Rectal Irrigation Decision Guide

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Support Resources

Training & Follow-up
Psychological Readiness
Assessments and Templates
FAQs
Efficacy, safety, and patient benefits
Tailored Guidance (Medications and Pregnancy)
Clinical Support

Further Information

The bed system is suitable for patients who:

  • have poor balance and are unable to transfer onto a toilet or commode
  • are confined to bed

High volume bed irrigation:

  • Irrigate daily
  • Instil 200mls and release. Allow water to flow into bag, replace stopper and repeat (maximum of 3 irrigations)
  • Irrigate with as much water as tolerated, up to a maximum of 800mls in 1 go


More information Qufora IrriSedo bed here.

View frequently asked questions here.

Qufora IrriSedo MiniGo

Qufora IrriSedo MiniGo Flex

Qufora IrriSedo Flow

Qufora IrriSedo Klick

Established users of rectal irrigation who become pregnant:

A clear and documented discussion with the multi-disciplinary team (MDT), about continuing with irrigation during pregnancy, is recommended.

Starting irrigation during pregnancy is generally not advocated, and should be delayed until after the birth of the baby. However, individual circumstances may warrant further MDT discussion. 

Studies have shown that rectal irrigation is safe to use. Teaching your patient how to use the equipment safely and advising on how much water to use and how often to irrigate will reduce the risks.

Rectal irrigation can be associated with passing sensations of:

  • Bowel discomfort
  • Nausea
  • Shivering
  • Fatigue
  • Sweating
  • Headache
  • Light bleeding from the rectum


There is a potential complication of bowel perforation. This is very rare (1 in 500,000). Following the instructions for use will reduce this risk. Your patient should see immediate medical attention if they think they have a perforation.

There is a potential complication of bowel perforation. This is very rare. Following the instructions for use will reduce this risk. Your patient should seek immediate medical attention if they think they have a perforation.

  • Bowel perforation is very rare (1 in 500,000)
  • 67% occurred within 1st 8 weeks of use
  • Risk not increased with long term use
  • Add reference Global perforations 2016


To reduce risk:

  • Thorough assessment
  • Structured  training
  • Use as instructed
    • water volume
    • frequency of irrigation

Rectal irrigation is an effective solution for bowel problems which:

  • Relieves constipation
  • Prevents faecal incontinence
  • Reduces bloating and abdominal discomfort
  • Is easy and hygienic to use
  • Is effective for all types of bowel dysfunction


Studies have shown rectal irrigation to be effective for up to 60% of patients with a range of bowel problems, including functional bowel conditions (Henderson et al 2022) and neurogenic bowels (Christensen et al ??).

Rectal irrigation helps your patient regain control of their bowel movements, increasing confidence and improving quality of life, allowing them to live life to the full, without the worry of unpredictable bowels.

Symptom improvement using RI for Functional Constipation (Etherson et al 2017)

Regular follow up with patient is important to ensure adherence, establish routine and troubleshoot any problems.

Recommended frequency of follow up is (see follow-up questions section):

  • 2 – 4 weeks
  • 4 – 6 weeks
  • 8 – 12 weeks. Discharge with patient-initiated contact.


Once settled into a routine, alternate day irrigation may be possible. This will be based on individual assessment.

Review regime – ensure daily, is timing of irrigation convenient, check compliance

Is volume of water – is it not enough / sufficient / too much?

What are the results – presence of stool / brown or clear water?

Does evacuation feel adequate?

Irrigation technique – address any problems, using equipment correctly?

Supplies – regular and timely orders being received?

Adjust regime as required – consider alternate day irrigation

Encourage to persevere

If not responding to irrigation after 3 months – may require alternative system and /or discuss at MDT for other treatment options OR onward referral to Consultant.

To be considered at initial assessment and during ongoing use of rectal irrigation.

Use rectal irrigation only after careful discussion with relevant medical practitioner under the following circumstances:

  • Inflammatory bowel disease (e.g. Crohn’s disease or ulcerative colitis) 
  • Active perianal sepsis (fistula or abscess, third or fourth degree haemorrhoids)
  • Previous rectal or colonic surgery
  • Diarrhoea of unknown aetiology
  • Faecal impaction / rectal constipation
  • Severe autonomic dysreflexia 
  • Severe diverticulosis or diverticular abscess 
  • Abdominal or pelvic irradiation 
  • Long term steroid therapy
  • Anticoagulant therapy
  • Low blood sodium
  • Previous severe pelvic surgery
  • Colonic biopsy within past 3 months
  • Use of rectal medications for other diseases which may be diluted by irrigation
  • Congestive cardiac failure


This list is not exhaustive, individual patient factors should also be considered.

To be considered at initial assessment and during ongoing use of rectal irrigation.

Irrigation should not be used under the following circumstances:

  • Known anal or colorectal stenosis
  • Colorectal cancer  / pelvic malignancy pre-surgical removal
  • Acute inflammatory bowel disease  (e.g. Crohn’s or ulcerative colitis)
  • Acute diverticulitis
  • Within 3 months of anal or colorectal surgery
  • Within 4 weeks of endoscopic polypectomy
  • Ischaemic colitis


This list is not exhaustive, individual patient factors should be considered too.

Aim to use sufficient warm water to achieve a feeling of adequate evacuation.

It is recommended that patients begin by irrigating once daily, for a minimum of 2 weeks, at a time to suit them. This allows familiarisation with the equipment and the procedure and also allows the patient to get into a routine which fits their lifestyle.

Patients can be encouraged to try irrigating at different times of day, with up to a maximum of 1000mls of water.

Since bowels respond best to a regular routine, the preference is to irrigate at a similar time each day. Irrigating 20 – 30 minutes after a meal may take advantage of the gastro-colic reflex, improving results.

Review parameters (frequency, water volume) at each scheduled follow up. Consider changing to alternate day irrigation.

Laxatives

  • Continue to take oral laxatives when rectal irrigation is started
  • Stop using suppositories or enemas when rectal irrigation is started
  • When routine is established consider reducing oral laxatives


Antidiarrhoeals e.g. Loperamide

  • Continue to take antidiarrhoeals when rectal irrigation is started
  • When routine is established consider reducing antidiarrhoeals
  • Prepare /assemble the equipment
  • Show patient each component, fill with water, connect parts, prime system, lubricate cone or catheter
  • Instil water
  • Expel water
  • Demo to patient – patient to reciprocate

  • Follow manufacturers step by step guide


Next steps:

  • Order equipment (individual companies will provide information on ordering)
  • Send GP letter

Assessment Form here

Assessment of the patient before initiating rectal irrigation will:

  • Confirm the reason for starting irrigation, for example inadequate response to other conservative therapy
  • Ascertain the optimal product for a patient to use
  • Identify the presence of any cautions or contra-indications for the use of irrigation


Assessment should include digital rectal examination prior to starting rectal irrigation, ideally within 48 hours of the first irrigation, so that irrigation can be performed safely.

The following factors should be  assessed prior to starting irrigation:

  • Toilet position /evacuation technique
  • Stability / balance on toilet
  • Hand function – dexterity / strength / wrist flexibility
  • Body habitus  / buttock contour / size
  • Psychological function – cognitive / language / visual
  • Examination features / perianal sensation / anal tone
  • Medical /surgical history
  • Home environment
  • Availability of care provision (if carers are required to assist)
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INFORMATION
GOOGLE TRANSLATE
The information provided on this webpage may be subject to different medical and regulatory requirements in different countries. This information should not be used for diagnosing or treating a health problem or disease. It is not medical advice and is not intended to substitute for the advice of your personal physician or other healthcare provider. Before use of any of our products, always consult the ‘Instructions for Use’ document delivered with the products. The Company cannot answer unsolicited emails requesting personal medical advice; please consult your healthcare provider.

Training & Follow – Up

Comprehensive training is essential for the safe and efficient long-term use of TAI. Bildstein and colleagues in their 2017 study found that the first training session should be structured in order to promote more realistic expectations about treatment efficacy, side-effects and, especially, constraints in order to reduce the discontinuation rate. The symptoms of perforation must be discussed, with the advice to stop irrigating and seek emergency medical help immediately, if suspected.

During the first training session, it is advisable to teach the patient the practical aspects of irrigation through demonstrations. Additionally, it is beneficial to supplement this hands-on training with literature.

Teaching aids for the use of TAI can complement the one-to-one training with the patient and may include:

  • Diagrams
  • Chosen equipment literature
  • Step by step guide
  • Practical teaching with a plastic rectum


Although education and training are crucial for long-term adherence to transanal irrigation (TAI), ongoing support is also essential. To ensure the safe and effective long-term use of TAI, a designated healthcare professional can provide a structured follow-up, even when the patient is managing well.

Follow-up is crucial during the first month of using TAI to help patients establish a routine and prevent early discontinuation. Therefore, follow-up should be frequent initially and can be gradually reduced over time. Once satisfactory bowel management is established, follow-up is necessary to maintain user motivation and identify any changes in bowel function and response to TAI over time. This follow-up need not be frequent or in-person but should ideally be conducted by the same professional for each patient.

The demonstration videos below are all part of a free online course titled Initiating Transanal Irrigation to enrol and complete the course at your own pace please visit: Qufora Academy (teachable.com)

Demo videos

Low Volume

High Volume – Flow

High Volume – Klick

Download Follow Up Form

Reference
Emmanuel, A., Krogh, K., Bazzocchi, G. et al. Consensus review of best practice of transanal irrigation in adults. Spinal Cord 51, 732–738 (2013). https://doi.org/10.1038/sc.2013.86

Emmanuel, A et al (2019) Development of a decision guide for transanal irrigation in bowel disorders. Gastrointestinal Nursing Vol. 17, No. 7. Published Online:16 Oct 2019 https://doi.org/10.12968/gasn.2019.17.7.24

Bildstein, C et al (2017) Predictive factors for compliance with transanal irrigation for the treatment of defecation disorders. World Journal of Gastroenterology, 23(11): 2029-2036

Psychological Readiness

Psychological Readiness – Determining if a patient is ready to start rectal irrigation

Please stay tuned for additional resources and education on psychological readiness coming in 2025!

Assessments and Templates

GP Letter Template
ICIQ-B Form
LARS – Score
PAC-SYM Score
The Neurogenic Bowel Dysfunction Score
Follow up template

FAQs

1. How often should the parts on a Qufora IrriSedo system be replaced?
Flow

Cone – single use only
Water Bag and Regulator – every 30 uses

MiniGo

Cone – single use only
Pump – every 30 uses

MiniGo Flex

Cone – single use only
Pump – every 30 uses

MiniGo Flex Small

Cone – single use only
Pump – every 30 uses

Mini

Cone – single use only
Mini pump – every 30 uses
Extension tube – single use only

Cone

Cone – single use only
Water bag – every 30 days

Klick

Water bag – every 30 uses
Catheters – single use only
Control unit – every 3 months (if irrigating daily) or every 6 months (if irrigation on alternate days)

2. How do I order or re-order supplies for my patients?

Patients can get their products delivered for free directly to their homes by using Qufora direct. For new patients they will get a teaching pack sent to them next day or up to 48 hours*. (Only available in the UK and Northern Ireland)

Registering them through Qufora direct also gives them access to our myqufora support service to get them off to the best start possible with irrigation. This service now also offers an automated delivery option. That way your patient can get their system delivery according to your instruction regularly. Our support team will help them with scheduled check ins and a three-month check-up – to make sure they are on track.

*Orders placed by 12pm will be delivered the next day. After that it will take up to 48 hours.

3. Can Children use Qufora IrriSedo rectal irrigation systems?

Yes. The Qufora IrriSedo range can be used by children over the age of 3 years. To focus on the needs of children and their families Qufora Mingo flex- small, with the same oval shape and delivering the same water flow, but with a shorter length and more narrow width. Ideal for children and those that require a smaller cone.

We recognise introducing Rectal Irrigation to children and their carers can be sensitive. There are many questions that healthcare professionals need to answer, but some questions are maybe better answered by those who have firsthand experience. We’ve worked with Birmingham Children’s Hospital to go that bit further to help parents and children. Visit our children and family lives page to hear directly from children and their parents who have used Qufora irrigation systems.

4. How can the Qufora team help me and my patients?

The Qufora team offers comprehensive support through MyQufora and Qufora Direct, ensuring your patients get off to the best possible start with irrigation.

MyQufora Support

  • Expert Guidance: Provides detailed instructions to get your patient off to the best possible start with Qufora IrriSedo systems.
  • Experienced Team: Our passionate team, with many years of experience, ensures patients use their products correctly, safely, and effectively.
  • Patient Monitoring: Our team, experienced in bowel management, understand individual patient needs and keep you informed of their progress, advising on potential treatment changes.
  • Adherence Support: Recognises the challenges in managing routines and supports patients to ensure adherence.


Qufora Direct

  • Personalised Experience: Tailors the irrigation experience to fit the patient’s lifestyle, ensuring they receive their Qufora system on time and follow their regime.
  • Convenient Delivery: Offers discreet delivery through personalized packs and automated services, enhancing the patient experience.
5. How soon will my patient see symptom improvement with rectal irrigation?

Every patient is different. When getting started, some people notice an improvement straight away while others may need to establish the best routine for them over the first 3 months.

With regular rectal irrigation patients can effectively clear the bowel, alleviating symptoms of constipation and faecal incontinence. Over time bowel patterns may change slightly, and their irrigation routines may need to be reviewed.

You and your patients are most welcome to contact us for further advice or support.

6. Does rectal irrigation contribute to a lazy bowel?
There is no clinical evidence suggesting a reduced bowel function after using rectal irrigation. The aim of rectal irrigation is to establish regularity and help manage bowel symptoms.
7. My patient stopped irrigation, do they need to see me again for another assessment before they restart?
It is important to find out why your patient stopped irrigating and for how long they have stopped. They may need to see you to be re-assessed if their condition has changed, they have developed new symptoms, or have new contraindications.
8. How is rectal irrigation different from suppositories or manual evacuation?

Suppositories or manual evacuation can help to empty the very end of the bowel (the rectum) whereas rectal irrigation can empty the rectum plus the lower part of the bowel, so some people find they get better results with rectal irrigation. Used regularly, rectal irrigation can prevent faecal incontinence and relieve symptoms of constipation. It can reduce bloating and abdominal discomfort. It is easy and hygienic to use.

Rectal irrigation can be quicker to use and can give more predictable results.

Your patient can choose when they want to empty their bowels, at a time that is convenient for them.

9. My patient is still at the bottom of the treatment period, should I wait before starting them on Rectal Irrigation?

When you start your patient on rectal irrigation it varies from patient to patient based on a variety of factors including their psychological readiness, condition, and past treatments. It is often appropriate to start them on rectal irrigation earlier in their treatment journey and in conjunction with other treatments. You can hear Professor Peter Christensen speak more about the where rectal irrigation fits into an evolving treatment period in the first lecture of the Low Volume Masterclass on Qufora Academy, or read Paula Igualada-Martinez and her teams research on Physiotherapy management of anorectal dysfunction. Seminars in Colon and Rectal surgery.

Igualada-Martinez, P et al (2022), Physiotherapy management of anorectal dysfunction. Seminars in Colon and Rectal surgery. https://doi.org/10.1016/j.scrs.2022.100936

If you have a question that isn’t answered here or have a patient specific situation you would like to discuss please reach out to our support team here: advice@myqufora.com or 0800 612 9080.

Efficacy, Safety and Patient Benefits

Efficacy
  1. The PERSPECTIVE study has shown transanal irrigation (TAI) to be effective for up to 60% of patients with functional bowel problems who use long term. Since irrigation requires motivation and commitment, long term use can be considered a surrogate for effectiveness.

    • TAI can be an effective treatment for all types of functional bowel disorders (constipation and diarrhoea/faecal incontinence of any cause such as slow transit or IBS or evacuatory difficulties).
    • TAI being effective at 3 months is a good indicator that it will still be effective longer term (at 12 months and beyond).
    • TAI is effective for diarrhoea such as diarrhoea predominant IBS(IBS-D) and mixed symptoms such as IBS-M (alternating constipation & diarrhoea). This has not been shown in studies before.

  2. Tamvakeras P, et al demonstrated a five-year retrospective review of patients practising TAI in a district general hospital. Patient demographics, indications, long-term compliance, adverse events, and patient reported Qufora bowel symptom bother scores were analysed in this 2023 study with some results as follows:

    • 5- year retrospective case note review, of patients using TAI, in a District General Hospital, Sutton Coldfield, UK
    • This is one of the longest follow-up studies in the literature
    • Irrigation was taught face to face
    • Patients were advised about different devices with guidance from their specialist nurse – studies usually use one device
    • Follow-up was frequent and in keeping with that in decision guide – 2, 6 ,12 weeks, 6 months, 1 year and ad hoc thereafter
    • Patients completed a bothersome score about how satisfied they were with using irrigation (0, low-10,high)
    • A high percentage of patients (14,78%) continued to use TAI long-term.
    • 12 (66%) used high volume, with Qufora IrriSedo Cone being most popular and 6 (33%) used low volume irrigation (IrriSedo Mini & Mini Go)
    • Significant improvements were observed in bowel symptom bother scores, reinforcing the positive impact of irrigation on patients’ quality of life

  3. Mekhael M et al (2021) conducted a systematic review, which evaluates the effect of TAI in neurogenic bowel dysfunction (NBD), low anterior resection syndrome (LARS), faecal incontinence (FI) and chronic constipation (CC)

    • TAI is beneficial treatment for different types of bowel problems (NBD, LARS, FI and CC of heterogeneous origin)
    • Supports the use of TAI for all types of bowel problems

  4. Etherson et al (2017) evaluated patient perceptions of the efficacy and safety of TAI for chronic idiopathic constipation (CIC) and whether there are predictive factors of perceived treatment response. Symptom improvement was demonstrated in patients using TAI for chronic constipation:

    • General well-being 65%
    • Rectal clearance 63%
    • Bloating 49%
    • Abdominal pain 48%
    • Bowel frequency 42%
Safety
TAI is generally regarded as a safe treatment, but there are some risks involved. Bowel perforation can occur, although it is very rare. The latest data indicate that the risk of bowel perforation due to TAI is two per one million irrigations. Patients are advised to weigh the risks against the potential benefits. Additionally, it is crucial to forewarn patients about common side effects of TAI, including abdominal cramping, dizziness, nausea, and minor rectal or anal bleeding, to prevent premature discontinuation of the treatment.
Patient Benefits

Despite these risks, when patients are correctly instructed, TAI can offer numerous benefits for both patients and healthcare professionals. These benefits include:

  • Consistent bowel routine, with regular bowel movements
  • Individuals can select time/place of evacuation
  • Reduction in time to achieve bowel care
  • Improvement of symptoms and reduction in the severity of chronic constipation
  • Potential prevention and reduction of frequency of faecal incontinence
  • Psychological improvement and enhanced quality of life for patients
  • Reduction in stoma surgery rates
  • Reduction in incidence, frequency and cost of urinary tract infections
  • Reduction in hospital admissions in people with NBD and associated treatment costs.
  • May reduce the use of and need for laxatives and anti-diarrhoeals.


TAI helps patients regain control of their bowel movements, boosting their confidence and improving their quality of life. This allows them to live without the constant worry of unpredictable bowel movements.

Bibliography

Henderson M, Chow J, Ling J, Ng CE, Embleton R, et al. (2022) Transanal Irrigation for the Management of Functional Bowel Disorders: An Observational Study. Int J Nurs Health Care Res 5: 1360. DOI: 10.29011/2688-9501.101360

Tamvakeras P, Horrobin C, Chang J, et al. (July 26, 2023) Long-Term Outcomes of Transanal Irrigation for Bowel Dysfunction. Cureus 15(7): e42507. DOI 10.7759/cureus.42507. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10371390/

Mekhael M et al (2021) Transanal Irrigation for Neurogenic Bowel Disease, Low Anterior Resection Syndrome, Faecal Incontinence and Chronic Constipation: A systematic review. Journal of Clinical Medicine, 10(4): 753

Etherson KJ et al (2017) Transanal Irrigation for Refractory Chronic Idiopathic Constipation: Patients Perceive a Safe and Effective therapy. Gastroenterology, Research and Practice: doi: 10.1155/2017/3826087

Christensen P et al (2016) Global Audit on bowel perforations related to transanal irrigation. Techniques in Coloproctology, 20(2): 109-15. doi: 10.1007/s10151-015-1400-8

National Institute for Health and Care Excellence (NICE)Peristeen Plus transanal irrigation system for managing bowel dysfunction. Medical technologies guidance [MTG36]Published: 23 February 2018 Last updated: 06 June 2022 : Overview | Peristeen Plus transanal irrigation system for managing bowel dysfunction | Guidance | NICE

Tailored Guidance (Medications and Pregnancy)

Medications

When advising patients on the use of laxatives and/or antidiarrheals in conjunction with transanal irrigation (TAI), key opinion leaders agree that patients should continue taking these medications initially and in the usual dose. After establishing a consistent routine with TAI, it may be appropriate to consider reducing the use of laxatives and antidiarrheals. Although, some patients may prefer to continue taking these medications for a period. Henderson et al. (2022) demonstrated that transanal irrigation (TAI) is an effective treatment for functional bowel problems. The study also showed a 47% reduction in laxative use.

Reference
Henderson, Alice et al., Transanal irrigation in the treatment of functional bowel disorders: a district general hospital perspective, Gastrointestinal Nursing, vol 20 no 1, February 2022
https://www.magonlinelibrary.com/doi/abs/10.12968/gasn.2022.20.1.19

Pregnancy

There is no clear consensus on the use of transanal irrigation (TAI) during pregnancy. However, Emmanuel et al. (2019) recommends that if a patient using TAI becomes pregnant, a thorough discussion and documentation involving a multidisciplinary team (MDT) should take place to determine whether to continue its use. Starting TAI during pregnancy is generally not advised, though this may require further discussion with an MDT.

Reference
Emmanuel, A et al (2019) Development of a decision guide for transanal irrigation in bowel disorders. Gastrointestinal Nursing Vol. 17, No. 7. Published Online:16 Oct 2019 https://doi.org/10.12968/gasn.2019.17.7.24

Clinical Support

Comprehensive training is essential for the safe and efficient long-term use of TAI. Bildstein and colleagues in their 2017 study found that the first training session should be structured in order to promote more realistic expectations about treatment efficacy, side-effects and, especially, constraints in order to reduce the discontinuation rate. The symptoms of perforation must be discussed, with the advice to stop irrigating and seek emergency medical help immediately, if suspected.

During the first training session, it is advisable to teach the patient the practical aspects of irrigation through demonstrations. Additionally, it is beneficial to supplement this hands-on training with literature.

Teaching aids for the use of TAI can complement the one to one training with the patient and may include:

  • Diagrams
  • Chosen equipment literature
  • Step by step guide
  • Practical teaching with a plastic rectum


Although education and training are crucial for long-term adherence to transanal irrigation (TAI), ongoing support is also essential. To ensure the safe and effective long-term use of TAI, a designated healthcare professional can provide a structured follow-up, even when the patient is managing well.

Follow-up is crucial during the first month of using TAI to help patients establish a routine and prevent early discontinuation. Therefore, follow-up should be frequent initially and can be gradually reduced over time. Once satisfactory bowel management is established, follow-up is necessary to maintain user motivation and identify any changes in bowel function and response to TAI over time. This follow-up need not be frequent or in-person but should ideally be conducted by the same professional for each patient.

Reference
Emmanuel, A., Krogh, K., Bazzocchi, G. et al. Consensus review of best practice of transanal irrigation in adults. Spinal Cord 51, 732–738 (2013). https://doi.org/10.1038/sc.2013.86

Emmanuel, A et al (2019) Development of a decision guide for transanal irrigation in bowel disorders. Gastrointestinal Nursing Vol. 17, No. 7. Published Online:16 Oct 2019 https://doi.org/10.12968/gasn.2019.17.7.24

Bildstein, C et al (2017) Predictive factors for compliance with transanal irrigation for the treatment of defecation disorders. World Journal of Gastroenterology, 23(11): 2029-2036