Every community healthcare professional (HCP) probably manages chronic constipation, characterised by infrequent stools, difficultly passing faeces or both for at least 3 months (Emmett et al, 2015). About 9.5% of children (Bolia et, 2024) and 14% of adults (Emmett et al, 2015) experience chronic functional constipation. Unless treated, chronic constipation can markedly impair quality of life, result in irreversible anatomical changes, such as megarectum and megacolon, and cause severe complications, including intestinal obstruction and bowel perforation (Bazzocchi et al, 2024).
Chronic constipation has numerous causes, including neurological (eg spinal cord injury or tumour, stroke, Parkinson's disease, multiple sclerosis) and other conditions, such as diabetes, hypothyroidism and hypopituitary disorders (Emmett et al, 2015, O'Donnell and Haviland, 2024). Several medicines can also cause or exacerbate constipation (Emmett et al, 2015; O'Donnell and Haviland, 2024). For example, up to 80% of opioid users experience constipation (O'Donnell and Haviland, 2024).
Lifestyle and dietary causes of constipation include low-fibre diets, low water consumption, stress, lack of physical exercise, excessive toileting time, phytobezoars (a mass of indigestible plant material trapped in the gastrointestinal system) and eating disorders (for example, anorexia) (Bouali et al, 2021; O'Donnell and Haviland, 2024). Chronic functional constipation, which lacks a clear underlying cause, encompasses obstructed defecation syndrome, functional defecation disorder, chronic idiopathic constipation and constipation-predominant irritable bowel syndrome (Emmett et al, 2015).
Treating constipation
HCPs should suggest that patients with functional constipation eat 25 to 30g of fibre, preferably soluble, a day, increase their physical activity and drink 2L of water a daily (O'Donnell and Haviland, 2024). Other treatments for functional constipation include laxatives, education, toilet training, cognitive behavioural therapy and biofeedback (Bolia et al, 2024). Ongoing research is assessing the gastrointestinal microbiome's contribution to constipation. However, constipated patients may benefit from prebiotics (insoluble fibre used by bacteria) and probiotics (Lactobacillus and Bifidobacterium) in supplements, cultured milk products and fermented vegetables, such as kimchi and sauerkraut (O'Donnell and Haviland, 2024).
Nevertheless, about a quarter of people with chronic functional constipation experience symptoms despite first-line treatments (Bolia et al, 2024). Transanal irrigation (TAI) uses one of a variety of devices that differ in rectal catheter (balloon or cone), water instillation (gravity or manual or electronic pumps) and volume administered to introduce water into the rectum through the anus to aid faecal evacuation (Emmett et al, 2015; Bolia et al, 2024; Tamvakeras et al, 2023).
TAI is effective and well tolerated in a variety of settings. For instance, TAI improves bowel function and quality of life in people with neurogenic bowel disease compared with conservative care (Tamvakeras et al, 2023). TAI is also effective and well-tolerated in adults (Emmett et al, 2015) and children (Bolia et al, 2024) with functional constipation. Emmett et al (2015) commented that in adults with chronic functional constipation, TAI's ‘effectiveness is at least comparable with pharmacological therapies’. Bolia et al (2024) remarked that ‘TAI can not only optimise bowel management but can also provide a complete cure’ in children with refractory functional constipation.
Effective and well tolerated
Although studies show that TAI is well-tolerated and effective in patients with chronic constipation, further robust prospective trials would be valuable (Emmett et al, 2015; Tamvakeras et al, 2023; Bolia et al, 2024). For instance, a meta-analysis of seven studies included 254 adults with chronic functional constipation. The average ages of people in the studies included in the meta-analysis were 46–55.4 years. Investigators reported that 50.4% of TAI treatments were successful. A different statistical analysis produced similar results: 50.9% of treatments were successful. However, the authors remarked that ‘Well-designed prospective trials are required to improve the current weak evidence base’ supporting TAI in adults with chronic functional constipation (Emmett et al, 2015).
A meta-analysis of five studies, two from the UK, including 192 children with refractory functional constipation managed with Peristeen, Qufora, Alterna or Navina devices. The median ages of children in the five studies were 7–12.2 years. Follow-up lasted from 5.5 months to 3 years. Investigators reported that 62% of treatments were successful. Again, the authors noted that well-designed prospective studies are needed to further assess TAI in children with refractory functional constipation (Bolia et al, 2024).
A recent position paper suggested daily TAI during the first 2 weeks of treatment, then every other day and no less than 2–3 times a week. Once stable, patients can use TAI less frequently based on their responses and needs (Bazzocchi et al, 2024). Over time, some patients stop TAI and other treatments for constipation (Bolia et al, 2024). For instance, 14% of the children with refractory functional constipation no longer needed TAI at last follow up (Bolia et al, 2024).
Some patients, however, use TAI long-term (Tamvakeras et al, 2023). A five-year retrospective review included 18 TAI patients in a UK district general hospital (DGH). Patients were aged 23–91 years (median age 61 years) and 83.5% were female. Constipation was the main symptom in nine patients, faecal incontinence in seven people and mixed in two participants. First-line management with dietary and lifestyle modifications, laxatives or antidiarrhoeal drugs had been unsuccessful in all of the patients. Bowel dysfunction arose from low anterior resection syndrome, neurogenic bowel, congenital anorectal malformations, obstructed defecation and functional disorders. Of these, 14 patients continued regular irrigation for 5.1–72.3 months (median 27.7 months). Bowel symptoms significantly improved during this time (Tamvakeras et al, 2023).
Adverse events
Most patients tolerate TAI. Serious adverse events are rare. Adverse events in the meta-analysis of adults with chronic functional constipation included: leakage of irrigation fluid (30–75%); expulsion of the rectal catheter (39%); abdominal cramps or discomfort (33–40%); anorectal pain (5–25%); and anal canal bleeding (1–20%). Patients may also experience ‘technical problems’ and rarely (less than once every 55 000 irrigations) perforated bowel (Emmett et al, 2015).
Bolia et al (2024) reported that 21.7% of children with refractory functional constipation experienced pain during irrigation, the most common side effect. Usually, the pain was mild and did not lead to discontinuation. However, 5.7% of children did not tolerate TAI and withdrew from treatment (Bolia et al, 2024).
Tamvakeras et al (2023) reported that four patients discontinued after a median follow-up of 4.8 months because of inadequate rectal evacuation or due to symptoms spontaneously improving. None of the patients experienced major adverse events, such as rectal bleeding or perforation (Tamvakeras et al, 2023). Other issues included occasional anal pain (21%), incomplete evacuation (14%), inefficiency in preventing passive leakage (14%) and anxiety that adverse affected mental health (5.5%) (Tamvakeras et al, 2023).
Best practice
The position paper suggests performing TAI at the same time of the day, preferably in the morning or after eating when the gastrocolonic reflex is most powerful. HCPs should suggest that patients empty their bladder before starting TAI. Each patient should use TAI in the position that is most comfortable and effective (Bazzocchi et al, 2024). Current devices allow most adults to perform TAI alone (Bazzocchi et al, 2024). Children and some other patients, however, need assistance with TAI. Nurses and other HCPs need to discuss the patient's need for assistance before starting TAI (Bolia et al, 2024).
HCPs also need to optimise the rate, volume administered and the number of puffs (typically 2–4) for those using balloon irrigation (Bazzocchi et al, 2024; Bolia et al, 2024). The position paper suggests starting with 400–500 ml water at 36° to 38°. HCPs and patients should tailor the amount of water depending on the response. Certain patients may need 600–800 ml, sometimes even 1000 ml, or as little as 200–300 ml. The position paper adds that pumps should deliver ‘pulses’ of water every 5–10 seconds at a rate of between 200 and 300 ml/minute (Bazzocchi et al, 2024).
Patient preference is important when choosing a TIA device. Bolia et al (2024) comment that ‘In all probability, all devices have a similar efficacy’. The studies in the meta-analysis included too few patients to assess the relative merits of the different TAI devices in children with refractory functional constipation (Bolia et al, 2024). In the long-term follow-up study, two-thirds of patients used high-volume irrigation systems (eg Qufora IrriSedo Cone System). A third of patients used low-volume irrigation systems (eg Peristeen Light) (Tamvakeras et al, 2023). The DGH helps patients choose their preferred device guided by a specialist nurse (Tamvakeras et al, 2023).
Training, careful follow-up and ongoing supervision improves adherence, which otherwise may be poor, and the success of TAI (Bazzocchi et al, 2024, Bolia et al, 2024). Many patients are ‘disheartened, dissatisfied … with distorted expectations’. So, personalised explanations of the realistic outcomes is important (Bazzocchi et al, 2024).
The DGH runs in-person TAI teaching sessions in the Gastrointestinal Physiology unit. Patients self-irrigate at home. But the department makes routine telephone follow-ups at 2, 6, and 12 weeks, 6 months, 1 year, and then ad hoc. In the meantime, patients can contact the unit if they had any concerns. Older patients or those with ongoing issues receive additional telephone follow-up consultations every 6 months or yearly after the first year (Tamvakeras et al, 2023). The position paper suggests that patients should complete a daily diary to record the number of bowel movements, faecal consistency (based on the Bristol stool scale) and instillation patterns (Bazzocchi et al, 2024).
Conclusion
Chronic constipation has numerous causes (Emmett et al, 2015) and about a quarter of people experience symptoms despite conventional treatments (Bolia et al, 2024). Increasing evidence suggests that TAI is effective and well tolerated (Bolia et al, 2024; Emmett et al, 2015; Tamvakeras et al, 2023) in people with chronic constipation who do not adequately respond to first-line treatments. Nevertheless, nurses and other HCPs need to discuss the need for assistance before starting TAI and optimise the irrigation protocol. In addition, training, careful follow-up and ongoing supervision improves adherence and success (Bolia et al, 2024; Tamvakeras et al, 2023). However, further prospective studies are needed (Emmett et al, 2015; Tamvakeras et al, 2023; Bolia et al, 2024) and many patients will not respond or be able to tolerate TAI. Such patients should be referred. Nevertheless, TAI is an important approach in the multifaceted community management of this common problem.