Management of Rectal Fecal Impaction

Treatment Options

The National Comprehensive Cancer Network recommends manual disimpaction following premedication with analgesic ± anxiolytic as a first-line treatment for rectal fecal impaction 1, 2
The National Comprehensive Cancer Network suggests administering a glycerine suppository ± mineral oil retention enema as part of the treatment regimen for rectal fecal impaction 1, 2

The National Comprehensive Cancer Network recommends considering tap water enema until clear for persistent impaction 1
The National Comprehensive Cancer Network suggests adding bisacodyl suppository (one rectally daily-BID) for persistent impaction 1
The National Comprehensive Cancer Network recommends considering polyethylene glycol (1 capful/8 oz water BID) for persistent impaction 1

The American College of Oncology and the European Society for Medical Oncology recommend implementing a maintenance bowel regimen to prevent recurrence after successful disimpaction, which may include adding stimulant laxatives (bisacodyl 10-15 mg daily) or bisacodyl or glycerol suppositories 30 minutes after meals to synergize with the gastrocolonic response 1, 2, 3
The American Gastroenterological Association recommends adding an osmotic laxative, such as polyethylene glycol (PEG) 17g daily mixed in 8 ounces of water, or lactulose 15g daily, especially in pregnancy 4
For refractory cases, consider newer agents such as Lubiprostone, Linaclotide, Plecanatide, and Prucalopride only if symptoms don't respond to above treatments, as recommended by the American Gastroenterological Association 4

The European Society for Medical Oncology and the National Comprehensive Cancer Network recommend optimizing toileting schedule, attempting defecation at least twice daily, 30 minutes after meals, ensuring privacy and comfort during defecation, and using proper positioning, such as a small footstool, to exert pressure more easily during defecation in patients with fecal impaction 2, 1
Increasing physical activity within patient limits and ensuring adequate fluid intake (at least 2.0 L of drinks daily unless contraindicated) can help manage constipation, as recommended by the National Comprehensive Cancer Network and other guidelines 1, 5
Providing access to toilets, especially for patients with decreased mobility, and optimizing dietary fiber intake (25g daily) if appropriate, can also help manage constipation 2, 5

The European Society for Medical Oncology and other guidelines list contraindications for enemas, including:

Contraindication	Description
Neutropenia or thrombocytopenia	Blood disorders that increase the risk of bleeding or infection
Paralytic ileus or intestinal obstruction	Conditions that affect the movement of food through the intestines
Recent colorectal or gynecological surgery	Recent surgery in the abdominal or pelvic area
Recent anal or rectal trauma	Recent injury to the anus or rectum
Severe colitis, inflammation or infection of the abdomen	Conditions that cause inflammation or infection in the abdominal area
Toxic megacolon	A life-threatening condition that causes the colon to become very large and inflamed
Undiagnosed abdominal pain	Abdominal pain that has not been diagnosed or treated
Recent radiotherapy to the pelvic area	Recent radiation therapy to the pelvic area
Children under 2 years of age	Fleet enemas are not recommended for children under 2 years old

Phosphate enemas should be avoided or used with extreme caution in certain patient populations, including elderly patients, patients with renal insufficiency or chronic kidney disease, and patients with bowel obstruction, as recommended by the Gut journal and other guidelines 6, 2, 7
Polyethylene glycol (PEG) 17g daily is recommended as the best laxative for elderly patients with constipation due to its efficacy and favorable safety profile, as supported by the American Geriatrics Society and the American Gastroenterological Association 2, 4
Patients with chronic kidney disease (CKD) should use PEG-based preparations, which are iso-osmotic and less likely to cause significant fluid shifts, according to the US Multi-Society Task Force on Colorectal Cancer and the American College of Gastroenterology 8
All patients should be screened for contraindications before ordering phosphate enemas, and baseline electrolytes and renal function should be checked in all patients being considered for phosphate enemas, as suggested by the American Journal of Kidney Diseases 9