Editing Enema (section)

=== Bowel cleansing ===
==== Acute treatments ====
As [[bowel]] stimulants, enemas are employed for the same purposes as orally administered [[laxative]]s: to relieve [[constipation]]; to treat [[fecal impaction]]; to empty the colon before a medical procedure such as a [[colonoscopy]]. When oral laxatives are not indicated or sufficiently effective, enemas may be a sensible and necessary measure.<ref name="Pharmacological treatment"/>

A large volume enema<ref>{{cite web |url=https://www.merriam-webster.com/medical/high%20enema|title=high enema |website=Medical Dictionary |publisher=Merriam-Webster |access-date=17 February 2018}}</ref> can be given to cleanse as much of the colon as possible of feces.<ref>{{cite web |title=Administering an Enema |url=http://intranet.tdmu.edu.ua/data/kafedra/internal/meds/prac_skills_alg/Care%20of%20patients/Administering%20an%20Enema.htm |website=Care of patients |date=14 July 2015 |publisher=Ternopil State Medical University |access-date=17 February 2018 |url-status=dead |archive-date=23 February 2018 |archive-url=https://web.archive.org/web/20180223111015/http://intranet.tdmu.edu.ua/data/kafedra/internal/meds/prac_skills_alg/Care%20of%20patients/Administering%20an%20Enema.htm}}</ref><ref name="Fundamentals of Nursing Practice">{{cite web |url=http://www.peoi.org/Courses/Coursesen/nursepractice/ch/ch12e1.html |title=Types of Enemas |website=Fundamentals of Nursing Practice |publisher=Professional Education, Testing and Certification Organization International |author=Rhodora Cruz |access-date=17 February 2018}}</ref> However, a low enema is generally useful only for stool in the rectum, not in the intestinal tract.<ref>{{cite web |url=https://www.merriam-webster.com/medical/low%20enema|title=low enema |website=Medical Dictionary |publisher=Merriam-Webster |access-date=17 February 2018}}</ref>

Such enemas' mechanism consists of the volume of the liquid causing a rapid expansion of the intestinal tract in conjunction with, in the case of certain solutions, irritation of the intestinal [[mucosa]] which stimulates peristalsis and lubricates the stool to encourage a bowel movement.<ref name=Nursing_and_Allied_Health/> An enema's efficacy depends on several factors including the volume injected and the temperature and the contents of the infusion.<ref name="Pharmacological treatment"/> For the enema to be effective, the patient should retain the solution for five to ten minutes, as tolerated.<ref name=Biology_Online_Dictionary/><ref name=Nursing_and_Allied_Health/> or, as some nursing textbooks recommend, for five to fifteen minutes or as long as possible.<ref name=Safety_and_effectiveness/>

===== Large volume enemas =====
{{anchor|Soapsuds enema}}
[[File:Soapsuds Enemas.jpg|thumb|Soapsuds enemas, one in an enema bucket with a nozzle typical for a cleansing enema, and another in an enema bag with a nozzle typical for a contrast enema]]

For emptying the entire colon as much as feasible<ref name="Fundamentals of Nursing Practice"/> deeper and higher enemas are utilized to reach large colon sections.<ref name="Pharmacological treatment"/> The colon dilates and expands when a large volume of liquid is injected into it. The colon reacts to that sudden expansion with general contractions, [[Peristalsis#Large intestine|peristalsis]], propelling its contents toward the rectum.<ref name= Biology_Online_Dictionary />

'''Soapsuds enema''' is a frequently used synonym for a large volume enema (although soap is not necessary for effectiveness).<ref name= Biology_Online_Dictionary />

A large volume enema may be used in a home setting to relieve occasional constipation, although medical care may be required for recurring or severe cases of constipation.<ref name= Biology_Online_Dictionary />

====== Water-based solutions ======

Plain water can be used, functioning mechanically to expand the colon, thus prompting evacuation.

[[saline (medicine)#Normal|Normal saline]] is least irritating to the colon. Like plain water, it simply functions mechanically to expand the colon, but having a neutral concentration gradient, it neither draws [[electrolyte]]s from the body, as happens with plain water, nor draws water into the colon, as occurs with phosphates. Thus, a salt water solution can be used when a longer retention period is desired, such as to soften an impaction.

[[Castile soap]] is commonly added because its irritation of the colon's lining increases the defecation urgency.<ref name=Safety_and_effectiveness>{{cite journal|title=Safety and effectiveness of large-volume enema solutions |author1=Marilee Schmelzer |author2=Lawrence R. Schiller |author3=Richard Meyer |author4=Susan M. Rugari |author5=Patti Case |date=November 2004 |journal=Applied Nursing Research |doi=10.1016/j.apnr.2004.09.010 |volume=17 |issue=4 |pages=265–274|pmid=15573335}}</ref> However, liquid handsoaps and detergents should not be used.<ref name=Biology_Online_Dictionary/>

[[Glycerol]] is a specific bowel mucosa irritant serving to induce peristalsis via a [[Osmotic laxative|hyperosmotic effect]].<ref name= Glycerol>{{cite web |url=https://www.drugs.com/cdi/glycerin-enema.html |title=Glycerin Enema |publisher=Drugs.com |access-date=2018-09-09}}</ref> It is used in a dilute solution, e.g., 5%.<ref>{{cite journal |vauthors=Bertani E, Chiappa A, Biffi R, Bianchi PP, Radice D, Branchi V, Spampatti S, Vetrano I, Andreoni B |title=Comparison of oral polyethylene glycol plus a large volume glycerine enema with a large volume glycerine enema alone in patients undergoing colorectal surgery for malignancy: a randomized clinical trial |journal=Colorectal Disease |volume=13 |issue=10 |pages=e327–e334 |year=2011 |pmid=21689356 |doi=10.1111/j.1463-1318.2011.02689.x |s2cid=32872781}}</ref>

====== Other solutions ======

Equal parts of milk and molasses were heated to slightly above normal body temperature.<ref>{{Cite journal|last1=Nicholls|first1=Pam Hufford|last2=Metules|first2=Terri J|date=April 2001|title=Some old-fashioned enemas still work and are still used|journal=RN|volume=64|pages=80}}</ref> Neither the milk sugars and proteins nor the molasses are absorbed in the lower intestine, thus keeping the water from the enema in the intestine.<ref>{{cite journal | url=https://med.virginia.edu/pediatrics/about/clinical-and-patient-services/patient-tutorials/chronic-constipation-encopresis/treatment-of-chronic-constipation | title=Treatment of Chronic Constipation | volume=58 | issue=4 | pages=503–512 | journal=Clinical and Patient Services > Tutorials for Patients & Families | access-date=12 September 2018 | bibcode=1954NYASA..58..503I | last1=Ingelfinger | first1=Franz J. | year=1954 | doi=10.1111/j.1749-6632.1954.tb45865.x | pmid=29831395 | pmc=5251364 }}{{Dead link|date=July 2023 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> Studies have shown that milk and molasses enemas have a low complication rate when used in the [[emergency department]]<ref>{{cite journal |url=https://www.jem-journal.com/article/S0736-4679(15)00059-1/fulltext |title=Safety and Efficacy of Milk and Molasses Enemas in the Emergency Department |volume=48 |issue=6 |pages=667–70 |author1=Gary M. Vilke |author2=Gerard DeMers |author3=Nilang Patel |author4=Edward M. Castillo |date=June 2015 |journal=The Journal of Emergency Medicine |publisher=American Academy of Emergency Medicine |access-date=2019-03-19 |pmid=25850633 |doi=10.1016/j.jemermed.2015.01.035 |s2cid=9638496 }}</ref> and are safe and effective with minimal side effects.<ref>{{cite journal |url=https://www.jenonline.org/article/S0099-1767(13)00413-3/fulltext |title=Milk and Molasses Enemas: Clearing Things Up |author1=Kimberley Wallaker |author2=Ezio Fortuna |author3=Stuart Bradin |author4=Michelle Macy |author5=Michelle Hassan |author6=Rachel Stanley |date=November 2014 |journal=Journal of Emergency Nursing |volume=40 |issue=6 |pages=546–551 |publisher=The Emergency Nurses Association |access-date=2019-03-19 |pmid=24182894 |doi=10.1016/j.jen.2013.08.012 |url-access=subscription }}</ref>

[[Mineral oil]] functions as a lubricant and stool softener, but may have side effects including rectal skin irritation and oil leakage.<ref>{{cite web |url=https://my.clevelandclinic.org/health/drugs/20248-mineral-oil-rectal-enema |title=Mineral Oil rectal enema |work=Drugs, Devices & Supplements |publisher=[[Cleveland Clinic]] |access-date=2019-04-01 }}</ref>

===== Micro-enemas =====
[[File:Enema prepared, disposable.jpg|thumb|A prepared, disposable enema.]]

====== ATC codes for drugs for constipation &mdash; enemas ======

{{ATC codes lead|A|06|Drugs for constipation}}
:A06AG01 [[Trisodium phosphate|Sodium phosphate]]
:A06AG02 [[Bisacodyl]]
:A06AG03 [[Dantron]], including combinations
:A06AG04 [[Glycerol]]
:A06AG06 [[Oil]]
:A06AG07 [[Sorbitol]]
:A06AG10 [[Docusate sodium]], including combinations
:A06AG11 [[Sodium lauryl sulfoacetate]], including combinations
:A06AG20 Combinations

====== Single substance solutions ======
{{Expand section|date=March 2019}}

''In alphabetical order''

* [[Peanut oil|Arachis oil (peanut oil)]] enema is useful for softening stools which are impacted higher than the rectum.<ref name="NHS_Laxativives">{{cite web |url=http://www.nhsgrampian.org/nhsgrampian/GJF_general_new.jsp;jsessionid=9D853EB1A4631954DC26F785F611F2B1?pContentID=4659&p_applic=CCC&pElementID=522&pMenuID=7&p_service=Content.show& |title=NHS Grampian Medicines Management – Laxatives |date=2011 |work=NHS Grampian Campaign |publisher=National Health Service |access-date=4 March 2019 }}{{Dead link|date=July 2023 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>
* [[Bisacodyl]] stimulates [[enteric nervous system|enteric nerves]] to cause colonic contractions.<ref>{{cite book |doi=10.1002/14356007.a15_183 |chapter=Laxatives |title=Ullmann's Encyclopedia of Industrial Chemistry |year=2000 |last1=Engelhorn |first1=Robert |last2=Seeger |first2=Ernst |last3=Zwaving |first3=Jan H. |isbn=3527306730 }}</ref><ref>{{cite web |url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=324e61eb-8f6b-48d7-85c2-b1b5642691c9 |title=Label: FLEET- bisacodyl enema |access-date=3 March 2019}}</ref>
* [[Dantron]] is a stimulant drug and stool softener<ref>{{cite book |doi=10.1016/B978-1-4377-1015-1.00018-7 |chapter=Constipation during active cancer therapy |title=Supportive Oncology |year=2011 |last1=Sykes |first1=Nigel P. |pages=177–186 |isbn=9781437710151 }}</ref> used alone or in combinations in enemas.<ref>{{cite web |url=https://www.whocc.no/atc_ddd_index/?code=A06AG&showdescription=yes |title=A06AG Enemas |date=13 December 2018 |work=WHO Collaborating Centre for Drug Statistics Methodology |publisher=World Health Organization |access-date=3 March 2019}}</ref> Considered to be a [[carcinogen]]<ref>{{cite web |url=https://ntp.niehs.nih.gov/pubhealth/roc/listings/index.html?substance=Danthron |title=Report on Carcinogens, Fourteenth Edition |date=November 2016 |work=Report on Carcinogens |publisher=National Toxicology Program, Department of Health and Human Services (HHS) |access-date=3 March 2019}}</ref> its use is limited, e.g., restricted in the [[United Kingdom|UK]] to patients who already have a diagnosis of terminal cancer and not used at all in the [[United States|USA]].
* [[Docusate#Constipation|Docusate]]<ref>{{cite web |url=https://www.nursingtimes.net/clinical-archive/medicine-management/docusate-sodium-18-12-2004/ |title=Docusate sodium|date=18 December 2004}}</ref><ref>{{Cite web |url=https://www.drugs.com/cdi/colace-microenema.html|title=Colace Microenema: Indications, Side Effects, Warnings|website=Drugs.com}}</ref>
* Glycerol has a hyperosmotic effect and can be used as a small-volume (2–10&nbsp;ml) enema (or suppository).<ref name="Glycerol" />
* [[Mineral oil]] is used as a lubricant because most of the ingested material is excreted in the stool rather than absorbed by the body.<ref name="food">{{Cite web |title=206. Food-grade mineral oil (FAO Nutrition Meetings Report Series 48a) |url=https://inchem.org/documents/jecfa/jecmono/v48aje08.htm |archive-url=https://web.archive.org/web/20070806023007/http://inchem.org/documents/jecfa/jecmono/v48aje08.htm|url-status=dead|archive-date=6 August 2007 |website=inchem.org}}</ref>
* [[Sodium phosphates#Uses|Sodium phosphate]].<ref>{{cite web |url=https://www.drugs.com/cdi/sodium-phosphates-enema.html |title=Sodium Phosphates Enema |access-date=3 March 2019}}</ref><ref>{{cite web |url=https://medlineplus.gov/druginfo/meds/a614018.html |title=Sodium Phosphate Rectal |access-date=3 March 2019}}</ref> Also known by the brand name Fleet. Available at drugstores; usually self-administered. [[buffer solution|Buffered]] sodium phosphate solution draws additional water from the bloodstream into the colon to increase the effectiveness of the enema. But it can irritate the colon, causing intense cramping or "griping."<ref>{{cite web |title=Fleet Enema Side Effects |url=https://www.drugs.com/sfx/fleet-enema-side-effects.html |website=www.drugs.com |publisher=Drugs.com |access-date=July 12, 2021}}</ref> Fleet enemas usually cause a bowel movement in 1 to 5 minutes. Known [[Sodium phosphates#Adverse effects|adverse effects]].
* [[Sorbitol#Laxative|Sorbitol]] pulls water into the large intestines, causing distention, stimulating the bowels' normal forward movement. Sorbitol is found in some dried fruits and may contribute to the laxative effects of prunes.<ref>{{cite journal |last1=Stacewicz-Sapuntzakis |first1=Maria |last2=Bowen |first2=Phyllis E. |last3=Hussain |first3=Erum A. |last4=Damayanti-Wood |first4=Bernadette I. |last5=Farnsworth |first5=Norman R. |title=Chemical Composition and Potential Health Effects of Prunes: A Functional Food? |journal=Critical Reviews in Food Science and Nutrition |date=July 2001 |volume=41 |issue=4 |pages=251–286 |doi=10.1080/20014091091814 |pmid=11401245 |s2cid=31159565 }}</ref> and is available for taking orally as a laxative.<ref>{{cite web|url=http://www.cancer.org/docroot/CDG/content/CDG_sorbitol.asp |title=ACS :: Cancer Drug Guide: sorbitol |archive-url=https://web.archive.org/web/20070630001051/http://www.cancer.org/docroot/CDG/content/CDG_sorbitol.asp |archive-date=2007-06-30}}</ref><ref>{{Cite web | url=https://www.webmd.com/drugs/2/drug-10305/sorbitol/details |title = Drugs & Medications}}</ref> As an enema for constipation, the recommended adult dose is 120 mL of 25-30% solution, administered once.<ref>{{cite web |url=https://reference.medscape.com/drug/sorbitol-342033|title= Sorbitol| access-date=3 March 2019}}</ref> Note that Sorbitol is an ingredient of the MICROLAX Enema.

====== Compounded from multiple ingredients ======<!-- Klyx redirects to here -->
{{Expand section|date=March 2019}}

''In alphabetical order of the original brand names''

Klyx contains [[docusate sodium]] 1&nbsp;mg/mL and sorbitol solution (70%)(crystallising) 357&nbsp;mg/mL and is used for faecal impaction or constipation or colon evacuation prior medical procedures,<ref>{{cite web |url=https://www.news-medical.net/drugs/Klyx.aspx |title=Klyx |date=March 2017 |work=NHS Grampian Campaign |publisher=[[National Health Service]] |access-date=4 March 2019 |archive-date=6 March 2019 |archive-url=https://web.archive.org/web/20190306043511/https://www.news-medical.net/drugs/Klyx.aspx |url-status=dead }}</ref> developed by [[Ferring Pharmaceuticals|Ferring B.V.]]

Micralax (not to be confused with MICROLAX®)<ref name=NHS_Laxativives_9099>{{cite web |url=https://www.medicines.org.uk/emc/product/9099/pil |title=NHS Grampian – Laxatives |date=16 May 2011 |work=Latest medicine updates |publisher=electronic Medicines Compendium (eMC) |access-date=4 March 2019}}</ref>

[[Sodium citrate/sodium lauryl sulfoacetate/glycerol|MICROLAX®]] (not to be confused with Micralax) combines the action of [[sodium citrate]], a peptidising agent which can displace bound water present in the faeces, with sodium alkyl sulphoacetate, a wetting agent, and with glycerol, an anal mucosa irritant and hyperosmotic. However, also sold under the name "Micralax", is a preparation containing [[sorbitol]] rather than glycerol;<ref>{{cite web |url=https://www.nps.org.au/medical-info/medicine-finder/microlax-enema |title=Microlax Enema |date=2018 |work=NPS MedicineWise |publisher=National Prescribing Service |access-date=4 March 2019}}</ref> which was initially tested in preparation for [[sigmoidoscopy]].<ref>{{cite journal |author=W. Lieberman|year=1964|title=Rapid patient preparation for sigmoidoscopy by microenema.|journal=American Journal of Proctology|volume=15|pages=138–41|pmid=14139893}}</ref>

Micolette Micro-enema® contains 45&nbsp;mg sodium lauryl sulphoacetate, 450&nbsp;mg per 5 ml sodium citrate BP, and 625&nbsp;mg glycerol BP<ref>{{cite web |url=https://www.medicines.org.uk/emc/product/4569/smpc |title=Micolette Micro-enema |date=10 July 2015 |work=Latest medicine updates |access-date=4 March 2019}}</ref> and is a small volume stimulant enema suitable where large-volume enemas are contra-indicated.<ref name=NHS_Laxativives/>

==== Chronic treatments ====
===== Transanal irrigation =====
{{Main|Transanal irrigation}}
''TAI'', also termed ''retrograde irrigation'', is designed to assist evacuation using a water enema<ref name=Emmanuel2013>{{cite journal|last1=Emmanuel|first1=A V|last2=Krogh|first2=K|last3=Bazzocchi|first3=G|last4=Leroi|first4=A-M|last5=Bremers|first5=A|last6=Leder|first6=D|last7=van Kuppevelt|first7=D|last8=Mosiello|first8=G|last9=Vogel|first9=M|last10=Perrouin-Verbe|first10=B|last11=Coggrave|first11=M|last12=Christensen|first12=P|title=Consensus review of best practice of transanal irrigation in adults|journal=Spinal Cord|date=20 August 2013|volume=51|issue=10|pages=732–738|doi=10.1038/sc.2013.86|pmid=23958927|doi-access=free}}</ref> as a treatment for persons with bowel dysfunction, including [[fecal incontinence]] or constipation, especially [[obstructed defecation]]. By regularly emptying the bowel using transanal irrigation,<ref name="Consensus review 2013">[http://www.nature.com/sc/journal/v51/n10/pdf/sc201386a.pdf], Consensus review of best practice of transanal irrigation in adults A V Emmanuel et al. Spinal Cord 2013.</ref> controlled bowel function is often re-established to a high degree, thus enabling a consistent bowel routine development.<ref name="Consensus review 2013" />  Its effectiveness varies considerably, some individuals experiencing complete control of incontinence but others reporting little or no benefit.<ref name=Emmanuel2013 />

An international consensus on when and how to use transanal irrigation for people with bowel problems was published in 2013, offering practitioners a clear, comprehensive and straightforward guide to practice for the emerging therapeutic area of transanal irrigation.<ref name="Consensus review 2013" />

The term ''retrograde irrigation'' distinguishes this procedure from the [[Malone antegrade continence enema]], where irrigation fluid is introduced into the colon proximal to the anus via a surgically created irrigation port.<ref>{{Cite journal |last1=Spinelli |first1=Michele |last2=Sampogna |first2=Gianluca |last3=Rizzato |first3=Luigi |last4=Spinelli |first4=Antonella |last5=Sammartano |first5=Fabrizio |last6=Cimbanassi |first6=Stefania |last7=Montanari |first7=Emanuele |last8=Chiara |first8=Osvaldo |date=2021-04-23 |title=The Malone antegrade continence enema adapting a transanal irrigation system in patients with neurogenic bowel dysfunction |journal=Spinal Cord Series and Cases |volume=7 |issue=1 |pages=34 |doi=10.1038/s41394-021-00397-3 |issn=2058-6124 |pmc=8065210 |pmid=33893272}}</ref>

===== Bowel management =====
{{Main|Bowel management}}
Patients who have a bowel disability, a medical condition which impairs control of [[defecation]], e.g., fecal incontinence or constipation,<ref name="Bowel management definition">{{cite web|title=Bowel Management After Spinal Cord Injury|url=http://www.sci-info-pages.com/bowel.html|website=sci-info-pages.com|date=2 June 2019|language=en}}</ref> can use bowel management techniques to choose a predictable time and place to evacuate.<ref name="Bowel management definition"/> Without bowel management, such persons might either suffer from the feeling of not getting relief or soil themselves.<ref name="Bowel management definition"/>

While simple techniques might include a controlled [[Healthy diet|diet]] and establishing a toilet routine,<ref name="Bowel management definition"/> a daily enema can be taken to empty the colon, thus preventing unwanted and uncontrolled bowel movements that day.<ref name="ReferenceA">Peña A, Guardino K, Tovilla JM, Levitt MA, Rodriguez G, Torres R Bowel management for fecal incontinence in patients with anorectal malformations Pediatr. Surg. 33:1 133–7 1998</ref>