Transanal bowel irrigation facilitates the evacuation of faeces from the bowel by introducing water (or other fluid) into the colon via the anus in sufficient quantity to reach beyond the rectum. It has been used for over 30 years as a conservative management strategy for patients with a variety of clinical problems but often primarily chronic constipation and/or faecal incontinence and standardised protocols exist for treatment of adults and children with transanal irrigation. Regular irrigation ideally allows patient controlled emptying of the colon and rectum, thus improving their symptoms, promoting dignity and autonomy, and reducing the risk of longstanding complications of bowel emptying dysfunction. We recognise that transanal irrigation has been shown to be a safe and efficacious procedure for many patients(1,2), however there is minimal data as to the subjective experience of the patient to the treatment, with regards to acceptability, ease of use and overall satisfaction. This study was therefore designed to address these questions and determine whether it would be possible to use the data to tailor treatment options for these patients to maximise the success of treatment. The aim of this study was to create a transanal irrigation patient satisfaction survey and collect data from all patients who underwent treatment in 2019.

A prospectively collected database was used to identify transanal irrigation patients to be included in this study. Consecutive patients from the year 2019 were included as the most recent group unaffected by the COVID-19 pandemic (given all treatment with normal face to face interaction and no restriction of service or follow up). Modified versions of the ICIQ-B(3) and a patient satisfaction index were used to create a questionnaire combining Likert scale responses to statements and open questions regarding improvement, which were evaluated by thematic analysis. Patients were contacted by telephone and asked to complete the questionnaire at the time of the call by independent clinicians (not part of the physiology department delivering the treatment as standard). We aimed to assess the global impact of transanal irrigation on patient quality of life with scores for ease of use, acceptability, impact on activities of daily living/ sexual activity, their confidence and congruence with expectation and reasons for stopping if use discontinued. All data was recorded on a designated proforma.

A total of 98 consecutive patients were contacted by telephone. 34 were non contactable, 3 had died and records not updated, 18 declined (various reasons), 5 didn’t start treatment. 40 patients (41%) completed the full questionnaire, of whom 37 were women (93%), and the median age was 58 years old (range 19-87 years old). 
The overall mean length of time for irrigation use was 396 days (range 7-743 days), only 23 patients were still using the system at time of call. Main reasons for stopping were that they found it uncomfortable, there was difficulty manipulating the equipment due to arthritis or needed help from family members. Suggestions for improvement revolved around modifications to product design (e.g. more discrete, less plastic, smaller) and desire for more follow up (e.g. more demonstration, home visits, support groups, telephone advice). Despite this 77% of patients surveyed found the irrigation systems ‘very/quite easy’ to use, and ‘totally/quite acceptable/ okay’ in general. 62% of patients reported that they had to plan their daily activities around the irrigation system ‘some/most of the time’ or ‘always’, although 55% of patients said that the irrigation ‘never/ rarely’ impacted on their daily plans. 88% of patients responded that the irrigation either ‘never’ interfered with sexual activities or that they were not sexually active. 72% of patients replied that they felt ‘very/quite confident’ when using the equipment. 58% said that they agreed with the statement “using irrigation met my expectations”. 55% of patients agreed with the statement “using irrigation improves my condition enough so that I will continue to use it for the same outcome”. 68% of responders agreed with the statement “I would recommend this treatment to a friend or family member with similar symptoms”.

Despite the success reported in ease of use and acceptability of transanal irrigation in this study, nearly half had stopped using the irrigation at an average of 8 months at an approximate cost of £464- £1192 (depending on system used) per patient, and 45% stating that it did not improve their condition enough to keep using it. There was mixed response to improvement in their condition following instigation of irrigation, most patients had to plan their day around treatment, with significant interference in activities for some.

Transanal irrigation is predominantly used by women. Despite high satisfaction with implementation of irrigation treatment for patients (ease of use, acceptability) and confidence in using the equipment, almost half of patients surveyed had ceased to use transanal irrigation. Given the high cost of transanal irrigation in combination with high dropout rate we have described here, we propose that it should be offered as a short-term trial before prescribed long-term as part of a tailored prescription along with precise medicine and trial of step-up routine of suppository care. This patient questionnaire may be used as key for early identification of dissatisfied patients who could therefore have early cessation of treatment and alternative therapy considered with associated cost savings.

Rosen H, Yap R, Tentschert G, Lechner M & Roche B. Transanal irrigation improves quality of life in patients with low anterior resection syndrome. Colorectal Dis. 2011, 13, e335-338
Christensen P, Krogh K, Buntzen S, Payandeh F & Laurberg S. Long-Term Outcome and Safety of Transanal Irrigation for Constipation and Fecal Incontinence. Dis Colon Rectum. 2009. 52(2):286-292
Cotterill N, Norton C, Avery K, Abrams P & Donovan J. Psychometric evaluation of a new patient-completed questionnaire for evaluating anal incontinence symptoms and impact on quality of life: the ICIQ-B. Dis Colon Rectum 2011, 54:1235-1250