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Not to be confused with Edema, Ænima, or Anima.
An enema, also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum.[1] Also, the word enema can refer to the liquid so injected,[2][3] as well as to a device for administering such an injection.[4]
Rectal bulb syringe to administer smaller enemas
In standard medicine, the most frequent uses of enemas are to relieve constipation and for bowel cleansing before a medical examination or procedure;[5] also, they are employed as a lower gastrointestinal series (also called a barium enema),[6] to treat traveler's diarrhea,[7] as a vehicle for the administration of food, water or medicine, as a stimulant to the general system, as a local application and, more rarely, as a means of reducing temperature,[1] as treatment for encopresis, and as a form of rehydration therapy (proctoclysis) in patients for whom intravenous therapy is not applicable.[8]
In other contexts, enemas are used by some alternative health therapies, used for enjoyment, chiefly as part of sexual activities, but also in sadomasochism, as well as simply for pleasure, used to intoxicate with alcohol, used to administer drugs for both recreational and religious reasons, and used for punishment.
The principal medical usages of enemas are:
As bowel stimulants, enemas are employed for the same purposes as orally administered laxatives: To relieve constipation; To treat fecal impaction; To empty the colon prior to a medical procedure such as a colonoscopy. A large volume of enema[9] can be given to cleanse as much of the colon as possible of feces.[10][11] However, a low enema is generally useful only for stool in the rectum, not in the intestinal tract.[12]
Such enemas' mechanism consists of the volume of the liquid causing rapid expansion of the intestinal tract in conjunction with, in the case of certain solutions, irritation of the intestinal mucosa which stimulates peristalsis and lubricates the stool to encourage a bowel movement.[13] In order for the enema to be effective the patient should retain the solution for five to ten minutes, as tolerated.[5][13] or, as some nursing textbooks recommend, for five to fifteen minutes or as long as possible.[14]
The colon dilates and expands when a large volume of liquid is injected into it, and the colon reacts to that sudden expansion with general contractions, peristalsis, propelling its contents toward the rectum.[5]
For relieving occasional constipation, a large volume enema may be used in a home setting, although for recurring or severe cases of constipation medical care may be required.[5]
Plain water can be used, simply functioning mechanically to expand the colon, thus prompting evacuation.
Castile soap is commonly added because its irritation of the colon's lining increases the urgency to defecate.[14] However, liquid handsoaps and detergents should not be used.[5]
Glycerol is a specific bowel mucosa irritant serving to induce peristalsis via a hyperosmotic effect.[15] It is used in a dilute solution, e.g., 5%.[16]
Normal saline is least irritating to the colon, at the opposite end of the spectrum. Like plain water, it simply functions mechanically to expand the colon, but having a neutral concentration gradient, it neither draws electrolytes from the body, as happens with plain water, nor draws water into the colon, as occurs with phosphates. Thus, a salt water solution can be used when a longer period of retention is desired, such as to soften an impaction.
Equal parts of milk and molasses heated together to slightly above normal body temperature have been used.[17] Neither the milk sugars and proteins nor the molasses are absorbed in the lower intestine, thus keeping the water from the enema in the intestine.[18] Studies have shown that milk and molasses enemas have a low complication rate when used in the emergency department[19] and are safe and effective with minimal side effects.[20]
Mineral oil functions as a lubricant and stool softener, but may have side effects including rectal skin irritation and leakage of oil[21] which can soil undergarments for up to 24 hours.[citation needed]
This section needs expansion. You can help by adding to it. (March 2019)
Arachis oil (peanut oil) enema is useful for softening stools which are impacted higher than the rectum.[22]
Bisacodyl stimulates enteric nerves to cause colonic contractions.[23][24]
Dantron is a stimulant drug and stool softener[25] used alone or in combinations in enemas.[26] Considered to be a carcinogen[27] its use is limited, e.g., restricted in the UK to patients who already have a diagnosis of terminal cancer and not used at all in the USA.
Glycerol has a hyperosmotic effect and can be used as a small-volume (2–10 ml) enema (or suppository).[15]
Mineral oil is used as a lubricant because most of the ingested material is excreted in the stool rather than being absorbed by the body.[30]
Sodium phosphate.[31][32] Also known by the brand name Fleet. Available at drugstores; usually self-administered. Buffered sodium phosphate solution draws additional water from the bloodstream into the colon to increase the effectiveness of the enema. But it can be rather irritating to the colon, causing intense cramping or "griping."[33] Fleet enemas usually causes a bowel movement in 1 to 5 minutes. Known adverse effects.
Sorbitol pulls water into the large intestines causing distention, thereby stimulating the normal forward movement of the bowels. Sorbitol is found in some dried fruits and may contribute to the laxative effects of prunes.[34] and is available for taking orally as a laxative.[35][36] As an enema for constipation, the recommended adult dose is 120 mL of 25-30% solution, administered once.[37] Note that Sorbitol is an ingredient of the MICROLAX Enema.
This section needs expansion. You can help by adding to it. (March 2019)
In alphabetical order of the original brand names
Klyx contains docusate sodium 1 mg/mL and sorbitol solution (70%) (crystallising) 357 mg/mL and is used for faecal impaction or constipation or for colon evacuation prior medical procedures,[38] developed by Ferring B.V..
Micralax (not to be confused with MICROLAX®)[39]
MICROLAX® (not to be confused with Micralax) combines the action of sodium citrate, a peptidising agent which can displace bound water present in the faeces, with sodium alkyl sulphoacetate, a wetting agent, and with glycerol, an anal mucosa irritant and hyperosmotic. However, also sold under the name "Micralax", is a preparation containing sorbitol rather than glycerol;[40] which was initially tested in preparation for sigmoidoscopy.[41]
Micolette Micro-enema® contains 45 mg sodium lauryl sulphoacetate, 450 mg per 5 ml sodium citrate BP, and 625 mg glycerol BP[42] and is a small volume stimulant enema suitable where large-volume enemas are contra-indicated.[22]
TAI, also termed retrograde irrigation, is designed to assist evacuation using a water enema[43] as a treatment for persons with bowel dysfunction, including fecal incontinence or constipation, especially obstructed defecation. By regularly emptying the bowel using transanal irrigation,[44] controlled bowel function is often re-established to a high degree, thus enabling development of a consistent bowel routine.[44] Its effectiveness varies considerably, some individuals experiencing complete control of incontinence but others reporting little or no benefit.[43]
An international consensus on when and how to use transanal irrigation for people with bowel problems was published in 2013, offering practitioners a clear, comprehensive and simple guide to practice for the emerging therapeutic area of transanal irrigation.[44]
The term retrograde irrigation distinguishes this procedure from the Malone antegrade continence enema, where irrigation fluid is introduced into the colon proximal to the anus via a surgically created irrigation port.
Patients who have a bowel disability, a medical condition which impairs control of defecation, e.g., fecal incontinence or constipation,[45] can use bowel management techniques to choose a predictable time and place to evacuate.[45] Without bowel management, such persons might either suffer from the feeling of not getting relief, or they might soil themselves.[45]
While simple techniques might include a controlled diet and establishing a toilet routine,[45] a daily enema can be taken to empty the colon, thus preventing unwanted and uncontrolled bowel movements that day.[46]
In a lower gastrointestinal series an enema that may contain barium sulfate powder or a water-soluble contrast agent is used in the radiological imaging of the bowel. Called a barium enema, such enemas are sometimes the only practical way to view the colon in a relatively safe manner.[6]
Failure to expel all of the barium may cause constipation or possible impaction[47] and a patient who has no bowel movement for more than two days or is unable to pass gas rectally should promptly inform a physician and may require an enema or laxative.[48]
The administration of substances into the bloodstream. This may be done in situations where it is undesirable or impossible to deliver a medication by mouth, such as antiemetics given to reduce nausea (though not many antiemetics are delivered by enema). Additionally, several anti-angiogenic agents, which work better without digestion, can be safely administered via a gentle enema.
The topical administration of medications into the rectum, such as corticosteroids and mesalazine used in the treatment of inflammatory bowel disease. Administration by enema avoids having the medication pass through the entire gastrointestinal tract, therefore simplifying the delivery of the medication to the affected area and limiting the amount that is absorbed into the bloodstream.
Rectal corticosteroid enemas are sometimes used to treat mild or moderate ulcerative colitis. They also may be used along with systemic (oral or injection) corticosteroids or other medicines to treat severe disease or mild to moderate disease that has spread too far to be treated effectively by medicine inserted into the rectum alone.
Improper administration of an enema can cause electrolyte imbalance (with repeated enemas) or ruptures to the bowel or rectal tissues resulting in internal bleeding. However, these occurrences are rare in healthy, sober adults. Internal bleeding or rupture may leave the individual exposed to infections from intestinal bacteria. Blood resulting from tears in the colon may not always be visible, but can be distinguished if the feces are unusually dark or have a red hue. If intestinal rupture is suspected, medical assistance should be obtained immediately.[13] Frequent use of enemas can cause laxative dependency.[59]
The enema tube and solution may stimulate the vagus nerve, which may trigger an arrhythmia such as bradycardia.
Enemas should not be used if there is an undiagnosed abdominal pain since the peristalsis of the bowel can cause an inflamed appendix to rupture.
There are arguments both for and against colonic irrigation in people with diverticulitis, ulcerative colitis, Crohn's disease, severe or internal hemorrhoids or tumors in the rectum or colon, and its usage is not recommended soon after bowel surgery (unless directed by one's health care provider). Regular treatments should be avoided by people with heart disease or kidney failure. Colonics are inappropriate for people with bowel, rectal or anal pathologies where the pathology contributes to the risk of bowel perforation.[60]
Recent research has shown that ozone water, which is sometimes used in enemas, can immediately cause microscopic colitis.[61]
A recent case series[62] of 11 patients with five deaths illustrated the danger of phosphate enemas in high-risk patients.
Enema entered the English language c. 1675 from Latin in which, in the 15th century,[3] it was first used in the sense of a rectal injection,[2] from Greek ἔνεμα (énema), “injection”, itself from ἐνίηναι (enienai) "to send in, inject", from ἐν (en), "in" + ἱέναι (hienai), "to send, throw".[63]
Clyster entered the English language in the late 14th century from Old French or Latin, from Greek κλυστήρ (klyster), "syringe", itself from κλύζειν (klyzein), "to wash out".[64] Also spelled glister in the 17th century, rarely cloiste" or clister,[citation needed] it is a generally archaic word for enema, more particularly for enemas administered using a clyster syringe.
The first mention of the enema in medical literature is in the Ancient Egyptian Ebers Papyrus (c. 1550 BCE). One of the many types of medical specialists was an Iri, the Shepherd of the Anus. Many medications were administered by enemas.[65] There was a Keeper of the Royal Rectum who may have primarily been the pharaoh's enema maker. The god Thoth, according to Egyptian mythology, invented the enema.[66]
In parts of Africa the calabash gourd is used traditionally to administer enemas. On the Ivory Coast the narrow neck of the gourd filled with water is inserted the patient's rectum and the contents are then injected by means of an attendant's forcible oral inflation, or, alternatively, a patient may self-administer the enema by using suction to create a negative pressure in the gourd, placing a finger at the opening, and then upon anal insertion, removing the finger to allow atmospheric pressure to effect the flow. Along the upper Congo River an enema apparatus is made by making a hole in one end of the gourd for filling it, and using a resin to attach a hollow cane to the gourd's neck. The cane is inserted into the anus of the patient who is in a posture that allows gravity to effect infusion of the fluid.[67]
The Olmec from their middle preclassic period (10th through 7th centuries BCE) through the Spanish Conquest used trance-inducing substances ceremonially, and these were ingested via, among other routes, enemas administered using jars.
As further described below in religious rituals, the Maya in their late classic age (7th through 10th centuries CE) used enemas for, at least, ritual purposes, Mayan sculpture and ceramics from that period depicting scenes in which, injected by syringes made of gourd and clay, ritual hallucinogenic enemas were taken.[68] In the Xibalban court of the God D, whose worship included ritual cult paraphernal, the Maya illustrated the use of a characteristic enema bulb syringe by female attendants administering clysters ritually.[69][70]
For combating illness and discomfort of the digestive tract, the Mayan also employed enemas, as documented during the colonial period, e.g., in the Florentine Codex.[68]
The indigenous peoples of North America employed tobacco smoke enemas to stimulate respiration, injecting the smoke using a rectal tube.[71][72]
A rubber bag connected with a conical nozzle, at an early period, was in use among the indigenous peoples of South America as an enema syringe,[73] and the rubber enema bag with a connecting tube and ivory tip remained in use by them while in Europe a syringe was still the usual means for conducting an enema.[74]
In Babylonia, by 600 BCE, enemas were in use, although it appears that initially they were in use because of a belief that the demon of disease would, by means of an enema, be driven out of the body.[75] Babylonian and Assyrian tablets c. 600 BCE bear cuneiform inscriptions referring to enemas.[76]
In China, c. 200 CE, Zhang Zhongjing was the first to employ enemas. "Secure a large pig's bile and mix with a small quantity of vinegar. Insert a bamboo tube three or four inches long into the rectum and inject the mixture" are his directions, according to Wu Lien-teh.[77]
In India, in the fifth century CE, Sushruta enumerates the enema syringe among 121 surgical instruments described. Early Indian physicians' enema apparatus consisted of a tube of bamboo, ivory, or horn attached to the scrotum of a deer, goat, or ox.[75]
In Persia, Avicenna (980-1037 A. D.) is credited with the introduction of the "clyster-purse" or collapsible portion of an enema outfit made from ox skin or silk cloth and emptied by squeezing with the hands.[76]
Hippocrates (460-370 BCE) frequently mentions enemas, e.g., "if the previous food which the patient has recently eaten should not have gone down, give an enema if the patient be strong and in the prime of life, but if he be weak, a suppository should be administered, should the bowels be not well moved on their own accord."[78]
In the first century BCE the Greek physician Asclepiades of Bithynia wrote "Treatment consists merely of three elements: drink, food, and the enema".[79] Also, he contended that indigestion is caused by particles of food that are too big and his prescribed treatment was proper amounts of food and wine followed by an enema which would remove the improper food doing the damage.[80]
In the second century CE the Greek physician Soranus prescribed, among other techniques, enemas as a safe abortion method,[81] and the Greek philosopher Celsus recommended an enema of pearl barley in milk or rose oil with butter as a nutrient for those suffering from dysentery and unable to eat,[82] and also Galen mentions enemas in several contexts.[54]
In medieval times appear the first illustrations of enema equipment in the Western world, a clyster syringe consisting of a tube attached to a pump action bulb made of a pig bladder.[citation needed] A simple piston syringe clyster was in use from the 15th through 19th centuries. This device had its rectal nozzle connected to a syringe with a plunger rather than to a bulb.[citation needed]
Beginning in the 17th century enema apparatus was chiefly designed for self-administration at home and many were French as enemas enjoyed wide usage in France.[82]
In 1694 François Mauriceau in his early-modern treatise, The Diseases of Women with Child, records that both midwives and
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