Enema Administration Mnemonic Video

Tap water is a hypotonic solution used to facilitate defecation through retention of fluid in the sigmoid colon, softening feces. Soapsuds (castile soap) can be added to tap water to stimulate peristalsis. Caution is exercised in repeat enema administrations, as certain formulations (like hypotonic solution) can lead to fluid and electrolyte imbalances due to its hydrostatic effect on the colon’s vascular system.

Normal saline is a safe solution used to stimulate defecation. There is less risk of fluid and electrolyte imbalances as it has a similar osmotic pressure and composition as intra-intestinal fluid.

Also known as a “Fleet Enema,” this hypertonic solution draws free water from the intestinal vascular system into the intestinal lumens to promote defecation. Practice caution in patients at risk for fluid and electrolyte imbalances, especially patients with dehydration, as this enema can result in loss of intravascular fluid or electrolytes.

Kayexalate enemas can treat dangerously high potassium levels through a process called cation-exchange, binding potassium in the intestines and removing it through defecation. Another enema using Lactulose works similarly in the management of hyperammonemia secondary to hepatic failure and cirrhosis. Antibiotics like Vancomycin can be given via enema administration for the management of C. Difficile infections, and neomycin can be used to sterilize the bowel (removing bacteria from the intestines) prior to surgery.

This enema helps lubricate the rectum and colon and facilitates fecal absorption of oil to soften stool.

Patient education includes how an enema is administered, clinical indications for this management, and possible side effects (e.g. discomfort, bowel incontinence, tenesmus) as well as risks (e.g. intestinal perforation, rectal trauma, etc). Inform the patient that the enema is most effective when the solution dwells in the colon for as long as possible (greater than 15 mins).

Standard precautions (hand hygiene, use of gloves) plus protection against “splash-back” (e.g. eye protection, facemask, gown, shoe/hair cover) may be needed and dependent upon the clinical scenario (e.g. patient requiring some assistance versus full assistance with enema administration). The presence of C. Difficile or other bowel infections should be approached with utmost caution and a high degree of personal protection.

Place the patient in a left side-lying Sims’ position. This gives the enema a downward flow into the sigmoid colon to improve collection and retention of fluid in the bowel. If the patient has poor sphincter tone or a history of bowel incontinence, place a bedpan near or under the patient prior to enema administration, and provide adequate towels, washcloths, and wet wipes for hygiene

The length of insertion will depend on the patient, typically between 2-4 inches. To prevent trauma to the rectum, insert the tip and advance slowly and steadily. Stop insertion if the patient complains of pain from insertion and continue when the patient is ready.

A rapid enema solution administration can cause the rectum to reflectively contract and push out the infusing enema. A slower administration is performed by raising the height of the enema bag slowly to a height of 12-18 inches above the patient. Raising the bag greater than 18 inches can also facilitate rapid administration and should not be performed.

Some discomfort from colon distention is normal. However, if the patient experiences sharp or constant pain during administration: stop the enema immediately by lowering the enema bag (or clamp the line). Allow the patient to relax and resume the flow slowly when the patient is ready.

Enema administration can stimulate the vagal nerve and lead to bradycardia and hypotension for some patients. Individualistic patient assessment and planning, and proper enema administration can deter this risk.