When can we restart enemas and suppositories in a patient with a history of diarrhea and impacted stool who had been receiving them on alternate days?

When to Restart Enemas and Suppositories After Impacted Stool

Enemas and suppositories should be restarted only after confirming the absence of impaction and when the patient has not had a bowel movement for 1-2 days, typically waiting at least 3 days after resolution of diarrhea symptoms. 1

Assessment Before Restarting

• Perform a digital rectal examination to rule out persistent impaction, especially when diarrhea accompanies constipation (which may indicate overflow around impaction) 1
• Check for signs of obstruction through physical examination and, if needed, abdominal X-ray 1
• Assess for other causes of constipation such as hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus, or medication effects 1
• Evaluate stool consistency and frequency to ensure diarrhea has fully resolved 1

Restart Protocol

When to Restart

• Wait until the patient has had no diarrhea for at least 3 days 1
• Resume when the patient has not had a bowel movement for 1-2 days 1
• Ensure adequate hydration and consider increasing dietary fiber if appropriate 1

How to Restart

• Begin with milder interventions first:
  • Consider glycerine suppositories as first-line therapy if rectal examination shows stool in the rectum 1
  • For more significant constipation, use bisacodyl suppositories (one rectally daily to BID) 1
  • Progress to mineral oil retention enemas if suppositories are insufficient 1
  • Reserve tap water enemas for more resistant cases 1

Special Considerations

• Contraindications for enemas: Do not use enemas in patients with neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, anal/rectal trauma, severe colitis, abdominal inflammation/infection, toxic megacolon, undiagnosed abdominal pain, or recent pelvic radiotherapy 1

• Overflow diarrhea: Be aware that what appears as diarrhea may actually be liquid stool flowing around an impaction; this requires treatment of the impaction rather than anti-diarrheal therapy 1, 2

• Elderly patients: Pay particular attention to:

  • Ensuring access to toilets, especially for those with decreased mobility 1
  • Optimizing toileting position (using a footstool may help) 1
  • Encouraging attempts at defecation 30 minutes after meals, no more than 5 minutes of straining 1

Maintenance Regimen After Restart

• Goal: Achieve one non-forced bowel movement every 1-2 days 1
• Consider oral laxatives alongside rectal therapies:
  • Osmotic laxatives (polyethylene glycol, lactulose) or stimulant laxatives (senna, bisacodyl) are generally preferred 1
  • For opioid-induced constipation, ensure all patients on opioids receive prophylactic laxatives 1
  • Avoid bulk laxatives for opioid-induced constipation 1

Monitoring After Restart

• Reassess for recurrence of impaction or obstruction if constipation returns 1
• Monitor for adequate bowel movements (goal: one non-forced bowel movement every 1-2 days) 1
• Adjust frequency of enemas and suppositories based on response 1

Remember that prevention of recurrent impaction is key, and a maintenance bowel regimen should be implemented after resolution of the initial problem 1.