From the Guidelines
For fecal impaction, it is generally recommended to perform an enema before digital disimpaction to soften the impacted stool and lubricate the rectum, making the subsequent digital removal easier and less traumatic. The most recent and highest quality study 1 suggests that if a patient is impacted, administering a glycerine suppository ± mineral oil retention enema can help soften the stool, followed by manual disimpaction after premedication with analgesic ± anxiolytic.
Key Considerations
- Start with a mineral oil enema (100-150 mL) or a sodium phosphate enema (Fleet enema, 118 mL) to soften the impacted stool and lubricate the rectum.
- Allow the enema to work for 15-30 minutes before attempting digital disimpaction.
- Position the patient in the left lateral position with knees flexed, use adequate lubrication (water-soluble lubricant with 2% lidocaine gel), and wear gloves.
- Insert a lubricated finger gently into the rectum and break up the hardened stool using a hooking motion, removing small pieces at a time to minimize discomfort and rectal trauma.
- After disimpaction, consider a follow-up cleansing enema to remove remaining fragments.
Prevention of Recurrence
- Recommend increased fluid intake (2-3 liters daily) and dietary fiber (25-30g daily) to help prevent recurrence of fecal impaction.
- Encourage regular physical activity to help stimulate bowel movements.
- Consider prescribing osmotic laxatives like polyethylene glycol (17g in 8oz water daily) for ongoing management.
Note that the provided guidelines 2 and 3 are related to the use of faecal microbiota transplant as treatment for recurrent or refractory Clostridioides difficile infection, which is not directly relevant to the management of fecal impaction. Therefore, these guidelines are not considered in the recommendation.
From the Research
Fecal Impaction Treatment Options
- Fecal impaction is a common digestive disorder that can be treated with various methods, including manual disimpaction, enemas, suppositories, and oral or nasogastric tube placement for polyethylene glycol solutions 4
- Treatment options may vary depending on the severity of the impaction, with surgical intervention being necessary in severe cases 4
Enema as a Treatment Option
- Enemas can be used as a treatment option for fecal impaction, and may be superior to polyethylene glycol (PEG) for immediate relief of symptoms 5
- A study comparing enema versus PEG 3350 for fecal disimpaction in children found that enema may be more effective for immediate relief, but larger trials are needed to assess any advantage 5
Digital Disimpaction and Enema
- There is no direct evidence to suggest that an enema should be done before digital disimpaction, but enemas can be used as part of the treatment process for fecal impaction 4, 5
- Digital disimpaction may be necessary in some cases, and enemas can be used in conjunction with this method to help soften the stool and make disimpaction easier 4
Other Treatment Options
- Polyethylene glycol plus electrolytes (PEG + E) has been shown to be effective in the treatment of fecal impaction in children, and can be used as a maintenance therapy to prevent reimpaction 6
- Lactulose has also been used as a maintenance therapy, but has been shown to be less effective than PEG + E in preventing reimpaction 6