The aim of this study is to develop and present a structured, multidisciplinary care pathway for the implementation of transanal irrigation (TAI) in a Portuguese Local Health Unit.
Although TAI systems are well established internationally, with robust evidence supporting their efficacy in bowel dysfunction management, their adoption in Portugal has been limited until recently, largely due to reimbursement constraints. The recent changes in reimbursement policy create a timely opportunity to implement standardised, evidence-based protocols to ensure safe, effective, and scalable integration into clinical practice.

A descriptive review of the literature was conducted to identify key barriers to TAI implementation and evidence-based mitigation strategies. 
These findings were subsequently adapted to the Portuguese healthcare setting by the local multidisciplinary team that included specialists from Colorectal Surgery, Gastroenterology, Physical and Rehabilitation Medicine, and Rehabilitation Nursing.
We present a structured care pathway defining patient selection criteria, pre-treatment assessment, device selection, training protocols, and follow-up strategies tailored to our Local Health Unit organisational structure and resource availability.

The main challenges identified include appropriate patient selection, requiring clear clinical indication and correct positioning within the therapeutic escalation pathway, as well as exclusion of contraindications and identification of the need for further investigations before initiation of TAI.
Patient-related factors such as motivation, cognitive and psychological status, educational level, manual dexterity, and availability of caregiver support were recognized as critical determinants of success.
Additional challenges encompass structured patient education with appropriate resources, correct device selection, supervised training to support the acquisition of correct technique, and the recognition and management of potential complications, as well as ensuring appropriate follow-up with guidance on technique optimisation, troubleshooting, positive reinforcement, alongside ongoing support from healthcare providers.
In response to these challenges, a comprehensive, multidisciplinary care pathway adapted to local resources was developed to standardise practice and support consistent implementation.

This approach facilitates the safe and effective integration of TAI into clinical practice while allowing individualisation according to patient characteristics and local resource constraints.
In the absence of such a framework, clinical practice may become heterogeneous, with inconsistent patient selection, inadequate training, and fragmented follow-up, ultimately compromising adherence and clinical outcomes.

Recent changes in reimbursement policies in Portugal have significantly increased the accessibility and clinical feasibility of TAI, representing an important advancement in continence care.
This work translates established international evidence into a structured, context-adapted implementation strategy aligned with the organisational realities of a Portuguese integrated health system.

Emmanuel AV, Krogh K, Bazzocchi G, Leroi AM, Bremers A, Leder D, van Kuppevelt D, Mosiello G, Vogel M, Perrouin-Verbe B, Coggrave M, Christensen P; Members of working group on Trans Anal Irrigation from UK, Denmark, Italy, Germany, France and Netherlands. Consensus review of best practice of transanal irrigation in adults. Spinal Cord. 2013 Oct;51(10):732-8. doi: 10.1038/sc.2013.86. Epub 2013 Aug 20. PMID: 23958927.
Mosiello G, Marshall D, Rolle U, Crétolle C, Santacruz BG, Frischer J, Benninga MA. Consensus Review of Best Practice of Transanal Irrigation in Children. J Pediatr Gastroenterol Nutr. 2017 Mar;64(3):343-352. doi: 10.1097/MPG.0000000000001483. PMID: 27977546.
Mekhael M, Kristensen HØ, Larsen HM, Juul T, Emmanuel A, Krogh K, Christensen P. Transanal Irrigation for Neurogenic Bowel Disease, Low Anterior Resection Syndrome, Faecal Incontinence and Chronic Constipation: A Systematic Review. J Clin Med. 2021 Feb 13;10(4):753. doi: 10.3390/jcm10040753. PMID: 33668658; PMCID: PMC7918662.