Management of Fecal Stasis (Fecal Impaction)
For fecal impaction, the primary treatment is digital fragmentation and manual extraction of the impacted stool mass, followed immediately by oil retention enemas or suppositories, then oral polyethylene glycol (PEG) to clear remaining stool, and finally implementation of a maintenance bowel regimen to prevent recurrence. 1, 2
Initial Diagnostic Confirmation
Perform a digital rectal examination (DRE) to confirm distal rectal impaction and assess the consistency and location of the fecal mass. 2 If the rectum is empty on DRE but clinical suspicion remains high (especially with overflow diarrhea), obtain abdominal imaging to rule out proximal sigmoid or colonic impactions. 2
Step-by-Step Treatment Algorithm
Step 1: Manual Disimpaction
Digital fragmentation and manual extraction of the impacted stool mass is the primary intervention for distal fecal impaction. 1, 2 This involves physically breaking up and removing the hardened stool through the anal canal. 1
Step 2: Enemas and Suppositories
Administer oil retention enemas to lubricate and soften remaining stool, which must be retained for at least 30 minutes for maximum effect. 2 Water retention enemas or suppositories can also facilitate passage of fragmented stool through the anal canal. 1
Step 3: Oral Laxatives
Once the distal colon has been partially emptied with disimpaction and enemas, administer oral polyethylene glycol (PEG) solutions containing electrolytes to soften or wash out remaining stool. 1, 2 For proximal fecal impaction in the absence of complete bowel obstruction, lavage with PEG solutions may help soften or wash out stool. 1
Critical Contraindications to Enemas
Avoid enemas in patients with:
- Neutropenia (WBC < 0.5 cells/μL) 1, 2
- Thrombocytopenia 1
- Paralytic ileus or intestinal obstruction 1, 2
- Recent colorectal or gynecological surgery 1, 2
- Recent anal or rectal trauma 1, 2
- Severe colitis, inflammation or infection of the abdomen 1
- Toxic megacolon 1
- Undiagnosed abdominal pain 1, 2
- Recent radiotherapy to the pelvic area 1
Maintenance Bowel Regimen to Prevent Recurrence
Immediately implement a prophylactic bowel regimen after treating the acute impaction, using osmotic laxatives (PEG preferred) or stimulant laxatives (senna, bisacodyl) as the foundation of ongoing therapy. 1, 2 This is essential because recurrence is common without preventive measures. 3, 4
Additional preventive measures include:
- Increasing daily water intake 3, 4
- Increasing dietary fiber content to 30 grams/day 4
- Limiting medications that decrease colonic motility 3
- Regular physical activity 5
Potential Complications Requiring Urgent Recognition
Complications of fecal impaction include urinary tract obstruction, colonic perforation, dehydration, electrolyte imbalance, renal insufficiency, fecal incontinence, decubitus ulcers, stercoral ulcers, and rectal bleeding. 1, 2 In the presence of suspected perforation or bleeding, avoid disimpaction and obtain urgent surgical consultation. 1
Common Pitfalls to Avoid
Do not attempt enemas as first-line therapy when DRE identifies a full rectum with hard impacted stool—manual disimpaction must come first. 1, 2 Attempting to push enema fluid past a hard fecal mass is ineffective and may cause complications. 3
Do not skip the maintenance bowel regimen after acute treatment. 1, 2 The majority of patients will re-impact without ongoing laxative therapy and lifestyle modifications. 3, 4