Management of Full Rectal Vault
Suppositories and enemas are the preferred first-line therapy when digital rectal examination identifies a full rectum or fecal impaction. 1
Causes of Full Rectal Vault
A full rectal vault typically results from:
- Constipation (most common cause)
- Fecal impaction
- Dyssynergic defecation (pelvic floor dysfunction)
- Rectal prolapse
- Anatomical abnormalities (rectocele, intussusception)
Assessment
Before initiating treatment, perform:
- Digital rectal examination (DRE) to confirm full rectum and assess for:
- Consistency of stool
- Presence of impaction
- Anal sphincter tone
- Abdominal examination to assess for distention or tenderness
- Plain abdominal X-ray may be useful to image extent of fecal loading and exclude bowel obstruction 1
Management Algorithm
1. Immediate Management of Full Rectal Vault
For confirmed full rectal vault on DRE:
First-line: Suppositories or enemas 1
- Glycerin suppositories: Lubricate stool and stimulate rectal contraction
- Bisacodyl suppositories: Promote intestinal motility
- Enemas (options based on clinical situation):
- Hypertonic sodium phosphate enema: Distends and stimulates rectal motility
- Docusate sodium enema: Softens stool by aiding water penetration
- Warm oil retention enema: Lubricates and softens stool (hold for at least 30 minutes)
For fecal impaction (hard, immobile stool mass):
- Digital fragmentation and extraction of stool 1
- Follow with enemas to clear remaining stool
- Once distal colon partially emptied, administer polyethylene glycol (PEG) orally
2. Subsequent Management
After initial evacuation:
Oral laxatives:
Caution: Magnesium and sulfate salts can lead to hypermagnesemia and should be used cautiously in renal impairment 1
3. Prevention of Recurrence
- Ensure adequate fluid intake
- Increase dietary fiber
- Regular physical activity
- Establish regular toileting schedule
- Proper positioning during defecation (using footstool to assist gravity) 1
- Consider abdominal massage to improve bowel efficiency 1
4. Special Considerations
For Opioid-Induced Constipation
- Unless contraindicated by pre-existing diarrhea, all patients receiving opioid analgesics should be prescribed a concomitant laxative 1
- Osmotic or stimulant laxatives are generally preferred 1
- Avoid bulk laxatives such as psyllium 1
- For unresolved cases, consider peripheral opioid antagonists (methylnaltrexone, naloxegol) 1
For Elderly Patients
- Ensure access to toilets, especially with decreased mobility
- Provide dietetic support
- Optimize toileting schedule (attempt defecation 30 min after meals)
- Individualize laxative therapy based on comorbidities 1
For Dyssynergic Defecation
- Consider biofeedback therapy to improve coordination of pelvic floor muscles 1, 3
- Patients may need to be taught correct posture and pelvic floor muscle interaction 1
Contraindications to Enemas
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
Potential Complications of Untreated Full Rectal Vault
- Urinary tract obstruction
- Perforation of the colon
- Dehydration and electrolyte imbalance
- Renal insufficiency
- Fecal incontinence
- Decubitus ulcers
- Stercoral ulcers 1
Follow-up
- Regular monitoring for recurrence
- Assess effectiveness of maintenance regimen
- Adjust treatment as needed based on response
- Consider further investigation (anorectal manometry, defecography) if symptoms persist despite appropriate management
Remember that a full rectal vault often indicates an underlying disorder that needs addressing to prevent recurrence and complications.