Blogs

Review By Michelle Henderson

Just imagine – you are doing your weekly shop, your trolley is full, you are waiting at the checkout  – suddenly you feel the urge to move your bowels, you can’t stop it, there is faeces (poo) running down your leg onto the floor…. What would you do? 

This happens in real life, the impact is devastating. You might not know if, or when, it could happen again. So you stop going out. When your friends ask you to go here and there, you decline. Your partner wants to take you out for a meal – you say no. You have to pick your children up from school, there is no one else to do it – but the anxiety this creates is huge, you leave the house at the last minute and rush back home – the children are unhappy, they want to go to the park with all their friends…. 

The impact of bowel symptoms is far reaching – not just for the individual but also their family and friends. Bowel symptoms can affect all aspects of lifestyle – work, leisure, relationships.  Anxiety and depression are common amongst people with bowel problems. It is easy to become isolated and lonely. 

We know that embarrassment is a barrier to accessing medical support. In a survey undertaken in 2021, more than 1 in 4 respondents (26%) have delayed visiting their doctor over something they consider to be embarrassing, equating to nearly 14 million people (Essity 2021). 

Getting support is essential to maintain mental health. That support will be more helpful from those who understand your symptoms and its impact. Whilst discussing your bowel problems may feel awkward and embarrassing, even with close family and friends, it is worthwhile in the long term. 

Most Embarrassing Incidents to Share with Family, Partners and Close Friends: 

• Having wet or defecated yourself 46%  
• Being in debt 23%  
• Struggling with mental health 20%  
• Sending a flirtatious text to the wrong person 14%  
• Having lost your job 10%  
• Having fallen out with a friend 5%  
• Having lost an engagement ring 5% 

Source: Essity (2021) 

Further information, please visit: 

www.talkhealthpartnership.com/support

www.mentalhealth.org.uk

www.bladderandbowel.org

Reference:  
Essity (2021) Check for Change Campaign. Available at: https://www.essity.com/Images/Essity-Check-for-Change-Report-05_tcm339-122049.pdf.  Accessed 29 April 2022 

Review By Brigitte Collins & Michelle Henderson 

Ellie Bradshaw (Colorectal / Biofeedback Nurse Specialist) at Princess Grace Hospital delivers an excellent article ‘Colorectal Nursing and Low Anterior Resection Syndrome’ in the British Journal of Nursing. The latest evidence around assessment and treatment for LARS is discussed.  

Ellie highlights how the aim of assessment is to understand the main problems for the patient and determine the precipitating and palliating factors and how they have an impact.  

Relating this to her own practice, Ellie suggests a systematic and multimodal approach to treatment of LARS. Initially, this will comprise of conservative therapies with a progression to treatments such as transanal irrigation, which can be used simultaneously.  

The clinical team at MacGregor Healthcare, having had experience in treating LARS, would recommend this article as a valuable update on the latest evidence with practical suggestions for treatments in keeping with NICE recommendations. 

Reference:  
Bradshaw E (2022) Colorectal nursing and low anterior resection syndrome. British Journal of Nursing. Vol 31, No. 4. pp2-4 

Andrea Jordan, Lead Clinical Nurse Specialist: Paediatric Surgery, and Georgina Malakounides, Consultant Paediatric Surgeon, Addenbrookes Hospital, Cambridge

In our centre we have found low volume transanal irrigation (LV TAI) to have revolutionised the management of children with faecal incontinence. In our surgical colorectal clinic, we see children with chronic idiopathic constipation, neuropathic bowel or with ongoing constipation after surgery for Hirschsprung’s disease and anorectal malformations. These children often have a distal evacuation disorder and can have a secondary megarectum.

This is an in-demand clinic in our East of England network with 136 children seen since its introduction in 2019. These children have not responded to treatments beneath the transanal irrigation approach on the ERIC ladder including laxatives and suppositories. Even in young children aged between 3-5 years we find a proactive TAI approach to be very useful. We currently have 85 children on our active caseload on transanal irrigation.

On review of our centre’s experience of TAI between 2015-19 we found almost all children (80%) were managed on low volume TAI in the first instance rather than requiring the cone toilet or balloon irrigation device with good success rates. We would only step up the treatment ladder if effective emptying was not achieved.

Since the introduction of the upgraded version ‘MiniGo’ and ‘MiniGoFlex’ in 2021 the proportion of children we can successfully manage with low volume has increased to near 100%.  We have found the ability to add laxatives in the LV TAI devices also reduces the need to step up the treatment ladder.  Our provision of close follow up, early input with play therapy as needed and emphasis on getting the fundamentals right (drinking enough, pre-emptive, and active toileting) along with TAI has proven to be a success. 

Parents and carers quote the use of LV TAI as ‘life changing’ and ‘amazing’ with one noting it ‘brought my happy and healthy child back to me after years of being sad and withdrawn because of previous soiling’ and as professionals these words give us increasing confidence in the LV TAI device. 

Review By Brigitte Collins

One of the most noticeable advancements in colorectal surgery within the last decade has been the increasing use of sphincter-preserving rectal surgery with a low colorectal or colo-anal anastomosis (Berger et al, 2016). This type of surgery avoids a permanent stoma, and the use of a temporary ileostomy is now considered to be standard practice for most colorectal surgeons in the UK (Powell-Chandler et al, 2018). 

However, such developments come with consequences, where up to 80% of patients will develop a considerable degree of bowel dysfunction, namely low anterior resection syndrome (LARS). 

Symptoms of LARS are epitomised by faecal incontinence / urgency / frequency / fragmentation / evacuation difficulties, which can have a detrimental effect on quality of life. Conservative management consists of a range of treatments including of transanal irrigation (TAI), which fits into the LARS treatment algorithm (Embleton and Henderson 2021). 

Rebecca Embleton and Michelle Henderson (2021), undertook a service audit at the Durham bowel dysfunction service, which aimed to determine whether the use of TAI improved patient outcomes. The audit concluded that TAI reduced both the frequency of bowel movements and episodes of faecal incontinence.

I always find that having valuable data such as the Durham audit, supports clinicians in developing services and generates a wider approach to treatments being offered.   

References 
Berger N et al (2016) Low anterior resection syndrome: current management and future directions. Clin Colon Rectal Surg. 29(03):239–245. 

Powell-Chandler A et al (2018) PARiS (Physiotherapy and Anterior Resection Syndrome) Trial Management Group. Physiotherapy and anterior resection syndrome (PARiS) trial: feasibility study protocol. BMJ Open. 8(6):e021855

Read article here.

Review By Brigitte Collins

It always pleases me when I receive notification of newly published systematic reviews. This means that individual studies to a specific research question have been identified, evaluated, and the findings summarised. Therefore, providing us with coherent evidence in one publication.

Mekhael et al 2021, have done just that where transanal irrigation (TAI) studies have been appraised in neurogenic bowel disease, low anterior resection syndrome, faecal incontinence, and chronic constipation. The review mainly evaluates effects of TAI on patients who have not responded to conservative treatments for their bowel dysfunction, which conforms fittingly within the boundaries of treatment pathways in the National Health Service (NHS). 

Not only does this systematic review illustrate that bowel function is indeed improved with the use of TAI, but also gives us food for thought on our approach for ways of monitoring success in the future. 

For more in-depth information see the following reference. 

Mekhael M, Kristensen HO, Larsen HM, Juul T, Emmanuel A, Krogh K, Christensen P (2021) Transanal Irrigation for Neurogenic Bowel Disease, Low Anterior Resection Syndrome, Faecal Incontinence and Chronic Constipation: A systematic review. Journal of Clinical Medicine, 10 (753); 1-29.

Review by Brigitte Collins of childbirth and its effects on the bowel

Bladder and bowel care during childbirth is a critical part of maternity care. Ineffective care and management can lead to short and long-term consequences for both the woman and her family.

After attending The MASIC Foundation’s study days over the last 2 to 3 years, it’s been apparent from the MASIC mums who tell their stories that complications during childbirth can have a really devastating effect on the bladder and bowel.

In the first year after a vaginal delivery, 27% of women suffer with anal incontinence. This figure remains fairly consistent at 5 years post-delivery.

Complications during childbirth can lead to obstetric injuries. MASIC are paramount in raising awareness and dealing with these issues and along with the RCN (Royal College of Nursing). The RCN produced guidance in April 2021 that discusses bladder and bowel issues during pregnancy, labour and postnatally. One of the key messages from the RCN document is that we need to talk more about bowels and what can go wrong, and what help there is available to women with obstetric injuries.

Read the RNC Report here.

Review by Brigitte Collins of The CapaCiTY Report

As we are aware chronic constipation affects a high number of the population, who tend to suffer for many years. The ‘CapaCiTY’ study has been investigating treatments appropriate for this group, which has been recently published. The study comprised of three randomised controlled trials (RCTs): 1 Habit training compared with habit training with direct visual feedback.  2. Low volume compared to high volume initiated transanal irrigation (TAI). 3. Laparoscopic ventral mesh rectopexy. 

My focus has been drawn to section 2 comparing low volume irrigation to high volume irrigation in chronic constipation. Recruitment was planned for 300, 65 were randomised with outcome assessments completed at 3 months (n=48), 6 months (n=44) and 12 months (n=34). Despite numbers being low, I believe the trial still has some valuable findings.  

There is an awareness in clinical practice, which is also supported by the ‘Decision Guide’ (Emmanuel et al, 2019), that high volume irrigation would generally be recommended for patients with chronic constipation. It was therefore not surprising that high volume demonstrated improvement in patient’s outcome measures. Interestingly, it was also pleasing to see that low volume irrigation also had clinical benefit with a reduction of scores in the same outcome measures. The paper also concurs that many of the treatment responses improved over time, as well as, seeing a 76% survival of the treatment at 1-year. Therefore, implying a continued significant effect. 

I really like the fact that the publication also shows the impact on quality of life with many suggesting they had a freedom from the ongoing discomfort of chronic constipation and how TAI was preferable to laxatives. At the same time patients did not feel their bowels were ‘normal’, although, TAI brought them back to their own sense of ‘normal’. 

What this RCT demonstrates is that TAI can be a beneficial bowel management option in chronic constipation. So good to see that TAI can improve such debilitating symptoms.

Patient Story by Garrett, Klick User

“At last, I can plan ahead and commit to family events or workplace meetings and travel.

I am now safe in the knowledge that my Klick “kit” has worked its wonders earlier in the day. The relief gives me energy and confidence. The daily burning cramps and nausea are gone. 

The easy to understand instructions means it takes only minutes to assemble and use the Klick system. My feelings of trepidation were swiftly put to one side from day one as I now was in control of my digestive system rather than vice versa. I can now go and do simple, regular tasks, not wondering where the nearest toilet is or will there be enough toilet paper there when I find one!!

Yes, there is a little bit of trial and error at first. However, by using your Klick at the same time every day, your body will respond, and straining or weakness stops.

The biggest benefit that I personally get out of the Klick system is the fact that it doesn’t involve any type of medication. There are no side effects. No extra medication. No issue with having to change your existing medicines.

Using it regularly means that I am clean from the inside out. Yet all I have to do is this simple procedure as part of a regular routine to free me from the binds of constipation. Life goes back to normal. Would I recommend the Klick system? The answer for relief is YES. Somehow the load has become tolerable.”

Review By Brigitte Collins

The Bowel Interest Group (BIG) do it again and provide a fantastic and valuable report and webinar on the ‘Importance of Adherence’. One of the four areas that the report has a focus for is transanal irrigation (TAI) and as BIG point out adherence is essential to ensure the best possible outcomes for the patient.

Professor Anton Emmanuel in the report highlights that the two most important key areas for adherence and success in using TAI is:

• The quality of training provided to the patient.
• The quality of the follow-up provided to the patient.

The report also emphasises some pointers that can help with patient assessment, selection and establishing a routine. Such practical advice in my mind is always beneficial in strengthening the vast amount of knowledge that is seen amongst HCPs and their clinics.

I have always been an advocate in having tools to support my clinical practice. This BIG report can definitely do that. Furthermore, the principles of this report are consistent with the 5-step approach in the ‘Decision Guide’, which can help guide the novice in initiating TAI as well as protect the practice of the experienced.

Having the BIG report and Decision Guide in practice can only assist HCPs, which in the end will benefit the patient, create adherence to this treatment and therefore improve quality of life, granting each person the chance to lead a more fulfilled life.

Read the Big Report here.

Dr JO Menakaya MA MRCP, Consultant Paediatrician Clinical Lead, The PURA Project, Hillingdon Hospital Middlesex, UK

Dr Menakaya, Consultant Paediatrician at the Hillingdon Hospital in Middlesex, discusses his newest project which focuses on the management of bowel conditions in children, and how we can ‘keep it fun’.

Included in this write up is some fabulous feedback from the mother of a little boy who uses the Qufora IrriSedo MiniGo Flex to irrigate his bowels on a daily basis.

We love hearing about how the Qufora IrriSedo MiniGo Flex is helping people of all ages to live a more fulfilled life and we are glad that we can share the story of this fabulous little boy with you.

‘He is brilliant with it’. His mother said. ‘He helps me run the water until it is the right temperature and then reminds me to click the pouch shut properly. He makes sure that I attach the flexible tube with cone to the pouch securely and flush it so there is no air in the circuit. The only thing that I do is support him with the cone. When he is ready, he squeezes the MiniGo pouch and once the water runs through, he sorts himself out.  No fuss. No mess’.

This is the experience of an eight-year-old child and his mother whose life has been transformed a few days after highly skilled training and continuing support managing constipation and encopresis. In the last six months we have been running a pioneering Quality Improvement Project focusing on the management of this condition in children. We offer these children more than thirty different interventions (including trans-anal irrigation) within a multi-disciplinary care framework to resolve this symptom. 

As the project continues, we are learning the key ingredients for a successful outcome in the management of this distressing condition in children. These are proactive, committed and engaged carers – parents, teachers, and other key adults around the child, consistent toileting routine, partnership with the child no matter how young, and……… Keep It Fun! 

‘Can you show him bum twinkle? His mum asks him. His physiotherapist has recommended a series of daily pelvic floor exercises. He begins a sequence of complex abdominal wall muscle movements that have me rolling on the floor in fits of laughter. His face beams with a wide smile.  

I know he can see the light at the end of the tunnel.