Adult Bowel Care Policy.pdf - NHS North Somerset

Adult Bowel Care Policy 

Author(s): 

Lead Clinician (if 

appropriate): 

In consultation with: 

To be read in 

association with: 

Ratified by: PEC 

Issue/Ratification date: June 2009 

Review date: June 2010 

Cath Williams, Continence Service 

Manager 

Hannah Braine, Senior Clinical 

Nurse in conjunction with BNSSG 

Continence Services 

Cath Williams, Clinical Lead, 

Continence 

Bristol and Weston Continence 

Group (BNSSG wide) 

Infection Control Policy , Hand 

Hygiene Policy , Anaphylaxis Policy, 

Consent Policy. 

If you require this document in a different format, 

please telephone the Corporate Manager on 

01275 546717 

Doc File Reference Issuer: Policy No: Issue Date: Issue No: Review Date: Page: 

Adult Bowel Care Policy PS 337 06/2009 1 06/2010 1 of 42 

1

Contents 

1. Purpose of Policy 3 

2. Scope 3 

3. Background 3 

4. Cross Reference with other policies 4 

5. Training & competence 5 

6. Consent 5 

7. Bowel Assessment 6 

8. Acute bowel care problems 7 

9. Chronic bowel problems 10 

10. Understanding Faecal Incontinence 11 

11. Understanding procedures 13 

12. Documentation 18 

19. References 19 

Appendices 

1. Digital Rectal Examination 20 

2. Manual Removal of Faeces 23 

3. Digital Stimulation 26 

4. Insertion of Suppository 27 

5. Insertion of Enema 30 

6. Trans-Anal irrigation using Peristeen System 32 

7. Insertion of PeristeenAnal Plug 38 

8. Core Competencies Relating to Bowel Care 40 

9. Specific Competencies 41 

10. Suggested type of consent for bowel care 42 



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1. Purpose of the policy 

1.1 To ensure a high standard of bowel care, including assessment, treatment and 

management including rectal interventions. 

1.2 To ensure safe, competent practice by all clinicians undertaking bowel care and 

reduce risk of complications associated with bowel management. 

1.3 To standardise practice across North Somerset PCT and the wider healthcare 

community. 

1.4 To ensure that all practice is evidence based, relevant, appropriate and minimised 

harm 

2 Scope 

The policy will apply to all staff undertaking bowel care for adults, with the exception of 

stoma care. 

In order to carry out invasive bowel care all staff should attend relevant training, achieve 

competency, and be working within their job description. 

It is recommended that this policy also be adopted in independent care homes within 

North Somerset, in order to promote consistently applied evidence based care. 

This policy does not include rectal examination for the purpose of prostate assessment. 

3 Background / Policy Statement 

“Bowel care is a fundamental area of patient care that is frequently overlooked, yet 

it is of paramount importance for the quality of life of our patients, many of whom 

are hesitant to admit to bowel problems or to discuss such issues.” 

(RCN 2008) 

Bowel care may include rectal interventions. This should only be carried out when there 

is a specific and adequate clinical indication. It is the policy of this PCT that bowel care 

should be carried out in a safe and consistent manner according to North Somerset PCT 

Procedures for bowel care are found in appendices 1-6 



3

4 Cross Reference with other Policies and Guidance 

Cross-reference must be made to other NSPCT policies and national guidance. 

• Autonomic Dysreflexia Policy. 

• North Somerset PCT Infection Control Policy and Guidelines Manual 

• Hand Hygiene Policy 

• Anaphylaxis Policy 

• Consent Policy 

• Medicines Management 

• Records Management policy 

• Continence Formulary 

• Bowel Care, including digital rectal examination and manual removal of faeces 

(RCN 2008) 

• Faecal Incontinence, The management of faecal incontinence in adults. (NICE 

2007) 

• Guidelines for the use of rectal irrigation (St Marks Hospital 2008) (Norton) 

• Skills for Health National Occupational Standards 2008, available at 

www.skillsforhealth.org.uk/competences/completed-competncesproject/list/continence-care 



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5 Training and Competence 

5.1 All practitioners undertaking bowel care must be able to demonstrate competence 

and theoretical understanding of bowel anatomy, physiology, function and dysfunction. 

5.2 All practitioners will have a working knowledge of the current legislation, national 

guidelines, organisational policies & protocols. 

5.3 All practitioners will have a working knowledge of working within your sphere of 

competence and when to seek advice. 

5.4 All practitioners undertaking this procedure must have attended a recognised 

training course and be assessed as competent. This will normally be accessed through 

NSPCT Continence Service. Every practitioner will have evidence of having performed at 

least one supervised practice with a competent assessor. 

5.4 Competent assessors are defined as practitioners who have undergone training, 

workplace assessment and who practice the technique as an integral part of their clinical 

role. Competent assessors will be nurses, midwives, and medical practitioners. Staff 

entering the PCT who have been trained in another Trust or any other healthcare 

organisation must produce evidence of their training and assessment and be assessed 

once in the clinical area using the PCT core competency assessment framework (see 

Appendices 7-8). The register of competent assessors will be maintained by the PCT 

training department. 

5.5 All staff must practise the skills regularly to maintain the competencies. They 

must refresh their knowledge and skills at least every 3 years. Retraining can be 

accessed through the Continence Department. 

5.6 Staff (practitioners and assessors) must maintain their competence through 

clinical practice, retraining and personal study. 

5.7 In some areas, care assistants are involved in carrying out some aspects of bowel 

care. The relevant bowel care interventions are delegated to the health care assistants 

by registered nurses who remain accountable for the actions. [The RCN Code 2008]. 

6 Consent 

Obtaining consent is essential before carrying out nursing care, treatment or 

procedures involving physical contact with a patient. Without consent the care or 

treatment may be considered to be unlawful. 

The mental capacity act 2005 provides a statutory framework to empower and protect 

vulnerable people aged 16 and over who are not able to make better decisions. 



5

When there is doubt about the mental capacity of a patient to make decisions relating to 

the procedure the PCT guidelines for assessing capacity and determining best interests 

must be followed. 

Consent policy should be followed at all times. 

See appendix 10 for suggested type of consent required for bowel management. 

7 Bowel Assessment 

Bowel care deals with intimate and private parts of the body. All interventions relating to 

assessment and treatment require discretion and sensitivity. 

Assessment of bowel continence and function should form part of the holistic patient 

assessment. Bowel assessment includes obtaining a history and carrying out relevant 

clinical examinations. It also includes carrying out and interpreting relevant baseline 

observations and tests. 

Bowel assessment should be completed using the Continence Assessment Form, and 

using information in the Appendices of the Continence Care Pathways. 



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8 Acute Bowel Care Problems 

Nurses need to know what constitutes a bowel care emergency, and be able to act 

without delay to prevent further complications. 

The table below lists the most common bowel care emergencies, presentation and 

management. 

Type of Emergency 

Autonomic Dysreflexia. 

Life- threatening complication of spinal 

injury , level T6 or above. 

Abnormal response to pain/ stimulus may 

result in seizure, stroke and death. 

Triggers include constipation, digital 

stimulation, manual evacuation and enemas 

and irrigation. 

Bowel Obstruction 

No bowel activity 

Abdominal pain & Distension 

Vomiting 

Possible dehydration 

Serious condition requiring immediate 

medical attention 

If untreated, bowel may rupture, leak its 

contents causing peritonitis. 

Perforation 

Hole in the bowel - allows leakage of 

intestinal contents into abdominal cavity. 

High fever 

Nausea 

Severe abdominal pain, worse on 

movement 

Intense vomiting leading to dehydration 

If untreated causes peritonitis. 

Management 

Management plan for all patients at risk. 

Patient and all care staff should be aware 

of triggers, symptoms and management 

plan. 

Refer to Autonomic Dysreflexia Policy. 

Seek urgent medical attention 




7

Strangulated Hernia 

Blood supply to the bowel cut off 

May lead to ischemia, necrosis, gangrene 

Diarrhoea 

Many causes eg:- 

Colitis 

Small bowel disease 

Pancreatic 

Endocrine 

Infection 

Antibiotic therapy 

Drug induced 

May lead to dehydration,& electrolyte 

imbalance 

Undiagnosed Rectal Bleeding 

Many causes eg:- 

Haemorrhoids 

Anal fissure 

Proctitis 

Diverticular Disease 

Colitis 

Polyps 

Ulceration 

Malignancy 


Full assessment - history and physical 

assessment to exclude impaction 

Exclude impaction - if constipated follow 

acute constipation plan. 

Send stool sample for culture 

Full assessment 

Referral on to medical practitioner. 



8

Recent Change In Bowel Habit. 

Can include any of the following when not 

associated with lifestyle changes. 

Stool consistency 

Unintentional Weight loss 

Rectal bleeding 

Anaemia 

Increased mucous and wind 

Faecal Impaction 

If not treated can cause an obstruction 


Referral on to medical practitioner. 


Macrogol 3350 (Movicol) is licensed to 

treat faecal impaction and should be used 

to resolve this before giving rectal 

medication. 

Phosphate enemas should only be given 

as a last resort. 

Manual evacuation may be appropriate 

for patients with impaction. 

(RCN 2008) 



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9. Chronic Bowel Problems 

Constipation Faecal Incontinence 

Increase fluid intake 

Adjust diet 

Encourage exercise as appropriate 

Allow time on the toilet (up to 10 mins) 

Abdominal massage 

Ensure correct positioning on toilet (brace & 

bulge) 

Improvement 

Continue regime 

Assess regularly 

Chronic Bowel Problem 

Complete Bowel Assessment 

To Include: 

Diet and stool diary for 2 weeks 

Stool type (Bristol Stool Scale) 

See Continence Assessment 

Form 

No Improvement 

Try laxatives 

Refer to continence 

Formulary 

No Improvement 

Refer to Continence Service 

Adjust diet 

Teach anal sphincter 

exercises 

Encourage time spent 

on the toilet 

Consider Loperamide 

Consider containment 

Refer to NICE 2007 

Improvement 

Continue regime 

Assess regularly 

Adapted from Southampton City PCT, cited in Wilson 2005 



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10 Understanding Faecal Incontinence (FI) 

Assessment – As above 

Initial Management: 

Diet 

• Take into account existing therapeutic diets. 

• Ensure overall nutrient intake is balanced 

• Consider use of a food & fluid diary 

• Advise patient to modify one food at a time 

• Encourage people with hard stools and/or clinical dehydration to aim for intake of 

at least 1.5 litres of fluid per day (unless contra-indicated) 

• Consider screening people for malnutrition or risk of malnutrition. 

Bowel Habit 

Interventions should promote ideal stool consistency and predictable bowel emptying. 

• Encourage bowel emptying after a meal. 

• Ensure toilet facilities are private, comfortable and can be safely used with 

sufficient time allowed. 

• Encourage people to adopt a sitting or squatting position where possible while 

emptying the bowel and avoid straining. 

Toilet Access 

• Ensure locations of toilets are made clear and any equipment or help needed to 

access the toilet is provided 

• Offer advice on easily removable clothing. 

• Refer for home and mobility assessment if appropriate 

Medication 

• Consider alternatives to drugs contributing to FI 

• Prescribe anti-diarrhoeal drugs, in accordance with summary of product 

characteristics, for people with loose stools and associated FI once other causes 

have been excluded. Loperamide should be 1 st drug of choice. 

o Consider Loperamide syrup for doses less than 2 mg 

o Offer codeine phosphate or co-phenotrope if unable to tolerate Loperamide. 

o Introduce at very low dose and escalate as tolerated until desired stool 

consistency is reached 

o Advise that dose can be altered up or down in response to stool 

consistency and lifestyle 

o Do not offer Loperamide to people with 

hard or infrequent stools 

acute diarrhoea without a diagnosed cause 

acute flare up of ulcerative colitis 

Coping Strategies 

• Offer advice on 

o Continence products 

o Emotional and psychological support 

o Talking to friends and family 

o Planning travel and carrying a toilet access card or RADAR key 



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• Offer people with FI 

o Choice of disposable body-worn pads and disposable bedpads in sufficient 

quantities 

o Anal plugs 

o Skin care, odour control and laundry advice 

o Disposable gloves 

Do not generally recommend reusable absorbent products. 

Review 

• Ask whether FI has improved 

• If symptoms persist discuss further treatment options 

• If individual does not wish to progress further in care pathway provide long term 

strategies 

o Advice on preservation of dignity and independence 

o 6 monthly review of symptoms 

o Discussion of other management options (including specialist referral) 

o Contact details for relevant support groups 

o Advice on coping strategies and skin care 

• Specific management will be needed for people with the following 

o Faecal loading 

o Limited mobility 

o Neurological/spinal disease 

o Learning difficulties 

o Severe or terminal illness 

o Acquired brain injury 

Specialised Management 

Consider specialised management options, which may be provided by a specialist 

continence service. These may include 

• Pelvic floor muscle training 

• Bowel retraining 

• Specialised dietary assessment and management 

• Biofeedback 

• Electrical Stimulation 

• Rectal irrigation 

Consider whether people with neurological or spinal disease / injury resulting it FI could 

benefit from specialised management 

Specialist Assessment 

Refer patients with continuing FI for consideration for specialist assessment including 

• Anorectal physiology studies 

• Endoanal ultrasound (if unavailable consider MRI, endovaginal ultrasound and 

perineal ultrasound) 

• Other tests including proctology as indicated. 

NICE 2007 



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11 Understanding Procedures involved in Bowel Care 

11.1 Digital Rectal Examination 

Digital rectal examination (DRE) is an invasive procedure and should only be performed 

after completion of a full assessment of constipation. It involves observing the perianal 

area and inserting a lubricated gloved finger into a patient's rectum. Its intimate nature 

and fears of litigation/accusation of abuse have led to confusion among nurses about 

their professional and legal responsibilities. (RCN 2008) 

A DRE may be performed for a number of reasons. It can establish the presence, 

amount and consistency of faecal matter in the bowel. It is also used to assess the need 

for rectal medication or digital removal of faeces in extreme cases of faecal impaction. 

DRE is also a method of gauging anal sphincter function and tone and rectal sensation. 

DRE to assess the size of the prostate gland is not within the scope of this policy. 

For full procedure see appendix 1 

11.2 Manual Evacuation of Faeces 

In most cases the need for the digital removal of faeces is preventable by using a 

stepped approach to the management of constipation (RCN 2008). The digital removal of 

faeces is an invasive procedure and should only be practiced when necessary, and after 

a comprehensive assessment (SSH CC01 and RCN 2008) 

For some patients such as those with spinal cord injury, cauda equina, spina bifida and 

multiple sclerosis the digital removal of faeces is an integral part of their routine bowel 

management ..... Only a competent practitioner should carry out this procedure. 


11.3 Digital Stimulation 

Kyle et al 2008 

Stimulation of the anus or anal sphincter can aid some patients with defaecation. It is 

suggested that this procedure can be effective when used together with techniques to 

enhance defaecation such as, adopting the correct position on the lavatory and taking 

hot drinks and food 20-30 minutes prior to instigating bowel care, to take advantage of 

the gastric colic reflex which is strongest after the first meal of the day but can be 

stimulated at other times. In spinal injury patients with a lesion above cauda equina, it's 

usually possible to stimulate a defaecation reflex using Digital stimulation (Powell and 

Rigby 2000). This stimulated reflex may be insufficient to completely empty the bowel 

and a digital removal of faeces may still be required. 


Kyle et al 2008 



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11.4 Insertion of Suppository 

A suppository is a medicated solid formulation prepared for insertion into the rectum. 

Once inserted the temperature of the body will dissolve the suppository from its solid 

form to a liquid. 

The administration of a suppository requires skill and competence on the part of the 

practitioner, as well as their compliance with the NMC guidelines on the administration of 

medicines (2008) and local drug administration policy. 

11.41 Indications for administration 

Suppositories may be a useful tool in the management of chronic constipation, 

particularly when combined with other interventions such as oral agents and preventative 

measures. They may also be used to empty the rectum in preparation for investigation 

and for other procedures such as colonoscopy. 

Suppositories may be used as a route of drug administration for local effect (haemorrhoid 

medication) or to be absorbed for systemic effect by the vascular network surrounding 

the rectum (analgesia, antibiotics). The rectal route of drug administration is particularly 

useful for patients who are fasting or nil-by-mouth before or after surgery. 

11.42 Precautions/considerations 

Care should be taken in the administration of suppositories to patients who have 

undergone rectal or lower colonic surgery, or who have experienced an obstruction, as 

the risk of perforation may be increased. This risk may also be increased in patients who 

have undergone gynaecological surgery or radiotherapy. 

Any pathology of the perianal region should be considered and risks assessed. 

Digital rectal examination, according to organisational policy, should be performed prior 

to administration to assess faecal loading and any abnormalities. 

The risks associated with suppository administration are considered to be low but 

suppositories can be detrimental and at worst fatal to the patient if administered in the 

wrong circumstances. Expert advice should be sought from specialist practitioners in any 

of the circumstances mentioned above. 

Suppositories are occasionally prescribed to be administered via a stoma. Again, it is 

important that expert advice should be sought in such situations. 

There has been some controversy over the correct insertion technique with regard to 

which end of the suppository to insert first – the apex (narrower end) or base (blunt end). 

In a small sample study (Abd-el-Maeboud et al 199, cited Higgins 2007) suggested that if 

suppositories are inserted apex first the circular base distends the anus and the sphincter 

may not close completely. However, there is as yet insufficient research evidence to be 

conclusive about which end of a suppository should be inserted first. 

Higgins, D. (2007) 




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11.5 Insertion of Enema 

Before considering the use of an enema for treatment of constipation please refer to the 

continence formulary for guidance on treating with high dose Movicol (Macrogol 3350) 

An enema is a liquid preparation that is introduced into the body via the rectum for the 

purposes of producing a bowel movement or administering medication. 

An enema may be required for the following: 

• Acute disimpaction of the bowel; 

• Bowel clearance before bowel investigations or surgery; 

• To soothe and treat bowel mucosa in chronic inflammatory bowel disease such as 

ulcerative colitis and Crohn’s disease. 

There are two main types of enemas – evacuant and retention. 

11.51 Evacuant 

An evacuant enema is designed to prompt the bowel to expel faecal matter or flatus, 

together with the contents of the enema. 

Phosphate and sodium citrate (Microlette) are the most common types. Possible risks 

associated with phosphate enemas have been raised (Davies, 2004) 

so an assessment of need is vital. A recent systematic review of the adverse effects of 

phosphate enemas (Mendoza, 2007) found an absence of conclusive evidence. Those 

aged under five and over 65 appear to be most at risk, especially older people with 

chronic renal failure and/or diseases that alter intestinal mobility. 

11.52 Retention 

A retention enema is designed to be retained in the rectum. The most common are: 

• Steroid and aminosalicylate preparations; 

• Arachis oil enemas, which soften and lubricate impacted faeces. They contain 

groundnut and peanut oil, which means they should be avoided in patients with a nut 

allergy. 

Nurses must have a sound knowledge of the use, action, dose and possible ill 

effects of administrating an enema. Volume retention enemas are contraindicated in all 

spinal injury patients. 

Kyle G (2007) 




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11.6 Trans-Anal Irrigation 

The terms Trans- anal Irrigation and Rectal Irrigation are used interchangably in current 

literature. 

This is a specialist procedure and should only be commenced following consultation with 

the Continence Service 

Trans-anal irrigation has been found in a randomized controlled trial to be effective for 

both constipation and faecal incontinence in patients with spinal cord injury. In 

scintigraphic studies anal irrigation has been found to empty stool as far as the splenic 

flexure. However there is a relatively small evidence base for this procedure at present 

and so much of the advice given is based on expert opinion and practical experience. 

(Norton 2008) 

Trans-anal irrigation must only be tried if other less invasive methods of bowel 

management have failed to adequately control constipation and or faecal incontinence. 

This procedure is designed for independent patient use, but there are some 

circumstances where it will need to be carried out by a health professional. 

Trans-anal irrigation should only be started and carried out for the first time under the 

direction of the doctor, nurse or other qualified health care professional. All healthcare 

professionals who are considering recommending the use of anal irrigation should 

discuss this with the continence service. 

11.61 Indications for use 

• neurogenic bowel dysfunction e.g. spinal cord injury, spina bifida, multiple 

sclerosis. 

• Chronic constipation including the evacuation difficulties and slow transit 

constipation 

• Chronic faecal incontinence 

11.62 Use with care and close monitoring 

Some types of patients require additional supervision or monitoring at least until it is clear 

that irrigation is not producing any problems. This will depend upon the judgement of the 

assessing professional but may include: 

• Spinal Cord injury at or above T6, monitor for autonomic dysreflexia until it is clear 

that the technique is well tolerated and does not promote provoke autonomic 

dysreflexia 

• unstable metabolic conditions (frail, known renal disease or liver disease: may need 

to monitor electrolytes and possibly use a line rather than water for irrigation) 

• Under 18 years old (consultant paediatric consultant and you say land for younger 

children) 

• Inability to perform the procedure independently or comply with the protocol in the 

absence of close involvement of carers (e.g. due to physical disability, cognitive 

impairments, major mental or emotional disorder). Experience to date with irrigation 

by a carer suggest that it is no more problematic than self irrigation forfeited the 

disabled individuals 



16

• anorectal conditions that could cause pain or bleeding during the procedure (e.g. 

third-degree haemorrhoids, anal fissure) 

11.63 Relative contraindications (use only after careful discussion with relevant 

medical practitioner and continence service) 

• Pregnancy - existing or anticipated 

• active perianal sepsis 

• diarrhoea 

• anal fissure 

• large haemorrhoids that bleed easily 

• faecal impaction 

• past pelvic radiotherapy which has caused bowel symptoms 

• known severe diverticular disease 

• use of rectal medications for other diseases 

• congestive cardiac failure 

• anal surgery within the past six months 

11.64 Absolute contraindications (irrigation should not be used) 

• acute active inflammatory Bowel disease 

• known obstructing rectal or colonic mass 

• severe cognitive impairments 

• rectal or colonic surgical anastomosis within the last six months 

(Norton 2008) 

For procedure see Appendix 6. However, before commencing Trans-anal irrigation the 

following information must also be viewed. 

Norton 2008 Guidelines for the use of rectal irrigation. Coloplast 

Coloplast 2007 A patient’s guide to Peristeen Anal Irrigation (DVD) Coloplast 

Both accessibla via the Continence Service or Coloplast 0800 132 787 

11.7 Use of Peristeen Anal Plug 

This is a useful device for individuals with passive soiling who can use it on a daily basis 

or when they want to do sports activities. It is not suitable for patients with frequency of 

defaecation, as it would have to be removed each time. The advantage is that it usually 

stops soiling, however some patients report discomfort and are unable to tolerate it. 

Patients with a neurological injury or condition benefit from it, as they frequently lack 



17

function in the anal canal. It is used after their normal bowel regime, and is inserted to 

prevent further soiling. (Chelvanayagam & Norton 2004) 

12 Documentation 

Ensure that all assessment, care and treatment is documented as per NMC guidance, 

and North Somerset PCT Records Management Policy. 



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13 References 

Chelvanayagam S, Norton C. 2004 Practical management of faecal incontinence. In 

Norton C, Chelvanayagam S (eds) Bowel Continence Nursing. Beaconsfield 

Higgins, D. (2007) Bowel care Part 6 – Administration of a suppository. Nursing Times; 

103: 47:, 26-27. in Practical Procedures, Bowel Care (CD- Rom) Norgine 2007 

Kyle G. 2007a Bowel Care Part 4. Administering an Enema Nursing Times 103: 45, 26- 

27 in Practical Procedures, Bowel Care (CD- Rom) Norgine 2007 

Kyle, G. 2007b Bowel care, part 5 – a practical guide to digital rectal examination. 

Nursing Times; 103: 45, 28-29. in Practical Procedures, Bowel Care (CD- Rom) Norgine 

2007 

Kyle G, Dunbar T, Prynn P. 2008 The procedure for the digital removal of faeces. Norgine 

Ltd. 

NICE 2007 Faecal incontinence. The management of faecal incontinence in adults. 

London NICE 

Norton 2008 Guidelines for the use of rectal irrigation. Coloplast 

Nursing & Midwifery Council 2008 Standards of proficiency for nurse and midwife 

prescribers http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1645 viewed 

29.11.08 

RCN 2008 Bowel care, including digital rectal examination and manual removal of 

faeces. London RCN 

Skills for Health National Occupational Standards 2008, available at 

www.skillsforhealth.org.uk/competences/completed-competnces-project/list/continencecare 

Wilson L 2005 Understanding Bowel problems in older people. part 2. Nursing Older 

People Vol 17 no 9 p 24-29 



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Appendix 1 

Procedure for Undertaking Digital Rectal Examination 

Equipment 

• Plastic-backed absorbent sheet; 

• Non-latex disposable gloves & apron 

• Gauze swabs; 

• Lubricating jelly. 

Prior to Procedure 

Before carrying out a DRE, observe the perineal and perianal area for signs of: 

Rectal prolapse and its degree, 

colour, swelling and any ulceration 

Haemorrhoids. Note number, size 

and any signs of bleeding 

Anal skin tags 

This occurs when the internal 

anal sphincter is incompetent 

and pelvic floor muscles are 

weak; 

Anal lesions or swelling. These could indicate anal/rectal 

malignancy 

Gaping anus This may indicate poor 

sphincter tone. If faecal matter 

is observed this can indicate 

faecal impaction 

Skin condition, broken areas, 

pressure ulcers 

Excoriation or puritus 

indicates possible signs of 

faecal incontinence 

Soiling This indicates faecal 

incontinence 

Bleeding, or mucus discharge This may indicate 

inflammatory bowel disease or 

malignancy 

Infestation 

Foreign bodies 

This may indicate anal 

warts caused by a virus or 

threadworms; 



20

Any of the above abnormalities 

should be documented and 

reported 

Procedure 

Prepare equipment To be prepared 

Explain the procedure and potential 

risks to the patient, and document 

that consent has been given; 

Encourage the patient to empty 

their bladder, as DRE may cause 

discomfort to a full bladder 

Cover the bed with a protective 

layer 

To ensure the patient 

understands and gives valid 

consent. 

To facilitate patient comfort 

To reduce possible infection 

caused by soiled linen and to 

avoid embarrassment 

Ensure the patient has privacy. this is an invasive and 

embarrassing procedure 

Ensure a commode or toilet is 

nearby 

Remove any clothing below the 

waist and ensure the patient is 

covered with a blanket 

Assist the patient to adopt, if 

possible, the left lateral position with 

knees flexed to expose the 

perineum and perianal area 

Wash hands, and put on disposable 

apron and gloves 

Observe the perineal and perianal 

area as above 

Place some lubricating gel on a 

swab and onto the gloved index 

finger 

DRE can stimulate the bowel 

giving the urge to defecate 

To avoid unnecessary 

embarrassment 

The left side is preferred 

as it allows DRE to follow the 

natural anatomy of the bowel 

but it is not essential, for 

example if a patient has a leftsided 

weakness; 

To minimise the risk of cross 

infection 

To ensure any conditions are 

detected and treated 

Lubricating reduces surface 

friction thus eases insertion and 

avoids anal and mucosal 



21

Inform the patient of imminent 

examination 

Part the buttocks and gently 

insert the gloved index finger into 

the anus. 

On insertion of finger, assess anal 

sphincter control 

Insert finger more than 5cm to 

ensure examination of the rectum 

Assess external sphincter tone by 

asking the patient to contract the 

anus 

Note the presence and consistency 

of faecal matter within the rectum 

Wipe the perianal area with a clean 

swab 

Remove gloves and apron, and 

dispose of appropriately 

trauma 

To ensure they are ready and 

as relaxed as possible 

To avoid trauma to the anal 

mucosa and prevent forced 

over-dilation of the anal 

sphincter 

Resistance should be 

felt. Digital insertion with 

resistance indicates good 

internal sphincter control. 

Conversely, a lack of 

resistance indicates poor 

sphincter tone 

The anal canal is about 5cm 

long 

Those who cannot hold a 

contraction may complain of an 

urgency to defecate 

To establish constipation or 

faecal impaction and the need 

for intervention 

To leave the patient 

comfortable and clean and 

prevent excoriation of the anal 

area 

To reduce the risk of infection 

Wash hands To reduce the risk of infection 

Help the patient into a more 

comfortable position 

Record all observations, findings 

and actions taken 

Adapted from 

To ensure that the patient is 

composed and comfortable 

To aid assessment and 

evaluate care 

Kyle, G. (2007) Bowel care, part 5 – a practical guide to digital rectal examination. 

Nursing Times; 103: 45, 28-29. 



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Appendix 2 

Procedure for Undertaking Manual Removal of Faeces 

Special attention should be paid to those patients susceptible to autonomic dysreflexia , 

spinal cord injury T6 or above. 

Equipment 


• Non-latex disposable gloves & apron 



• Rubbish Bag 

Action Rationale 

Complete bowel assessment with the 

patient 

Check the individual situation to identify 

exclusions, contra-indications or 

circumstances when extra caution is 

required 

To see if the procedure is necessary 

To see if there is a particular risk for 

the patient 

Discuss the treatment with the patient To ensure that the patient understands 

the reason for the procedure 

Explain the procedure and gain 

consent and document if consent is 

given or document why the procedure 

is in the best interest of the patient if 

they are unable to give valid consent 

To ensure the patient understands 

what the procedure entails and gives 

valid consent 

Ensure the patient has privacy To avoid unnecessary embarrassment 

Take the patient’s pulse rate at rest 

prior to the procedure 

Take the baseline blood pressure in all 

spinal injury patients 

Cover the bed with a protective layer 

and ensure a suitable receiver is at 

hand 

Assist the patient into an appropriate 

and comfortable position, normally 

To find the baseline pulse to monitor 

for changes 

To find the baseline blood pressure to 

monitor for changes 

To reduce possible infection caused by 

soiled linen and to avoid 

embarrassment 

This positioning, if feasible allows ease 

of entry into the rectum following the 



23

lying in the left, lateral position with the 

knees well flexed, not sitting 

Examine the perineal/perianal area for 

any adverse signs and symptoms 

before proceeding, document and 

report any abnormalities and proceed if 

confident that it is safe to do so 

Perform hand hygiene and put on 

disposable apron and non-latex gloves 

For patient’s receiving this 

treatment on a regular basis use a 

water-based lubricating gel on the 

gloved index finger 

13. As an acute procedure a local 

anaesthetic gel may be applied 

topically to the anal area, check for 

contra-indications, warnings, 

precautions and interactions. Do not 

use it there is any evidence of rectal 

bleeding. 

Reassure the patient throughout the 

procedure and inform of imminent 

examination 

Insert the non-latex gloved, lubricated 

index finger slowly and gently, 

encouraging the patient to relax, into 

the anus and on into the rectum 

Assess for the presence of faecal 

matter using the Bristol stool scale 

If stool is type 1 on the Bristol stool 

scale remove the faecal material slowly 

one lump at a time until no more can 

be felt, place in the suitable receiver 

If the patient becomes distressed, 

check the pulse again and check 

against the baseline reading, stop if the 

pulse rate has dropped or the patient is 

clearly distressed, if there is pain or 

anal area bleeding 

In a solid faecal mass, push the finger 

into the middle of the mass to split it, 

then remove small pieces with a 

hooked finger until no more can be felt 

If the faecal mass is too hard or larger 

than 4cm across or you are unable to 

natural anatomy of the colon 

To ensure that it is safe to proceed 

To minimise the risk of cross infection 

Lubricating reduces surface friction and 

thus eases insertion and avoids anal 

mucosal trauma 

To make the patient as comfortable 

and pain free as possible 

To ensure lignocaine is not absorbed 

systemically 

To avoid unnecessary distress or 

embarrassment 

To minimise trauma 

To establish rectal loading and the 

consistency of the stool 

The stool can be manipulated 

To monitor condition of the patient 

To remove the faecal matter 

To minimise risk as patient safety is 



24

eak it up, stop and refer to the 

medical team as a general anaesthetic 

may be required 

For patients receiving this care on a 

regular basis encourage them to rest 

for a period to allow further faecal 

matter to descend into the rectum, the 

patient and nurse if trained in the 

Valsalva manoeuvre should use this. 

paramount 

To maximise quantity of faecal material 

removed, the Valsalva manoeuvre 

assists with the faecal descent 

technique 

Use extra lubrication as required To minimise friction and discomfort 

Check the patient’s pulse and stop if 

the heart rate slows or the rhythm 

changes 

Check the blood pressure of all spinal 

injury patients and stop at the first sign 

of autonomic dysreflexia 

When the procedure is completed 

wash and area dry the patient’s 

buttocks and anal 

Ensure the patient is left feeling as 

comfortable as possible and inform 

them of the outcome 

Dispose of all equipment according to 

Trust Policy 

To monitor the patient’s condition 

To monitor the patients condition 

To remove any lubricating gel/faecal 

material that may cause excoriation 

and to leave the patient clean and fresh 

To inform patient of level of success of 

an unpleasant procedure 

To minimise the risk of cross infection 

Perform hand hygiene To minimise the risk of cross infection 

Document the procedure and outcome, 

monitor the after-effects and report any 

abnormal findings immediately 

Adapted from 

To monitor the patient’s bowel function 

and to provide a record of the 

procedure and condition of the patient 

Kyle G, Prynn P, Dunbar T (2008) The procedure for the digital removal of faeces. 

Norgine Ltd 



25

Appendix 3 

Digital Stimulation 

Equipment 


• Non-latex disposable gloves; 



Action 

A patient using digital self- stimulation 

should be in a comfortable sitting position. 

If the procedure is being undertaken by a 

nurse/carer they should assist the patient 

to adopt the left lateral position with knees 

flexed. 

Insert a glove (non- latex) lubricated index 

finger through the anal sphincter to 

second joint of finger only. 

Gently rotate the finger 6- 8 times in a 

clockwise motion and withdraw. 

This may be repeated up to three times 

allowing 5-10 minutes between each 

stimulation. 

Results should be noted and documented. 

Adapted from 

Rationale 

Gravity will aid evacuation 

(Banwell et al, 1993) 

To expose anus and to avoid damage to 

the anal canal. 

To facilitate easier insertion and rotation 

of finger also to prevent trauma to the 

anal and rectal mucosa. 

To minimize discomfort and to stimulate 

anorectal reflex. 

(Spinal Injuries Unit 1999) 

To establish effectiveness of procedure. 

Kyle G, Prynn P, Dunbar T (2008) The procedure for the digital removal of faeces. 

Norgine Ltd 



26

Appendix 4 

Insertion of Suppository 

Equipment required 

• Gloves. 

• Disposable apron. 

• Plastic-backed absorbent sheet. 

• Lubricating solution. 

• Bedpan or commode. 

• Prepared solution. 

Complete bowel assessment with the 

patient (NICE 2007, SFH CC01). 

Discuss treatment with patient and the 

Team, justify and document the need 

for this procedure. 

Be aware of legislation regarding 

mental capacity (NMC 2008, SFH 

CC01 and CC09). 

Explain Procedure. 

Consider cultural and religious beliefs. 

Explain potential risks to the patient. 

Document consent given 


To ascertain the need for suppositories 

• other bowel emptying techniques 

have failed, 

• faecal impaction/loading, 

• incomplete defaecation, 

• inability to defaecate, 

• neurogenic bowel dysfunction, 

• patient with spinal injury. 

To allow patient choice and to ensure 

optimum treatment (NMC 2008, SFH 

CC01, CC09). 

To gain the patient’s consent and co- 

operation, you must ensure that the 

patient has the mental capacity to give consent. 

Valid consent requires three key elements: 

1.It must be given freely and voluntarily 

without coercion or manipulation (SFH 

CC01, CC09). 

2.The patient must be appropriately 

informed of the proposed intervention. 

3.The patient must be deemed 

competent to make the decision. 

Failure to satisfy these three elements 

will invalidate any consent. 

So that consent is valid. 

To comply with legislation. 

Ensure privacy and respect the To help the patient relax and minimise 



27

patient’s dignity. 

Document if the patient is unable to give 

valid consent because of 

unconsciousness, sedation or confused 

state. Reasons why the procedure is in 

the patient’s best interest must be 

documented. 

Record if the patient refuses the 

procedure. 

Take the patient’s pulse at rest prior 

to the procedure. 

Place protective pad under the patient 

and ensure a suitable receiver is to 

hand. 

Assist patient to adopt, if possible, the 

left lateral position with knees flexed. 

A sitting position should be avoided. 

Observe the perineal and perianal area. 

Document and report any 

abnormalities. 

Wash hands, put on a disposable 

apron and non- latex gloves of a 

suitable thickness. 

Place water- based lubricating gel on 

gloved index finger. 

Inform patient of imminent examination. 

Insert non- latex gloved, lubricated index 

finger slowly and gently, encouraging 

the patient to relax. Use one finger only. 

Assess for faecal matter noting against 

the Bristol Stool Chart. 

Assess need for medication. 

embarrassment (NMC 2008, SFH CC01). 

Professional accountability must be maintained and 

clear, accurate, current records must be kept (NMC 

2008). 

To obtain a baseline of the patient’s 

condition prior to the procedure as vagal stimulation 

can slow the heart rate. 

To protect bedding from faecal matter. 

To expose anus and allow easy access 

to carry out the procedure. 

To prevent overstretching of the anal 

sphincter and discomfort for the patient. 

To check for rectal prolapse, 

haemorrhoids, 

anal skin tags, wounds, discharge, 

anal lesions, gaping anus, bleeding, 

foreign bodies 

To minimise cross infection and to protect 

your hands. 

To facilitate easier insertion of index 

finger. 

To ensure the patient is prepared and 

relaxed. 

To avoid trauma to the anal mucosa and 

prevent forced over dilation of the anal 

sphincter. 

Document stool type in patient’s notes 

later. 

Lubricate the end of suppository. For easier insertion. 

To support individual bowel management. 



28

Inform patient of insertion of suppository 

Gently insert the suppository via 

anus into the rectum. 

Remove gel by wiping residual from area. 

Clean anal area. 

Help patient into comfortable position. 

Dispose of equipment as per local policy. 

Inform the patient of outcome and 

ensure procedure and outcomes are 

documented. 

Adapted from 

To ensure patient is prepared and relaxed. 

To relieve patient’s discomfort. 

To leave the patient clean and comfortable. 

To preserve patient dignity. 

To prevent spread of infection. 

Documentation should provide clear 

evidence of planned care, decisions made 

and care delivered. 

(NMC 2008, SFH CC09). 

Higgins, D. (2007) Bowel care Part 6 – Administration of a suppository. Nursing Times; 

103: 47: 26-27. 



29

Appendix 5 

Insertion of Enema 


• Incontinence sheet; 

• Disposable gloves; 


• Lubricating jelly; 

• Enema; 

• Jug. 

Preperation 

The use of enemas in clinical practice for bowel evacuation is declining because of the 

availability of a range of oral alternatives. (Refer to the continence formulary) 

The procedure is invasive and patients often find it uncomfortable and embarrassing. 

Nevertheless, for some patients, an enema may still be the preferred method of 

treatment. A careful assessment of need for an evacuant enema is required, which 

will necessitate a digital rectal examination to assess faecal loading. A microenema 

must always be considered before using a phosphate enema. 


Explain the procedure and any 

potential risks to the patient. 



CC01, CC09). 

Document that consent 


has been given. 

Encourage the patient to empty bladder Fluid entering the rectum may cause 

discomfort to an already full bladder. 

Ensure the patient has privacy. To maintain dignity 

Make sure that a commode or toilet is Inserting an enema often 

nearby 

gives the patient urgency to defecate 

Remove any clothing below the waist To maintain privacy 

and ensure that the patient is covered 

with a blanket. 

Help the patient to adopt, if possible, To expose the anus and allow easy 

the left lateral position with knees insertion of the enema The left side is 

flexed 

preferred for this procedure because of 

the position of the rectum. However, 

this position is not essential – for 

example it should be avoided if the 

patient has a leftsided weakness. 

If not using a micro-enema warm the A cold enema 

enema in a jug of water to a 

is unpleasant and uncomfortable. 

hand-hot temperature 

Check the perineal and perianal area. To check for rectal prolapse, 

Document the findings and report any haemorrhoids, 



30

abnormalities observed. anal skin tags, wounds, discharge, 

anal lesions, gaping anus, bleeding, 

foreign bodies 

Wash hands, then put on a disposable To prevent spread of infection 

apron and non-latex gloves. 

Place a plasticbacked 

To protect bedding from faecal matter 

absorbent sheet under the patient. 

Remove the cap from the enema, place 

lubricating jelly on a swab and lubricate 

the end of the nozzle 

To ease insertion 

Expel any excess air Air in the colon may cause distension 

and abdominal 

Part the buttocks and gently insert the 

enema into the anus, or into the anal 

canal and then on to the rectum 

Slowly introduce the contents 

of the enema slowly withdraw the 

nozzle 

Wipe the perianal area with a 

clean swab. 

Ask the patient to retain the enema for 

up to 10–15 minutes before using the 

commode or lavatory. Patients often 

find this easier if they remain lying 

down. 

Ensure the patient has access to a call 

bell, commode and/or lavatory with a 

supply of toilet paper 

The patient may complain of lightheadedness 

during the insertion of an 

enema or during evacuation of the 

bowel 

Remove and dispose of equipment 

Remove gloves and apron, and wash 

hands. 

Inform the patient of the outcome and 

ensure that the procedure and its result 

are 

documented using the Bristol Stool 

Chart 

Adapted From 

discomfort 

The anal canal is approximately 5cm in 

length so the insertion of more than this 

length ensures that the nozzle of the 

enema is in the rectum. 

To avoid a reflex emptying of the bowel 

To leave the patient clean and 

comfortable 

To ensure maximum effect 

Kyle G. 2007 Bowel Care Part 4. Administering an Enema 

Nursing Times 103: 45, 26-27 

This is due to vagal nerve stimulation, 

which 

can slow the heart rate and alter its 

rhythm 



31

Appendix 6 

Anal Irrigation Using Coloplast Peristeen System 

Anal irrigation will usually only be tried after less invasive methods of bowel management 

have failed to adequately control constipation and or faecal incontinence. There is a 

relatively small evidence base for this procedure at present and so much of the advice 

given is based on expert opinion and practical experience. 

Indications for use 

• Neurogenic bowel dysfunction 

• Chronic constipation including both evacuation difficulties and slow transit 

constipation 

• Chronic faecal incontinence 

Rectal irrigation should only be started and carried out for the first time under the 

direction of the doctor, nurse or other qualified health care professional. All healthcare 

professionals who are considering recommending the use of anal irrigation should 

discuss this with the continence service. 

This is a medical device available on prescription. 

For full instructions and diagrams please see leaflet entitled guidelines for the use of 

rectal irrigation (Norton 2008). 

Relative contraindications (use only after careful discussion with relevant medical 

practitioner) 

• pregnant or planning pregnancy 

• active perianal sepsis 

• diarrhoea 

• anal fissure 

• large haemorrhoids that bleed easily 

• faecal impaction (clear, if possible before starting irrigation: Digital rectal examination 

if unsure) 

• Past pelvic radiotherapy which has caused bowel symptoms 

• Known severe diverticular disease 

• use of rectal medication for other diseases 

• congestive cardiac failure 

• anal surgery within past six months 

Absolute contraindications (irrigation should not be used) 

• Acute active inflammatory bowel disease 

• knowing obstructing rectal or colonic mass 

• severe cognitive impairment 



32


Coloplast Peristeen anal irrigation control unit 

Single use rectal catheter, 

Water bag, 

Leg straps (if required). 

Gloves and apron (if performed by health care professional) 


Explain the procedure to the patient To gain comfort 

and ensuring their comfort, privacy and 

dignity 

Gain informed consent To ensure legal compliance 

Wash and dry hands thoroughly. If 

assisting a patient non sterile gloves 

and an apron should be worn. 

Fill water Reservoir. Use lukewarm tap 

water. There is no need to measure the 

water temperature 

Assemble the equipment 

connect the irrigation bag, control unit 

and single use rectal catheter, blue to 

blue and grey to grey 

Strap pumps to lead if this is most 

convenient 

Open the packaging of the rectal 

catheter 2 to 3 cm, use a self-adhesive 

tab tab to fix the package to a vertical 

surface is convenient 

Turn the control dial to the water 

symbol 

It is important to fill the bag completely, 

even if the full volume will not be used: 

this makes it easy to control how much 

water is inserted and ensures the 

system works efficiently 

To ensure the system works correctly 

To allow ease of use 

To prevent the catheter and falling 

down 

To facilitate catheter lubrication 

Pump the control unit 2 to 3 times To prime the tubing with water and 

activate the self lubricating coating on 

the catheter 

Turn the control dial to the balloon To allow time to prepare 

symbol. Do not pump yet. 

Transfer to the toilet if not already on it 

Holding the catheter by the finger grip, 

gently insert into the anus as far as the 

finger grip will allow. If you feel any 

resistance while inserting the catheter 

never use force. Take the catheter out. 

Check there is not hard still blocking 

the insertion and gently try again. 

While still holding the catheter in place 

pump the balloon 

The catheter balloon will not blow up if 

there is hard still blocking the rectum 

This will inflate the balloon 

Now let go of the catheter. The balloon will hold it in place. 



33

Turn the control unit to the water 

symbol and start to pump water into the 

rectum. About one pump each two 

seconds is the usual speed to avoid 

discomfort. People with a high spinal 

injury may need to pump more slowly 

than this. 

Continue pumping until the required 

volume has been instilled it may take 

up to 10 to 15 minutes to pump in all 

the water. 

Turn the control unit style to the air 

symbol to deflate the balloon. 

To avoid autonomic dysreflexia. 

To allow the fluid into the rectum 

The catheter is likely to drop out under 

gravity. If not a gentle pull will remove 

it. 

For safe disposal 

Use the catheter package to dispose of 

the catheter in a rubbish bin 

Water and stool should start to pass To facilitate bowel emptying 

into the toilet very soon after the 

catheter is removed. Abdominal 

massage or pressure on the abdomen 

may help this process. Avoid the 

temptation to strain. It is better to be 

patient and wait. It can take 10 to 20 

minutes for the bowel to stop emptying. 

With practice you will learn when you 

have finished and it is safe to leave the 

toilet. 

Clean and dry the anal area To prevent soreness 

Empty any remaining water from the The equipment needs to be cared for 

bag and tubing 

carefully to continue working properly. 

The equipment can be cleaned using 

warm soapy water and must be dried 

thoroughly 

Turn the control unit dial to the finish 

position for storage 

Store the equipment in a dry place 

away from direct heat sources 

Remove and discard gloves if worn. To promote hygiene 

Wash and dry hands. 

The tube with the blue connector is changed as required. The rectal catheter is single 

use only. If using the system every other day the reservoir should be changed once or 

twice a month. This is done by removing the cap, discarding the bag and attaching the 

cap to a new bag. The controller should be changed every six months or 90 uses. 

Troubleshooting 



34

Problem Advice 

Pain occurs when 

pumping water 

If pain should occur when pumping water, pause for a while 

and then continue. If the pain is acute or severe STOP 

IMMEDIATELY, DEFLATE THE BALLOON AND REMOVE 

THE CATHETER. If the pain persist for more than a few 

minutes, or is accompanied by a lot of bleeding seek medical 

assistance immediately 

Bleeding Occasional spots of bright red blood may be seen on the 

catheter, especially if the patient has haemorrhoids. This is 

not a cause for concern. If bleeding is occurring regularly, 

this needs to be reported to the medical team. If a sudden 

major bleed occurs, urgent medical attention must be sought. 

More major or regular bleeding should lead to a referral for a 

flexible sigmoidoscopy. Altered (dark red) bleeding should 

prompt urgent referral to colorectal services. If the patient 

experiences a haemorrhage with or without pain, emergency 

care is indicated as the rectum could theoretically be 

perforated. This might necessitate emergency surgery and 

the patient should know to gain emergency medical help in 

the VERY UNLIKELY event. 

Abdominal cramps If these occur, then pumping the water more slowly may help. 

It may be worth stopping pumping the water for a minute and 

then re-start when cramps subside. Cramps may also be a 

sign that the irrigation water is too cool or is stimulating the 

gut to contract. Cramps can indicate that the irrigation is 

working well. 

Feeling unwell Occasionally irrigation can make the patient feel unwell during 

or after irrigation. It is not uncommon for the patient to sweat 

a little or have palpitations. They may also feel a little lightheaded 

when first using the procedure. This should settle 

with time. If the patient is affected in this way it would be 

helpful for them to have someone nearby that they could call 

for help. 

Difficult to insert 

catheter 

Catheter expelled 

during pumping 

Difficult catheter insertion may be due to anorectal 

abnormalities or impaction 

If the balloon is deflated check the balloon for signs of 

impairment. The patient could practice the inflation technique 

with the catheter outside the body to ensure the balloon 



35

Balloon is 

immediately 

expelled after 

inflation 

Balloon is expelled 

once pumping has 

begun 

Female patients 

have a problem 

Nothing is passed 

from the rectum 

Water is passed but 

no stool 

Water or stool 

leakage after 

irrigation 

Adapted from 

symbol is used and enough air is instilled. Check that the dial 

is not accidentally being turned to the air symbol, when 

intending to use the water symbol to introduce water. 

The balloon is stimulating rectal contractions. Try inflating the 

balloon more slowly or inflate it a little less. 

Check that the water is not too hot or cold. Expelling the 

balloon is more likely to happen if irrigation is performed after 

meals. So try irrigation at other times. 

Ensure the catheter has not been inserted into the vagina by 

mistake. 

Check that the patient is not dehydrated. Encourage the 

patient to drink at least 1.5 litres per day, more if the weather 

is hot. (Unless otherwise directed by medical staff). The 

patient could be heavily constipated, this should be removed, 

as much as possible before commencing irrigation). Regular 

use of irrigation can be used to prevent constipation occurring 

in the future 

There may not be any stool passed if there was a good result 

at the last irrigation. The patient may need to irrigate less 

often if this is happening regularly, this needs to be discussed 

within the medical team. If the patient has not had any results 

for several days the stool may be very hard and impacted. A 

laxative may be required 

It may be necessary for the patient to wear a small 

continence pad when first carrying out irrigation. This may 

not be necessary once the patient is used to the irrigation. 

Maybe try some of the following – 

• Try sitting the patient on the toilet for longer to 

ensure they are empty. 

• Try using more water. 

• Try using less water. 

• If incontinent of faeces between irrigations, then 

more frequent irrigation may be required. 

An anal plug may be worth considering, please discuss with 

medical or continence team. 



36

Norton C 2008. Guidelines for the use of Rectal Irrigation. Coloplast 



37

Appendix 7 

Insertion of Coloplast Peristeen Anal Plug 

This is a useful device for individuals with passive soiling who can use it on a daily basis 

or when they want to do sports activities. It is not suitable for patients with frequency of 

defaecation, as it would have to be removed each time. The advantage is that it usually 

stops soiling, however some patients report discomfort and are unable to tolerate it. 

Patients with a neurological injury or condition benefit from it, as they frequently lack 

function in the anal canal. It is used after their normal bowel regime, and is inserted to 

prevent further soiling. 

This is a medical device, available on prescription 

Equipment Required 

Anal plug 

Lubricating gel 

Gloves 

Apron 


Discuss treatment with patient and the 

Team, justify and document the need 

for this procedure. 

Be aware of legislation regarding 

mental capacity (NMC 2008, SFH 

CC01 and CC09). 

Explain Procedure. 

Consider cultural and religious beliefs. 

Explain potential risks to the patient. 

Document consent given 

Ensure privacy and respect the 

patient’s dignity. 



CC01, CC09). 

To gain the patient’s consent and co- 

operation, you must ensure that the 

patient has the mental capacity to give 

consent. 

Valid consent requires three key 

elements: 

1.It must be given freely and voluntarily 

without coercion or manipulation (SFH 

CC01, CC09). 

2.The patient must be appropriately 

informed of the proposed intervention. 

3.The patient must be deemed 

competent to make the decision. 

Failure to satisfy these three elements 

will invalidate any consent. 


To comply with legislation. 

To help the patient relax and minimise 

embarrassment (NMC 2008, 

SFH CC01). 

Smear a small amount of Peristeen gel To lubricate and ease insertion 



38

on the tip of the Peristeen anal plug 

Insert the Peristeen anal plug gently 

into the anus, just as you would a 

suppository. 

Ensure that the entire Peristeen anal 

plug is inserted into the rectum. Only 

the gauze should be visible. 

The Peristeen anal plug is removed 

from the rectum by gently pulling the 

gauze which is moulded into the plug. 

Removing the plug will not activate the 

emptying reflex, so there is no need to 

hurry. 

A fresh plug may be inserted 

immediately after removal of the old 

one. 

After use, put the plug in waste bin not 

into the toilet. 

The peristeen anal plug should be 

changed as often as necessary and 

must not be left in place for more than 

12 hours. 

To ensure the plug is placed correctly. 

The Peristeen anal plug is now 

correctly positioned in the rectum and 

will very quickly (in about 30 seconds) 

expand to full size as the film dissolves 

in the body's natural warmth and 

moisture. It may be left in the rectum 

for up to 12 hours. 

Each plug must not be left in situ longer 

than 12 hrs. 

The plug will swell and could cause 

blockage of the toilet 

As per manufacturer instructions 

Keep out of reach of children. If placed in a mouth the Peristeen anal 

plug will expand and may cause 

choking. 

Please see instruction leaflet for further information. 

Adapted from 

Coloplast Peristeen Anal Plug Instructions for Use 



39

Appendix 8 Core Competencies Relating to Bowel Care 

Eligible practitioners: Doctors, Physicians Assistants, Registered Nurses, specific other 

Health Care Practitioners following agreement with their Manager, and the Continence 

Service 

The core competency should be achieved, before achieving the individual competencies 

in appendix 9. 

The candidate is able to: 

Ensure that the need for digital rectal examination is 

confirmed prior to procedure 

Demonstrate effective communication with the patient in 

gaining informed consent 

Demonstrate the ability to assess the individual patient’s 

needs, including their anxieties about digital rectal 

examination 

Demonstrate a good understanding of the anatomy and 

physiology of the gastro-intestinal tract 

Discuss and highlight risk factors pertaining to digital 

rectal examination 

Demonstrate the ability to discuss the results with the 

patient 

Demonstrate the ability to initiate further interventions / 

investigations as appropriate. 

Demonstrate accurate record keeping of procedure 

Initial/sign when competent 

The candidate attended a teaching session given by _____________________________ 

on the subject of______________________________________On __________________ 

The candidate has been assessed and has achieved the core competencies above. 

Assessor Signature _______________________ Print Name ________________________ 

Candidate Signature ______________________ Print Name_________________________ 

Candidate’s Designation ___________________Base _____________________________ 

Date of Assessment ._________________________ 

Assessor Candidate 

IT IS ESSENTIAL THAT YOU FORWARD A PHOTOCOPY OF THIS ASSESSMENT 

FORM TO THE TRAINING DEPT. A SECOND COPY SHOULD BE TAKEN FOR 

YOUR MANAGER TO PLACE IN YOUR PERSONAL FILE. 



40

Appendix 9 

Specific competencies relating to bowel care. 

Each competency may be achieved individually, but only after achieving the Bowel 

Care core competency above. 

Eligible practitioners: Doctors, Physicians Assistants, Registered Nurses, specific other 

Health Care Practitioners following agreement with their Manager, and the Continence 

Service 

The candidate is able to: 

Competency 

Perform Digital Rectal Examination 

as per PCT policy and procedure 

Administration of suppository as 

per PCT policy and procedure 

Administration of enema as per 

PCT policy and procedure 

Perform Digital Stimulation as per 


Manual removal of faeces as per 


Perform Anal irrigation as per 


Insert anal plug as per PCT policy 

and procedure 

Sign 

Sign 

Assessor Candidate Date 

The candidate has been assessed and has achieved the competencies 

above. 

Assessor Signature _______________________ Print Name ________________________ 

Candidate Signature ______________________ Print Name_________________________ 

Candidate’s Designation ___________________Base _____________________________ 

Date of Assessment ._________________________ 

IT IS ESSENTIAL THAT YOU FORWARD A PHOTOCOPY OF THIS ASSESSMENT FORM TO THE 

TRAINING DEPT. A SECOND COPY SHOULD BE TAKEN FOR YOUR MANAGER TO PLACE IN 

YOUR PERSONAL FILE. 



41

Appendix 10 

Suggested Consent Required for Bowel Care 

Type of Consent – Bowel Care 

Bowel care deals with intimate and private parts of the body. All interventions relating to 

assessment and treatment require discretion and sensitivity. However this does not 

necessarily equate to the need for written consent. 

Using the criteria within North Somerset PCT Consent Policy the Continence Service 

have agreed the following for specific procedures. 

Procedure Signific 

ant Risk 

Digital 

Rectal 

Examination 

Manual 

removal of 

faeces 

Insertion of 

Suppository 

Insertion of 

Micro- 

enema 

Insertion of 

rectal 

medication 

eg 

suppository, 

foam, 

micro- 

enema 

Insertion of 

phosphate 

enema 

Ongoing 

use of anal 

irrigation 

Use of Anal 

Plug 

Anaesthesia 

/ Sedation 

Clinical 

Care 

not 

Primar 

y 

Purpos 

e 

Significant 

Consequence 

s for 

employment, 

personal or 

social life 

Researc 

h 

purpose 

Type of 

Consen 

t 

No No No No No Verbal/ 

Implied 


Implied 


Implied 


Implied 


Implied 

Yes No No No No Written 

Thought 

to be 

minimal 

but long 

term 

unknow 

n 

No No No No Written 


Implied 



42

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