What is the treatment for a fecal impaction visible at the rectum?

Treatment of Fecal Impaction Visible at the Rectum

For fecal impaction visible at the rectum, perform manual disimpaction with digital fragmentation and extraction after administering appropriate analgesia and/or anxiolytic, followed immediately by glycerin suppository or enema, and then implement a maintenance bowel regimen to prevent recurrence. 1

Immediate Bedside Management

Pre-procedure Preparation

• Administer analgesia and/or anxiolytic before the procedure to minimize patient discomfort 1, 2
• Position the patient in the left lateral decubitus position for optimal access 1
• Rule out complications such as perforation, bleeding, or obstruction before proceeding 1

Manual Disimpaction Technique

• Perform digital fragmentation and extraction of the stool using a lubricated, gloved finger 1, 2
• This bedside extraction is successful in approximately 80% of fecal impaction cases 3
• Manual disimpaction is the first-line therapy when digital rectal examination identifies a full rectum or fecal impaction 2

Immediate Post-disimpaction Interventions

• Administer a glycerin suppository immediately after manual removal 1, 2
• Alternative options include tap water enema, docusate sodium enema, or bisacodyl enema 1
• Suppositories and enemas work more quickly than oral laxatives by increasing water content and stimulating peristalsis 2

Adjunctive Laxative Therapy

If impaction persists or to facilitate complete evacuation:

• Add bisacodyl 10-15 mg, 2-3 times daily with a goal of 1 non-forced bowel movement every 1-2 days 2, 1
• Consider oral polyethylene glycol, lactulose, magnesium hydroxide, or magnesium citrate 2, 1
• Rectal bisacodyl can be used if oral route is ineffective 2

Critical Prevention Strategy

Implement a maintenance bowel regimen immediately after disimpaction to prevent recurrence 1:

• Discontinue any non-essential constipating medications (antacids, anticholinergics, antiemetics) 2, 1
• Increase fluid intake and physical activity when appropriate 2, 1
• Consider dietary fiber only for patients with adequate fluid intake 2, 1
• Titrate bisacodyl 10-15 mg daily to three times daily to maintain regular bowel movements 1

Special Considerations and Contraindications

When to Avoid Enemas

Do not use enemas in patients with 1:

• Neutropenia or thrombocytopenia
• Paralytic ileus or intestinal obstruction
• Recent colorectal, gynecological, anal, or rectal surgery/trauma
• Severe colitis, abdominal inflammation, or infection
• Toxic megacolon
• Undiagnosed abdominal pain
• Recent pelvic radiotherapy

Gastroparesis Consideration

• If gastroparesis is suspected, add a prokinetic agent such as metoclopramide 2, 1

Opioid-Induced Constipation

• For patients on chronic opioids with refractory constipation, consider peripherally acting μ-opioid receptor antagonists (methylnaltrexone 0.15 mg/kg every other day, no more than once daily) 2

When Manual Disimpaction Fails

If bedside extraction is unsuccessful 4:

• Consider oral or nasogastric administration of polyethylene glycol solutions containing electrolytes 4
• In severe cases, surgical intervention may be necessary 4, 5
• Post-treatment evaluation should include colonic evaluation by flexible sigmoidoscopy, colonoscopy, or barium enema after the impaction resolves 4

Common Pitfall: Overflow Diarrhea

Be aware that paradoxical diarrhea may indicate fecal impaction, not true diarrhea 1. When watery stool leaks around the impaction, patients may present with diarrhea as their chief complaint 1. Always perform digital rectal examination in patients with new-onset diarrhea, especially in elderly or immobilized patients, to rule out impaction 1.