth thoracic vertebra (Kavchak-Keyes, 2000). Noxious stimulation of the sympathetic nervous system – due most commonly to distension of abdominal organs such as the bladder or bowel – can result in sweating, chills, bradycardia and rapidly rising blood pressure, which can result in stroke or death.

Other problems associated with bowel dysfunction include abdominal and rectal pain, abdominal bloating and discomfort, haemorrhoids, anal fissures and rectal bleeding (Ng et al, 2005;

De Looze et al, 1998; Kirk et al, 1997; Glickman and Kamm, 1996). Faecal incontinence or the fear of incontinence are experienced by many patients with a SCI and are socially limiting.

Bowel management can be very time consuming and may interfere with an individual’s ability to work or socially integrate outside the home.

The interventions used for conservative bowel management include:
- Stimulation of the gastrocolic reflex;
- Abdominal massage;
- Digital rectal stimulation;
- Digital evacuation of stool;
- Oral and rectal laxatives;
- Dietary manipulation (Haas et al, 2005; Lynch et al, 2000; Han et al, 1998; Kirshblum et al, 1998; Kirk et al, 1997; Glickman and Kamm, 1996).

These conservative methods are successful in avoiding faecal incontinence and constipation for most individuals with a SCI; when they are not successful the alternatives include surgery, for example formation of colostomy.

There has been a need for an effective intervention which lies between the conservative approach and surgical interventions. Transanal bowel irrigation appears to meet this need (Christensen et al, 2006a).


Bowel irrigation
Bowel irrigation is defined as a process of facilitating evacuation of stool by passing water (or other liquids) into the bowel via the anus in a quantity sufficient to reach beyond the rectum.

Transanal irrigation has been evaluated using scintigraphy (Christensen et al, 2002), which demonstrated that irrigation can empty the bowel beyond the splenic flexure of the colon. Because the descending colon is effectively emptied, an individual using irrigation is less likely to experience faecal incontinence and the period between planned evacuations can sometimes be extended. This provides greater choice and control over the timing of bowel management. With regular emptying, the occurrence of constipation is also reduced.

Irrigation reduces the need for digital interventions such as anorectal stimulation and digital evacuation of stool. Suppositories are not required and the need for oral laxatives may be reduced.

A recent study (Christensen et al, 2006a) of people with SCI who experienced problems with bowel care found that irrigation significantly improved faecal incontinence, constipation and quality of life, reduced time spent on bowel management and tended to improve symptoms such as abdominal pain. The irrigation group in the study also reported fewer urinary tract infections compared with the conservative care group.


Precautions and contraindications
It is important to carry out a digital rectal examination to exclude anal stenosis or obstruction or the presence of any painful anorectal conditions (Norton, 2007a) before anal irrigation.

Relative contraindications include anal fissure and faecal impaction, which should be treated prior to instigating irrigation, and large haemorrhoids that bleed easily (Norton, 2007a).

Absolute contraindications include:
- Acute active inflammatory bowel disease;
- An obstructing rectal or colonic mass;
- Rectal or colonic surgical anastomosis within the past six months (Norton, 2007a).

The only major risk associated with irrigation is perforation of the bowel, although this is very rare (Christensen et al, 2006a). Faecal incontinence may worsen in the short term, and abdominal cramps and minor rectal or anal bleeding may occur.


Starting anal irrigation
Guidelines for the use of irrigation have recently been published (Norton, 2007a). Nurses should read these and manufacturers’ instructions before using the system.

It is essential that the patient understands what irrigation is and the risks involved, so that informed consent can be given. Carers who are willing to undertake the procedure need to be involved in the learning process. Irrigation guidelines for patients are available (Norton, 2007b). Most individuals with reflex bowel function will aim to irrigate every other day, while those with cauda equina injuries resulting in flaccid bowel function may opt for daily irrigation. In all cases, individual assessment is essential.

The Peristeen kit (Box 1 and Fig 1), an anal irrigation system, provides a reusable water reservoir, hand pump unit and connecting tubing, and single-use catheters.

The catheters have a balloon similar to those found on urinary catheters and this enables the catheter to be retained in the rectum without the need to hold it in place. The balloon also provides a seal inside the rectum to help to retain the water as it is pumped into the bowel. The kit is available on prescription. Irrigation is conducted in the upright position over a toilet or commode.

The amount of water needed to enable an individual to evacuate successfully can vary considerably. The average amount is 750–800ml, although the volume can vary from 250–1,500ml (Christensen et al, 2006a). It is advisable to start with around 500ml for women and 700ml for men, using trial and error to determine the most effective volume for each individual. The fluid can be inserted in two separate episodes if required.


Catheter insertion
The catheter is inserted into the rectum as far as the finger grip on the irrigation system. This ensures that the balloon is situated in the rectum prior to inflation. If resistance to the catheter is felt, it must be removed immediately. A digital rectal examination should be conducted and any stool obstructing the insertion of the catheter removed. If this is not the cause of the resistance, a medical opinion should be sought before a further attempt at irrigation.

Elasticated leg straps are provided in the Peristeen kit. These can be used to hold the pump unit on the individual’s thigh to facilitate independent use of the kit, and are particularly useful for those with limited hand function. The steps involved in irrigation are shown in Box 1.


Common problems in establishing irrigation

- Expulsion of the balloon and leakage around the balloon while inserting the water. If leakage occurs when pumping water into the bowel, stop the procedure and wait a few moments before resuming. If the leaking continues, more air can be pumped into the catheter balloon up to a total maximum of five pumps. In individuals with reflex bowel function, reflex activity may be strong enough to push the inflated balloon out. If this happens as soon as the balloon is inflated, try inflating the balloon more slowly, or try reducing the amount of air inserted. If it occurs during the pumping of water, make sure the water temperature is hand hot and try pumping more slowly.

- No fluid is expelled after removal of the catheter. This may be due to dehydration or constipation. Encourage the patient to take adequate fluids. Constipation should be treated before starting transanal irrigation.

- Fluid but no stool is passed. This may again be due to constipation. If this happens frequently, it may indicate that the frequency of irrigation can be reduced.

- Abdominal pain or cramping during the irrigation. If this happens, stop the irrigation and wait until the pain resolves and then continue, pumping more slowly. If the pain is severe or does not settle, stop the irrigation and seek advice.

- Fluid leaks some time after irrigation. The individual may need to spend longer on the toilet to ensure that their bowel is empty, or they may need to use more or less fluid to irrigate.

- Patient needs to evacuate their bowel between irrigations. The patient may need to irrigate more often. They may wish to wear a pad until they feel confident with the irrigation method.


The support of an experienced nurse in learning to use irrigation is essential (Christensen et al, 2006a). This is important for individuals with a SCI due to their other disabilities, lack of anorectal sensation and the risk of autonomic dysreflexia.

Both nurse and patient must be committed to the use of irrigation and willing to work at establishing the technique, as it may take some weeks before a routine is established. It is best to continue with any oral laxatives that the patient is already using, and to tail these off gradually if possible, once a routine has been achieved.


Costs of treatment
There are financial implications as the catheters are single use, the fluid reservoir is replaced monthly and the pump unit six-monthly. However, a recent health economic evaluation of irrigation using Peristeen found that it was slightly less expensive than conservative bowel care (Christensen et al, 2007). When aspects such as labour costs associated with direct care, loss of patient productivity due to time spent on bowel care, product costs and the reduction in urinary tract infections were taken into account, the annual cost for Peristeen was estimated at €38 (£26.50), compared with €40 (£28) for conservative care.


Conclusion
There is good evidence for the use of transanal irrigation in individuals with SCI who experience difficulties with their bowel management (Christensen et al, 2006a). Irrigation does not suit all individuals and as yet we cannot predict who will benefit (Christensen et al, 2006b).

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Box 1. transanal irrigation using Peristeen kit – key points

The procedure should only be carried out by a competent practitioner

- Obtain informed consent.

- Talk about the equipment with the patient. Encourage them to familiarise themselves with it. Supervise while they put the kit together.

- Fill the water bag with lukewarm (hand-hot) tap water to the 1L mark.

- Connect the equipment together according to the manufacturer’s instructions and leave the catheter in its protective sleeve.

- Turn the dial on the handset to the water droplet symbol and pump to prime the
system with water and to wet the self-lubricating catheter.

- Leave the catheter immersed in water for at least 30 seconds and remove from packaging. If leg straps are to be used, apply now.

- On the toilet, the patient or carer inserts the catheter through the anus into the rectum up to the hand grip.

- If resistance is felt while inserting the catheter, stop immediately and remove the catheter. If competent to do so, carry out a digital rectal examination to identify if the stool is obstructing the catheter and treat according to the patient’s plan of care.

- With the dial turned to the balloon inflation symbol, an average of three pumps of air can be put into the balloon slowly. This can range from two to five depending on the individual.

- With the dial on the water symbol, slowly pump in a previously determined volume
of fluid.

- When the fluid is instilled, deflate the balloon by turning the dial to the green symbol and remove the catheter.

- Fluid and stool evacuation may commence immediately or after 10–15 minutes. The patient can massage their abdomen or lean forward to assist with emptying. Complete emptying may take a further 10–15 minutes, although this varies for each individual.

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REFERENCES

Banwell, J. et al (1993) Management for the neurogenic bowel in patients with spinal cord injury. Urology Clinics of North America; 20: 3, 517–526.
Camilleri, M., Bharucha, A.E. (1996) Gastrointestinal dysfunction in neurologic disease. Seminars in Neurology; 16: 3, 203–216.
Christensen, P. et al (2006a)
A randomised controlled trial of transanal irrigation versus conservative bowel management in spinal cord injured patients. Gastroenterology; 131: 3, 738–747.
Christensen, P. et al (2006b) Predicting Successful Outcome of Transanal Irrigation for Treatment of Bowel Dysfunction in Spinal Cord Injury Patients. www.icsoffice.org/publications/2006/pdf/0207.pdf
Christensen P. et al (2007) Cost Effectiveness of Transanal Irrigation Versus Conservative Bowel Management for Spinal Cord Injury Patients. www.icsoffice.org/publications/2007/pdf/0033.pdf
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Norton, C. (2007a) Guidelines for the Use of Rectal Irrigation (Healthcare Professionals). St Mark’s Hospital Continence Service.
www.burdettinstitute.org.uk/Files/Documents/d3ae914acf604324a3b4b19b48859030.pdf
Norton, C. (2007b) Guidelines for the Use of Rectal Irrigation. Patient Information Leaflet. St Mark’s Hospital Continence Service.
ww.burdettinstitute.org.uk/Files/Documents/d3ae914acf604324a3b4b19b48859030.pdf
Stiens, S. et al (1997) Neurogenic bowel dysfunction after spinal cord injury: clinical evaluation and rehabilitative management. Archives of Physical Medicine and Rehabilitation; 78: Suppl 3, S86–S102.

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