Guidelines for Using Fleet (Sodium Phosphate) Enema
Fleet enemas should only be used if oral treatment for constipation fails after several days and to prevent fecal impaction, with careful consideration of contraindications and risks. 1
Indications for Fleet Enema Use
Fleet enemas (sodium phosphate) are indicated in the following situations:
- When oral laxative treatments have failed to relieve constipation
- To prevent fecal impaction
- For bowel preparation before certain procedures (e.g., flexible sigmoidoscopy)
Contraindications
Fleet enemas are contraindicated in patients with:
- Neutropenia or thrombocytopenia
- Paralytic ileus or intestinal obstruction
- Recent colorectal or gynecological surgery
- Recent anal or rectal trauma
- Severe colitis, inflammation or infection of the abdomen
- Toxic megacolon
- Undiagnosed abdominal pain
- Recent radiotherapy to the pelvic area 1
- Renal insufficiency or kidney disease 2, 3
- Children under 2 years of age 3
- Bowel dysfunction 3
Administration Guidelines
Proper Administration
- Small-volume self-administered enemas are commercially available and often adequate for most patients
- Larger volume clinician-administered enemas should only be administered by an experienced health professional 1
- Position the patient properly to maximize effectiveness and minimize discomfort
Patient Selection
- Consider patient's medical history, medications, and previous response to bowel preparations 1
- Use with extreme caution in elderly patients due to increased risk of adverse events 4
- For children between 2-5 years, use only with extreme caution and consider alternative preparations 3
Risks and Adverse Events
Fleet enemas carry several significant risks:
- Perforation of the intestinal wall (suspect if abdominal pain occurs)
- Rectal mucosal damage
- Bacteremia
- Bleeding complications or intramural hematomas (especially in patients on anticoagulation or with coagulation disorders) 1
- Severe hyperphosphatemia and hypocalcemic tetany/coma (particularly in elderly and those with renal impairment) 2
- Shock in pediatric patients 5
- Mortality rate of up to 4% has been reported in vulnerable populations 4
Alternative Options
Consider safer alternatives, especially for high-risk patients:
- Normal saline enemas (distend rectum and moisten stools with less irritating effects) 1
- Tap water enemas (safer for patients with renal insufficiency) 2
- Glycerin suppositories (though less effective than Fleet enemas for procedures like flexible sigmoidoscopy) 6
- Docusate sodium enemas (soften stool by aiding water penetration) 1
Monitoring and Follow-up
- Monitor for signs of perforation (abdominal pain)
- Watch for electrolyte disturbances, especially in high-risk patients
- Assess for adequate response within expected timeframe
Special Populations
Elderly
- Use with extreme caution due to higher risk of perforation and electrolyte disturbances 4
- Consider lower volume or alternative preparations
Children
- Avoid use in children under 2 years of age
- Use with extreme caution in children 2-5 years old
- Never use adult Fleet enemas in children 5
- Pediatric formulations should be used when absolutely necessary for children over 2 years 3
Patients with Renal Impairment
- Avoid use due to risk of severe hyperphosphatemia 2
- Consider tap water or saline enemas as alternatives
Clinical Pearls
- The effectiveness of Fleet enemas for flexible sigmoidoscopy preparation is superior to glycerin suppositories 6
- Always verify the appropriate formulation (adult vs. pediatric) before administration
- Educate patients and caregivers about proper administration techniques and potential risks
- Consider prophylactic oral laxative therapy in patients at risk for constipation to avoid the need for enemas