From the Guidelines
Fleet enemas can cause bowel perforation, although this is a rare complication, and their use should be approached with caution, especially in high-risk populations. The risk of perforation is higher in certain populations, including elderly patients, those with severe constipation, inflammatory bowel disease, or weakened rectal tissues 1. Perforation can occur due to improper insertion technique, forceful administration, or the rigid tip of the enema bottle causing direct trauma to the rectal wall. Signs of perforation include severe abdominal pain, rectal bleeding, fever, and symptoms of infection or sepsis, which require immediate medical attention.
To minimize risk, the enema should be inserted gently, with the tip pointed toward the navel rather than straight in, and administration should stop if resistance or pain is encountered. According to the most recent guidelines, enemas are contraindicated for patients with neutropaenia or thrombocytopaenia, paralytic ileus or intestinal obstruction, recent colorectal or gynaecological surgery, recent anal or rectal trauma, severe colitis, inflammation or infection of the abdomen, toxic megacolon, undiagnosed abdominal pain or recent radiotherapy to the pelvic area 1.
Alternative constipation treatments like oral laxatives, increased fluid intake, dietary fiber, or glycerin suppositories may be safer options for regular use, especially in high-risk individuals. The use of rectal suppositories or enemas should be avoided in patients with neutropenia or thrombocytopenia, and oral laxatives or enemas that contain sodium phosphate should be limited to a maximum dose of once daily in patients at risk for renal dysfunction 1.
Some key points to consider when using fleet enemas include:
- The risk of perforation is higher in certain populations, including elderly patients, those with severe constipation, inflammatory bowel disease, or weakened rectal tissues
- Perforation can occur due to improper insertion technique, forceful administration, or the rigid tip of the enema bottle causing direct trauma to the rectal wall
- Signs of perforation include severe abdominal pain, rectal bleeding, fever, and symptoms of infection or sepsis, which require immediate medical attention
- Alternative constipation treatments may be safer options for regular use, especially in high-risk individuals.
From the Research
Fleet Enemas and Perforation
- Fleet enemas can cause perforation, as reported in several studies 2, 3, 4, 5.
- The perforation rate and mortality associated with enema use can be significant, with a pooled prevalence estimate of mortality of 38.5% reported in one study 2.
- The primary location of the perforation is often the rectum, with 80.9% of patients experiencing rectal perforation in one study 2.
- The administration of Fleet enemas by a nurse or self-administration can increase the risk of perforation, with 90% of cases administered by a nurse and 7.5% self-administered in one study 2.
Prevention and Management
- Guidelines for the safe use of enemas, including Fleet enemas, are urgently needed to prevent perforation and other complications 2, 3, 6.
- Awareness of the possible injury from enemas administered to chronically constipated patients is crucial, and a high degree of suspicion by the attending physician is extremely important 4.
- Prompt diagnosis and early surgical treatment can carry a relatively good prognosis, with 10 patients surviving in one study where diagnosis was made within 36 hours of perforation 4.
- The use of alternative enema solutions, such as Easy Go enema, which is free of sodium phosphate, may reduce the risk of perforation and other complications 3.