What is the treatment for fecal impaction (fecal loading)?

Treatment of Fecal Impaction

The first-line treatment for fecal impaction is digital fragmentation and extraction of the stool, followed by enema administration (water or oil retention), and then implementation of a maintenance bowel regimen to prevent recurrence. 1, 2

Initial Assessment and Diagnosis

• Confirm fecal impaction through digital rectal examination (DRE), which identifies a large mass of dry, hard stool in the rectum 1, 2
• Important caveat: DRE may be non-diagnostic if the impaction is located in the proximal rectum or sigmoid colon 1, 2
• Rule out perforation or bleeding before proceeding with any disimpaction procedure 1, 2
• Check for contraindications to enema use (see below) 1

Treatment Algorithm by Location

For Distal Fecal Impaction (Rectal)

Step 1: Manual Disimpaction

• Provide appropriate analgesia and/or anxiolytic medication before the procedure 2
• Perform digital fragmentation and extraction of the stool manually 1, 2
• This approach is successful in approximately 80% of cases 3

Step 2: Enema Administration

• After partial manual removal, administer water or oil retention enema to facilitate passage of remaining stool 1, 2
• Options include hypertonic sodium phosphate enema, docusate sodium enema, warm oil retention enema, or bisacodyl enema 2
• Suppositories are also a preferred first-line therapy when DRE identifies fecal impaction 1

Step 3: Oral Laxatives

• Once the distal colon has been partially emptied, administer polyethylene glycol (PEG) orally 1

For Proximal Fecal Impaction (Sigmoid/Proximal Colon)

• In the absence of complete bowel obstruction, use lavage with PEG solutions containing electrolytes to soften or wash out stool 1, 2
• This approach helps manage impactions that cannot be reached by digital examination 1

For Treatment-Resistant Cases

• Consider endoscopic disimpaction when conservative measures fail and there is no severe obstructive colitis 4
• Surgical resection is reserved only for cases complicated by ulceration, perforation, or peritonitis 5

Critical Contraindications to Enemas

Do not use enemas in patients with: 1, 2

• Neutropenia (WBC < 0.5 cells/μL) or thrombocytopenia
• Paralytic ileus or intestinal obstruction
• Recent colorectal or gynecological surgery
• Recent anal or rectal trauma
• Severe colitis, abdominal inflammation, or infection
• Toxic megacolon
• Undiagnosed abdominal pain
• Recent pelvic radiotherapy

Prevention of Recurrence (Essential Step)

Immediately implement a maintenance bowel regimen after successful disimpaction to prevent recurrence: 1, 2

Preferred first-line laxatives:

• Osmotic laxatives: PEG (17 g/day for elderly), lactulose, or magnesium salts 1, 2
• Stimulant laxatives: senna, cascara, bisacodyl, or sodium picosulfate 1, 2

Avoid these laxatives:

• Bulk laxatives such as psyllium are not recommended, especially in opioid-induced constipation or patients with limited mobility 1, 2
• Liquid paraffin in bed-bound patients or those with swallowing disorders (risk of aspiration lipoid pneumonia) 1
• Magnesium salts should be used cautiously in renal impairment due to hypermagnesemia risk 1

Special Considerations for Elderly Patients

Elderly patients are at particularly high risk for fecal impaction and require specific attention: 1, 2

• Ensure toilet access, especially for those with decreased mobility 1, 2
• Provide dietetic support and manage decreased food intake 1, 2
• Educate patients to attempt defecation at least twice daily, preferably 30 minutes after meals, straining no more than 5 minutes 1
• PEG (17 g/day) is the preferred option for elderly patients due to its efficacy and good safety profile 1, 2
• If swallowing difficulties or repeated impaction occur, rectal measures (isotonic saline enemas and suppositories) are the preferred treatment 1
• Monitor closely if on diuretics or cardiac glycosides due to risk of dehydration and electrolyte imbalances 1

Common Pitfalls to Avoid

• Never attempt aggressive disimpaction in patients with suspected perforation or bleeding 1, 2
• Do not use enemas in neutropenic patients (risk of sepsis) 1
• Avoid bulk-forming laxatives in non-ambulatory patients with low fluid intake (increased risk of mechanical obstruction) 1
• Do not forget to implement maintenance therapy—recurrence is common without preventive measures 5