What can be done for hard feces (stool) that won't come out of the rectum?

Management of Hard Feces Impacted in the Rectum

For hard stool impacted in the rectum, perform digital fragmentation and manual extraction as the primary intervention, followed immediately by oil retention enemas and oral polyethylene glycol (PEG) to clear remaining stool. 1, 2

Immediate Treatment Algorithm

Step 1: Confirm the Diagnosis

• Perform a digital rectal examination (DRE) to confirm the presence of hard, impacted stool in the distal rectum and assess the consistency and location of the fecal mass 1, 2
• If the rectum feels empty on DRE but symptoms persist (especially with overflow diarrhea or abdominal distension), obtain abdominal imaging to identify proximal sigmoid or colonic impactions 1

Step 2: Manual Disimpaction (First-Line Treatment)

• Administer analgesia and/or anxiolytic medication before the procedure to minimize patient discomfort 2
• Perform digital fragmentation and manual extraction of the impacted stool mass—this is the primary intervention for distal fecal impaction 1, 2
• This approach is more effective than relying solely on enemas or oral laxatives when hard stool is palpable in the rectum 1, 2

Step 3: Oil Retention Enema

• After manual disimpaction, administer an oil retention enema (warm mineral oil or olive oil) to lubricate and soften any remaining stool 1, 2
• The enema must be retained for at least 30 minutes for maximum effectiveness 1
• Alternative enema options include hypertonic sodium phosphate, docusate sodium, or bisacodyl enemas 2

Step 4: Oral Polyethylene Glycol (PEG)

• Once the distal colon has been partially emptied, administer oral PEG solutions containing electrolytes (17-34 g/day) to soften or wash out remaining stool and prevent recurrence 3, 1, 2
• PEG is preferred over bulk-forming laxatives like psyllium, which can worsen impaction in patients with limited mobility or opioid use 2

Critical Contraindications to Enemas

Do not use enemas in the following situations: 1, 2

• 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 pelvic radiotherapy

Prevention of Recurrence (Essential)

Immediately implement a prophylactic bowel regimen after disimpaction to prevent recurrence—this is not optional. 3, 1, 2

Maintenance Regimen Options:

• Osmotic laxatives (preferred): PEG 17-34 g/day, lactulose, or magnesium salts 3, 1, 2
• Stimulant laxatives: Senna 5-15 mg/day or bisacodyl 3, 2, 4
• Avoid stool softeners alone (such as docusate), as they are less effective than stimulant laxatives when used without additional agents 3, 5
• Avoid bulk-forming laxatives (psyllium) in patients with opioid-induced constipation or limited mobility, as they are ineffective and may worsen impaction 3, 2

Additional Preventive Measures:

• Increase daily water intake and dietary fiber (goal: 30 g/day) 6, 7
• Educate patients to attempt defecation at least twice daily, ideally 30 minutes after meals 2
• Discontinue or minimize medications that decrease colonic motility (opioids, anticholinergics, calcium channel blockers) 6, 7

Special Considerations for Opioid-Induced Constipation

If the patient is on chronic opioid therapy and standard laxatives fail: 3

• Consider opioid rotation to fentanyl or methadone 3
• Add peripherally acting mu-opioid receptor antagonists (PAMORAs) such as naloxegol (0.2 mg/day), naldemedine (12.5-25 mg/day), or methylnaltrexone (subcutaneous 12 mg/day) 3
• These agents block opioid receptors in the gut without affecting pain control 3

Potential Complications to Monitor

Fecal impaction can lead to serious complications including: 1, 2

• Urinary tract obstruction
• Colonic perforation and peritonitis
• Stercoral ulcers
• Dehydration and electrolyte imbalances
• Renal insufficiency
• Fecal incontinence (overflow diarrhea)
• Rectal bleeding

Rule out perforation or bleeding before proceeding with manual disimpaction. 2, 6, 7

When Surgery Is Needed

Surgical resection is reserved for cases complicated by bowel perforation leading to peritonitis—this is rare but life-threatening 6, 7