What is the proper technique for bedside fecal disimpaction?

Proper Technique for Bedside Fecal Disimpaction

The proper technique for bedside fecal disimpaction involves premedication with analgesics and/or anxiolytics, followed by digital fragmentation and extraction of the stool, and then administration of enemas to facilitate passage of remaining stool. 1

Initial Assessment

• Confirm diagnosis through digital rectal examination (DRE) to identify the presence of a large mass of dry, hard stool in the rectum 1
• Rule out impaction in the proximal rectum or sigmoid colon, where DRE may be non-diagnostic 1
• Exclude complications such as perforation or bleeding before proceeding with manual disimpaction 1, 2
• Rule out obstruction through physical examination and abdominal radiograph if needed 3

Pre-Procedure Preparation

• Ensure privacy and comfort to allow for patient dignity during the procedure 3
• Position the patient appropriately (typically in left lateral position) to assist with access to the rectum 3
• Administer appropriate analgesia and/or anxiolytic before the procedure to minimize discomfort and anxiety 3, 1
• Use proper personal protective equipment including gloves, lubricant, and appropriate collection materials 1

Disimpaction Procedure

1. Manual disimpaction technique:

   • Apply generous lubrication to gloved finger 1
   • Insert finger gently into rectum 1
   • Systematically fragment the fecal mass using a gentle rotating motion 1, 2
   • Extract fragments gradually to avoid trauma to rectal mucosa 1, 4
   • Continue process until the impacted mass is sufficiently broken down 1

2. Post-manual disimpaction:

   • Administer glycerine suppository and/or mineral oil retention enema to soften remaining stool 3
   • Consider additional enema options including:
     • Hypertonic sodium phosphate enema
     • Docusate sodium enema
     • Warm oil retention enema
     • Bisacodyl enema 1
   • For elderly patients, isotonic saline enemas are preferable due to fewer adverse effects 3

Management of Proximal Impaction

• If impaction is higher in the colon, administer lavage with polyethylene glycol (PEG) solutions containing electrolytes 1, 2
• Consider adding other laxatives such as:
  • Bisacodyl suppository (one rectally daily-BID)
  • Polyethylene glycol (1 capful/8 oz water BID)
  • Lactulose (30-60 mL BID-QID)
  • Sorbitol (30 mL every 2 hours × 3, then PRN)
  • Magnesium hydroxide (30-60 mL daily-BID)
  • Magnesium citrate (8 oz daily) 3

Prevention of Recurrence

• Implement a maintenance bowel regimen immediately after disimpaction 1, 4
• Preferred options include osmotic laxatives (PEG, lactulose, magnesium salts) or stimulant laxatives (senna, cascara, bisacodyl, sodium picosulfate) 3
• Consider methylnaltrexone for opioid-induced constipation (0.15 mg/kg subcutaneously every other day) 3
• Avoid bulk laxatives such as psyllium, especially in patients with opioid-induced constipation or limited mobility 3, 1

Special Considerations and Contraindications

• Contraindications for enemas:

  • 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 3, 1

• For elderly patients:

  • Ensure access to toilets, especially for those with decreased mobility 3
  • Provide dietetic support and manage decreased food intake 3
  • Optimize toileting by educating patients to attempt defecation at least twice daily, usually 30 minutes after meals 3
  • PEG (17 g/day) offers an efficacious and tolerable solution with a good safety profile 3, 1

Complications to Monitor

• Bowel perforation leading to peritonitis 2, 5
• Stercoral ulceration 2, 4
• Rectal bleeding 1, 2
• Cardiopulmonary collapse with hemodynamic instability in severe cases 2

By following this structured approach to fecal disimpaction, clinicians can effectively manage this common condition while minimizing complications and patient discomfort.