Enema Administration for Fecal Impaction in Elderly Women
Yes, you can and should give an enema to an elderly woman with fecal impaction, but only after manual disimpaction and with specific precautions—use isotonic saline enemas rather than sodium phosphate enemas in this age group. 1
Treatment Algorithm for Fecal Impaction in Elderly Patients
Step 1: Initial Manual Disimpaction
- Perform digital fragmentation and extraction of stool first, before administering any enema 1, 2
- Premedicate with an analgesic ± anxiolytic for patient comfort 2
- This initial manual removal is essential to prevent complications and improve enema effectiveness 3, 4
Step 2: Enema Administration After Partial Manual Disimpaction
- Following partial manual disimpaction, administer a water or oil retention enema to facilitate passage of remaining stool 1, 2
- Use isotonic saline enemas preferentially in elderly patients due to significantly lower risk of adverse effects compared to sodium phosphate enemas 1
- Glycerine suppositories can serve as an alternative or adjunct 2
Critical Contraindications to Screen For
Before administering any enema, ensure the patient does NOT have: 1
- Neutropenia or thrombocytopenia (absolute contraindication)
- 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
Why Isotonic Saline Over Sodium Phosphate in the Elderly
The evidence strongly favors isotonic saline enemas in elderly patients because sodium phosphate enemas carry significant risks in this population 1:
- Risk of hyperphosphatemia and metabolic derangement 5
- Higher perforation rates documented with Fleet® (sodium phosphate) enemas—one study showed 1.4% perforation rate and 3.9% 30-day mortality with phosphate enemas 5
- Elderly patients with cardiac or renal comorbidities are particularly vulnerable to electrolyte imbalances 1
Post-Treatment: Mandatory Maintenance Regimen
After successful disimpaction, immediately implement a maintenance bowel regimen to prevent recurrence 1, 2:
- Polyethylene glycol (PEG) 17g daily is the safest first-line option for elderly patients with good safety profile 1, 2
- Avoid magnesium-based laxatives due to hypermagnesemia risk, especially if renal impairment present 1, 2
- Stimulant laxatives (senna, bisacodyl) can be added if PEG insufficient 2
Essential Non-Pharmacologic Measures
Implement these preventive strategies immediately 1, 2:
- Ensure toilet access and privacy, critical for patients with decreased mobility 1, 2
- Optimize toileting schedule: attempt defecation twice daily, 30 minutes after meals, strain no more than 5 minutes 1, 2
- Use small footstool to assist with positioning and leverage gravity 2
- Increase fluid intake within cardiac tolerance limits 2
- Maximize mobility even if only bed-to-chair transfers 2
Common Pitfalls to Avoid
Do not administer enema without first attempting manual disimpaction—this increases risk of perforation and is less effective 1, 2
Do not use bulk laxatives or fiber supplements in non-ambulatory elderly patients with low fluid intake—these increase risk of mechanical obstruction 1
Do not use liquid paraffin in bed-bound patients or those with swallowing difficulties—risk of aspiration lipoid pneumonia 1
Review all constipating medications (anticholinergics, opioids, calcium channel blockers, diuretics) and discontinue if possible 2, 3, 4