Aims of the session

• Types of patients • Assessment • Bowel management • Types of anal irrigation • Case studies • Outcomes and issues

Bowel problems

• Slow transit • Chronic constipation • Obstructed defaecation • Faecal incontinence • Spinal problems • Head injury • Multiple Sclerosis

MS

• 85,000 MS sufferers in UK (Fowler et al 2008) • 3:1 women:men (Fowler et al 2008) • 75% will experience constipation and/or faecal incontinence (MS Society 2010) • 50% incontinent of faeces in past 3 months • 20-30% incontinent of faeces at least once a week. (Krogh & Christensen 2009)

Bowel management

• Diet and fluids • Exercise if possible • Osmotic laxatives • Stimulant laxatives • Suppositories/enemas • Irrigation • Anal irrigation recommended by NICE (2007)

Home visit

• Luxury of time • Comfort of own home • Holistic assessment • Medical and surgical history • Medication • DVD and information

Types of irrigation

• Cone system • Electrical pump system • Rectal catheter pump system

Pump cone system

Qufora • Patient holds cone in place • Performed on toilet • Water and faeces empty into toilet

Pump Cone system

Biotrol pump • Patient holds cone in place • Pump assists flow of water • Performed on toilet • Water and faeces empty into toilet

Catheter system

Peristeen • Rectal catheter held in place by balloon • Water pumped into bowel • Performed on the toilet • Water and faeces empty into toilet when balloon released

Referral pathway

• Cone system – assessment by suitably trained healthcare professional • Rectal catheter system – must be assessed by a doctor with appropriate knowledge and skills before commencing irrigation • MDA alert – risk of perforation • 1:100,000 – minimal risk

Never teach irrigation to the following patients:

• Acute inflammatory bowel disease • Known obstructing rectal or colonic mass • Rectal or colonic surgical anastamosis within the last 6 months • Severe cognitive impairment (unless tolerated and carer able to supervise/administer) • Pregnant or breastfeeding

Proceed with caution

• Spinal cord injury at or above T6 – risk of autonomic dysreflexia – 1st two irrigations must be supervised • Unstable metabolic conditions – renal or liver disease • Physical or cognitive disability/mental or emotional disorder • Anorectal conditions that cause pain or bleeding (e.g anal fissure, 3rd degree haemorrhoids)

Proceed with caution

• Pregnant or planning pregnancy • Any bowel or abdominal surgery within the last 6 months • Acute diarrhoea • Anal fissure • Large haemorrhoids that bleed easily • Past pelvic radiotherapy which has caused bowel problems • Severe diverticular disease • Rectal medications for other diseases • Congestive cardiac failure • Anal surgery within the past 6 months

Home visit

• Ensure exclusion criteria discussed • Ensure risks and benefits discussed • Demonstrate kit • Documentation and consent • Patient performs irrigation • Information and re-ordering • Contact details • Follow-up

Positive impact

• Reduced toileting time • Clean and quick • Improved confidence • Quality of life • The word gets round!

• Check suitability first

Issues encountered

• Acceptance • Not for everyone • Confidence • Dexterity • Frequency of use • Abdominal cramps • Volume of water • Balloons bursting • Catheter falling out • Leakage of water • Support from companies

Sally age 52

• MS diagnosed 15 years ago • Our patient 2 years for bladder symptoms • Disclosed bowel problems • Occasional faecal incontinence • Constipation • 3 hours a day bowel care • Using laxatives and suppositories • Digital stimulation and removal

Sally

• Reluctant to go out • Depressed and isolated • Life revolved around bladder and bowels • Thought nothing else was available • DVD and information about irrigation system

Sally

• New lease of life • Half hour bowel care • Reduced laxative use • Increased activity • Forgets about bowels for rest of day • Happier • Massive impact on QOL

Thank you

Maria Moor Continence Nurse Specialist 01274 322171 Maria [email protected]