Clare Bohr, RSCN,is paediatric stoma nurse, Bristol Royal Hospital for Children, Bristol.
Bohr, C.(2009) Using rectal irrigation for faecal incontinence in children.Nursing Times;105: 7, 42-44
Claire Bohr describes how she introduced rectal irrigation as a treatment for children with faecal incontinence who had failed to respond to conservative treatment. She won a Nursing Times Award in the continence care category for this service in 2008.
Achieving continence is an important milestone in a child’s development. It helps them to socialise independently with their peers and enables them to participate in normal childhood activities. Failure to achieve continence beyond the toddler stage may restrict social and psychological development.
The Paris Consensus on childhood constipation Terminology group (PACCT), defines faecal incontinence as a ‘passage of stools in an inappropriate place’.
Treatment for constipation and faecal soiling may include dietary changes, an increase in fluid intake, oral and or rectal medication and behavioural training. Education of the child and parent or carer is an essential part of the treatment programme.
Using a single or combination of treatments at an early stage can prevent long-term psychological and physiological problems (Claydenand Wright, 2007).
A very small number of children will not respond to conservative treatment and, until recently, surgery, such as formation of a colostomy or antegrade continence enema, was often considered to be the only option.
Alternatives to surgery
Rectal irrigation is a method of alleviating faecal incontinence and constipation by emptying the rectum. Until recently, stoma irrigation equipment was often adapted for rectal irrigation with limited success. A purpose-made irrigation system (Peristeen) has recently been introduced in the UK for adult use (Box 1).
Box1. Peristeen rectal irrigation system
The Peristeen system consists of a rectal catheter that is passed into the rectum and is retained by a balloon that is inflated while the patient is sitting on the toilet. Warm irrigation fluid from a reservoir is slowly pumped in to the rectum using a hand-held pump. Once the fluid has been pumped in, the balloon is deflated and the rectum is emptied. The whole process can take up to 45 minutes but this is adjusted to suit the patient. It is recommended that the procedure is carried out every day for a few weeks then, depending on the result, the frequency can then be reduced to every other or every third day.
Indications for use:
Although there is evidence supporting its use in adults (Coggrave, 2007), no research has been conducted with children.
Using rectal irrigation systems with children
In my clinical practice, I observed that children who had long-standing faecal incontinence were willing to undergo surgery to relieve their symptoms.
I was aware that a new purpose-made rectal irrigation system (Peristeen) was available for adults and I explored the possibility of using it with children.
Lack of evidence for new products is often a problem in paediatric nursing but I felt that using a purpose-made system rather than adapting equipment could benefit the children in my care.
When a new procedure is used in clinical practice it is important that the nurse follows the NMC (2008) code of conduct. It states that the ‘professional is personally accountable for actions and omissions in your practice and must always be able to justify your decisions’. I was confident that I had enhanced my knowledge to practise in a safe and competent manner when I began to use the system with children.
I discussed using the rectal irrigation system with paediatric surgeons and a representative from the manufacturers (Coloplast). The system had one size of rectal catheter but the medical team felt that it was suitable for children to use. The volume of fluid used to irrigate the bowel also needed to be considered and, after discussion with medical colleagues, a volume of 20ml/kg was calculated to be a sufficient and safe quantity of fluid to establish effective irrigation.
I assess children with the consultant paediatric surgeon for suitability to undertake irrigation. They require manual dexterity, must be able to sit on the toilet and understand the time and commitment required for the procedure.
A DVD had been made for adult users and this was the only visual information available at that time, so it was shown to the parents first then the child. I provided additional information.
The child was taught the procedure so they are in control of treatment. They should be able to handle the irrigation system before they try to use it and their competence has to be carefully assessed.
Results of using the system
The author has 12 patients enrolled on the bowel management programme. Eight have anal-rectal malformations, one has spina bifida, one has Hirschsprung’s disease and two, both of whom have learning difficulties, have chronic constipation. They are aged 5–16.
All the children have administered the irrigation themselves (the five-year-old needed assistance to fill the system as he was not able to reach the tap) and two children needed assistance to find the anal opening. All the children were happy to learn how to use the irrigation system.
All the children using the irrigation system have seen a dramatic improvement in the management of their faecal incontinence. Verbal feedback from both patients and parents is that the system has proved to be successful.
A purpose-designed rectal irrigation system has the potential to improve the quality of children’s lives. The problem is the lack of evidence for its use with children.
Paediatric nurses regularly have to use expert opinion and practical experience because of a lack of evidence. However, this should not prevent nurses considering new procedures. It is important to seek expert opinion and always act in the best interest of the child. The NMC’s code of conduct provides a framework for specialist nurses to consider when they are reviewing the use of new procedures or equipment in clinical practice.
Case study: using the irrigation system
Sarah was born with an anal-rectal malformation; she had a formation of a temporary colostomy as a baby. The colostomy was successfully reversed at the age of eight months but she remains incontinent of faeces.
She has been seen regularly by the consultant paediatric surgeon, her diet was assessed and she tried a strict toileting regimen. Oral and rectal medications were prescribed at varying times over the following four years to control the continence problem.
At the age of seven, Sarah and her family were seen by the consultant surgeon for a surgical opinion. Sarah was wearing pull-up nappies. She was continent of urine but had no sensation or warning when she passed
Sarah and her family were given a DVD about rectal irrigation and I saw them on several occasions before she was taught how to use the irrigation system.
Sarah was able to use the irrigation system by herself at the first teaching session. She wore
Sarah used the irrigation system every day and she was wearing pants by the end of the first week, with no soiling.
Her parents thought that Sarah was an outgoing child before she started irrigation but they now realise that she was being held back socially by faecal soiling.
Coggrave, M. (2007) Transanal irrigation after spinal cord injury. Nursing Times; 103: 47, 44–46 .
Clayden, G., Wright, A. (2007) Constipation and incontinence in childhood: two sides of the same coin? Archives of Disease in Childhood; 92: 6, 472–474.
NMC (2008) TheCode: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London : NMC.