Digital Rectal Stimulation and Manual Evacuation of Faeces in Adults - Guidelines for

Publication: 01/01/2009  --
Last review: 16/07/2021  
Next review: 16/07/2024  
Clinical Guideline
CURRENT 
ID: 1481 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guidelines for Digital Rectal Stimulation and Manual Evacuation of Faeces in Adults

Introduction, Aims & Objectives

In recent years there has been much debate regarding the interventions of digital rectal stimulation (DRS) and manual evacuation of faeces (ME). The debate appears to stem from the invasive nature of the procedure and potential accusations of abuse54. Therefore it is vital to clarify professional and legal aspects of care and also provide guidelines for these interventions. Consequently this document will provide insight and guidance for health care practitioners within the Leeds Teaching Hospitals.

For many patients DRS and ME are essential aspects of care and practitioners must be prepared to perform these procedures in a safe and effective manner.4, 37, 38, 55, 57 Furthermore employers have a responsibility to provide information and training to allay practitioners’ fears and ultimately ensure effective bowel care is provided.37, 40, 55, 57

The main points of reference for these guidelines are three Royal College of Nursing publications;

  • Digital Rectal Examination and Manual Removal of Faeces (2006) 55
  • Bowel care, including Digital Rectal Examination and Manual Removal of Faeces (2008).56
  • Management of Lower Bowel Dysfunction, including DRE and DRF (2012).57

Further information can be obtained from the Multidisciplinary Association of Spinal Cord Injury Professionals (MASCIP) publication – Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions. (2012).37

It is suggested that all practitioners make themselves familiar with these documents.
.
* NB please note that these guidelines are relevant to practitioners within an adult care setting only. The RCN have published separate guidance on ME for nurses working with children and advice should be sought from this. (“Digital Rectal Examination. Guidance for Nurses Working with Children and Young People” (2005).

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What is DRS and ME?

DRS is a procedure, which involves inserting a gloved finger into the anus. The finger is rotated in a clockwise direction. This technique increases the reflex muscular activity in the rectum, raises rectal pressure which stimulates the rectum to contract to expel faeces and relaxes the external sphincter to facilitate this action.

ME is the digital removal of faecal matter to prevent a build up of stool in the rectum, which in turn could lead to incontinence, increased constipation and impaction of faeces. ME usually lasts from 15-20 seconds but not normally longer than one minute but can be repeated every 5-10 minutes until evacuation is complete.35, 52, 55

Who can perform the procedure?

DRS and ME are considered to be suitable procedures for nurses to undertake.1,37, 50, 57 A Registered nurse can perform these procedures if they act within the Code of Professional Conduct and Scope of Professional Practice competency requirements.49, 61 Therefore nurses should ensure they possess the necessary knowledge and skills regarding DRS and ME and decline these duties if they are unable to perform the procedures in a safe and skilled manner. 47

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Legal and Professional Aspects for Registered Nurses

Many nurses appear confused about the professional and legal aspects of DRS and ME. These procedures are invasive and risks include perforation of the colon and bradycardia due to stimulation of the vagal nerve. 50, 51 However after a review of the RCN, Association of Continence Advice (ACA) and National Patient Safety Agency (NPSA) there has never been in recent history a documented incident of perforation during routine neurogenic bowel management.

As stated earlier, nurses must act within the Code of Professional Conduct and Scope of Professional Practice consequently ensuring nurses remain accountable for their own practice. 47 Therefore if a nurse does not perform a procedure, which the patient requires, fails to ensure it is done competently and/or fails to seek advice and/or help, the Nursing & Midwifery Council (NMC) can call the nurse into account for their actions37, 47, 55, 57. The nurse can still be called into account if the patient does not suffer any harm and/or legal negligence is unable to be established.55

Employers are also explicit in their expectations of employees. Once a nurse has entered into a contract whether oral or written, practitioners must perform professional duties competently and adhere to procedures/policies.55 Therefore if a nurse feels less than competent in this provision of care they, should inform their line manager and identify their required training needs.

They must also keep their knowledge and skills up to date throughout their professional working life and therefore must regularly participate in learning activities that develop competence and performance.55
 
If the employing organisation permits DRS and ME can be delegated to Health Care Assistants on a named patient basis.6, 55 However existing care should not be compromised and the Registered Nurse remains accountable for the delegation of this aspect of care.55 Health care assistants also have a responsibility to ensure they feel competent regarding both theoretical and practical aspects of this procedure and are also familiar with local procedures and guidelines.55

DRS and ME procedures may also be delegated to carer’s and/or patients as appropriate.

Whether a health care assistant, carer or patient all must be assessed as competent and should be subject to regular review/assessment.55 Such competencies should include understanding of the anatomy of the lower gastro-intestinal tract, indications for DRS and ME and contra indications and exclusions for the procedures.55 Supervision whilst performing DRS and ME should also be undertaken on an individual patient basis on at least three occasions.

The Department of Health, Health Care Trusts and professional bodies are clear in their expectations yet difficulties still occur in practice. Consequently, following investigation by the Spinal Injury Association (SIA) into these procedures in general hospitals, the National Patient Safety Agency58, 39 issued four recommendations for all NHS Trusts to follow.

  1. NHS Trusts should have a policy for ME.
  2. NHS Trusts must ensure that employees are aware of the risks and dangers of not providing these interventions and know where to access staff members who can perform these procedures.
  3. NHS Trusts should ensure competent health care practitioners are consistently available to teach and undertake the procedures.
  4. NHS Trusts should recognise that patients with established spinal cord lesions are the experts in managing their own bowel care.

Furthermore the Royal College of Nursing55 state that the contract of employment or job description should ensure that the employer has given approval for these procedures to be undertaken, that policies and procedures are insitu and training/instruction are also provided. The Care Quality Commission 10 state that competencies should be evaluated at regularly agreed intervals and recently the RCN 57 recently advocated mandatory half day study sessions.

Training can be achieved in the clinical area whilst caring for patients with a competent Registered Nurse.64 Training can also be assessed through local Continence Advisory Services. A directory of services is available through the Bladder and Bowel Foundation by calling 01536 533255. Bowel related competencies from the Skills for Health website may also be useful for practice.36

It is vital that nurses possess the necessary theoretical knowledge as well as practical competencies to ensure safe and effective care. Such theoretical knowledge and core skills should include,

  • Knowledge of anatomy and physiology of the gastro-intestinal tract in relation to the normal bowel.  
  • An understanding of disease and/or dysfunction of the rectum and colon.
  • Awareness of common peri-anal and anal conditions.
  • Ability to discuss constipation management options.
  • Knowledge of stool type and the ability to identify stool type by palpitation of the rectum.
  • Use of medication in bowel dysfunction.
  • Professional accountability.
  • Issues of consent.
  • Documentation.
  • Familiarity with DRS and ME guidelines including, indications, procedure and precautionary measures.55
  • Consideration of cultural and religious beliefs.30, 34, 37, 57

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Consent

Consent is an important, necessary and accepted part of professional clinical practice, which affirms the patient’s right to self-determination and autonomy.28, 37, 55, 57, 62. When obtaining consent discussion/s offer the opportunity to provide detailed and clear explanations regarding treatment and/or interventions and risks. If the patient refuses to have the intervention alternative options can also be discussed.55. Such provision of information can reduce patient anxiety and is vital if informed consent is to be truly obtained from a professional and legal stance.28, 55  The nurse does not have to explain every risk or advantage to the patient however all questions must be answered honestly. If a nurse withholds information the nurse would have to be able to justify this decision in court.55

Other factors to consider include,

  • The patient must give consent freely – no threats or implied threats should be utilised. If consent has been obtained this way it is unlawful and therefore invalid.55, 67
  • If there is a lack of consent the procedure must not be undertaken as litigation against the Trust may result.28,55
  • The patient must have the mental capacity to provide consent. Individuals over the age of 16 are deemed by law to have the mental ability to give consent.55 If there is any doubt as to a patient’s mental capacity advice should be sought from the Trust’s psychiatric service.
  • Consent by the patient, verbal or written or by implication through the patient's cooperation with the procedure is the legal means of authorisation. There should be documented evidence that the patient has agreed to the procedure including who was present, what information was provided and whether consent was verbal or written.55
  • A signed consent form is not required as it does not prove the consent is valid. However it is normally good evidence that a discussion about consent has occurred.55
  • Consent should be sought according to RCN guidelines and in keeping with the Leeds Teaching Hospital policy on consent.

Because of the invasive and intimate nature of these procedures, it is expected that the practitioner will seek voluntary consent from the competent patient on each and every occasion. 37, 57 Withdrawal of consent may be an indicator that a patient is struggling to understand or cope with the care being offered.31

Patients also have the right to a chaperone during the procedure and should be informed of this. If a chaperone is unable to be provided the patient must be told and asked if they wish to continue. This should be documented in the patient notes.42 However to safeguard the health professional undertaking the procedure it is advisable to have a chaperone present especially in acutely ill patients who are relatively unfamiliar with these procedures.

It is important to note that in emergency situations such as in an unconscious or sedated patient and/or no available next of kin consent is difficult to obtain. Therefore if treatment is required to safeguard the health or life of the patient it is not a legal requirement that the patient’s consent is obtained.55 Further consideration should be given to patients who may have communication issues such as language barriers and/or those with a tracheostomy.

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Diagnosis, Investigation, Treatment & Management. When Should Nurses Undertake DRS and/or ME?

The current consensus of opinion is that ME can be avoided as improved bowel emptying techniques have been developed.1, 9, 16, 52, 53, 55 Advances in oral, rectal and surgical treatments have also assisted in reducing the need for ME.23, 55 However the RCN55, 57 state those patients who suffer with faecal impaction, incomplete defecation and/or an inability to defecate may require assisted evacuation. This is most evident in people suffering with neurogenic bowel. Where usual bowel emptying techniques have failed DRS and ME are essential aspects of the patient’s bowel care regime ensuring effective evacuation of faeces and prevention of incontinence.  The patient’s normal bowel management routine should not be interrupted regardless of the health care setting.1, 23, 29, 31, 55, 58

The RCN55 state that digital rectal examination (DRE) can be used to establish the following,

  • Presence of faecal matter in the rectum including the amount and consistency.
  • To check if anal tone is present and the ability to initiate a voluntary contraction, to what degree, and also to teach pelvic floor exercises.
  • Assess anal pathology.
  • Assess for anal and rectal sensation.
  • The need for and effects of rectal medication.
  • The need for manual removal of faeces and evaluating whether the bowel is empty following ME of faeces.
  • The outcome of rectal and colonic washout/irrigation.
  • The need and outcome of using digital stimulation to trigger defecation by stimulating the recto-anal reflex.

It must be acknowledged that DRS and ME are invasive procedures and should only be performed when necessary and after an individual assessment including considering cultural and religious beliefs and providing psychological and emotional support.29, 43

Complications of ME whether it is performed acutely or as an established procedure includes, distress, discomfort, pain, collapse, bowel perforation, bradycardia, damage to nerve and muscle fibres within the anal sphincter if performed without care and Autonomic Dysreflexia (AD) in spinal cord injury (SCI) patients. 27, 37, 50, 51, 52, 55

However patients with acute and chronic spinal cord injury (SCI) remain the most common client group, which may rely on DRS and ME to ensure an effective and efficient bowel care regime.12, 29, 37, 43, 55, 57

Failure to perform the procedure for such patients can result in overflow, bowel obstruction, autonomic dysreflexia and in severe instances, death. It is therefore imperative that staff providing care to the spinal cord injured patient be able to perform the procedure for manual evacuation of the bowel if deemed necessary.

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Patients with a Spinal Cord Injury

A spinal cord injury at any level generally affects bowel control. Sensations, which would normally travel upwards from the bowel to the brain, are interrupted and the patient is unable to feel when they need to defecate. Motor signals that travel downwards to control the sphincter are also interrupted.

Peristalsis is also less effective which may result in stool taking up to 80 hours to pass through the colon; more water is absorbed resulting in a greater risk of constipation, which can lead to obstruction and increase the risk of bowel perforation.27, 40, 44

If faeces are allowed to accumulate in the rectum over-distension of the stretch receptors in the bowel wall inhibit the return of reflex ano-rectal activity, which can further complicate patients’ rehabilitation with an Upper Motor Neurone SCI. (UMN).

‘Automatic’, ‘spastic’ or a ‘reflex’ bowel are terms utilised in UMN injury. This is where the injury is at or above the conus medullas (above T12), therefore this involves patients with a cervical or thoracic injury.

In UMN injury spastic paralysis of the bowel occurs with an inability to control defecation.8, 15, 56 Although the nerve pathways are interrupted the reflexes, which partly control the bowel, are intact and reflex activity is uninhibited. Therefore when the rectum is stimulated it will contract and reflex bowel emptying can be achieved with minimal intervention.7, 52, 66 A full rectum may be enough to stimulate the bowel but the use of aperients and/or digital removal of faeces may also be necessary.7, 15

People with lower motor neurone (LMN) SCI have the sacral cord segments in the conus medullaris or sacral nerve roots in the cauda equina are affected (T12 and below).52 The lower motor neurones – the reflex defecation centre is damaged resulting in flaccid paralysis of the bowel.8, 15, 66 Therefore there is no reflex activity in the rectum and a relaxed anal sphincter is evident and pharmacological or digital stimulation are not effective.18, 68

Combined with oral aperients daily manual removal of stool is required in this client group.7, 15, 26, 68 The oral aperients should include a stimulant laxative.

An injury sustained around the T12 area of the spine may result in the bowel adopting a mixture of UMN and LMN bowel effects and function.

Regardless of whether the SCI is classified as UMN or LMN immediately following injury the rectum and anus are flaccid due to spinal shock therefore the use of rectal stimulants and DRS are considered to be largely ineffective.15, 27 The first spinal reflex to return is the anal reflex which normally returns about 48 hours following injury.27 The anal reflex is when the skin around the anus contracts then relaxes when touched. This reflex can be utilised to allow easier insertion of the finger. 57

Within 24 hours of admission it is vital that the assessment and planned care/interventions are documented. 37

After spinal shock has resolved bowel training should be commenced and be relevant to the patients level of SCI. In acute SCI patients a daily PR should be performed to assess for anal tone.14 If anal tone is not evident and stool is present gently, digitally remove the faeces.14 If anal tone is present in UMN SCI spinal shock has resolved. Bowel management should be performed at approximately the same time of day on each occasion however a lack of flexibility is equally disadvantageous for the SCI patient.14

If the spinal injury is unstable bowel care/interventions must be performed whilst maintaining spinal alignment i.e. logroll.

DRS and ME are established and accepted methods of bowel emptying for SCI patients, which continues throughout their lifetime.5, 36

It is vital to assess patients with a SCI on an individual basis and provide bowel care following a through assessment.11, 62 The aim is to produce effective evacuation i.e. avoiding faecal incontinence/constipation within a reasonable time period suggested to be one hour, at a predictable and socially acceptable time.14 following a SCI the loss of bowel control is more significant than the loss of mobility therefore this is a vital aspect of care which impacts upon the person’s independence and community integration. 37

From the literature it appears that bowel irrigation may be useful for patients with long term SCI. Bowel irrigation involves passing water (or other liquids) into the bowel in a quantity to reach past the rectum to aid evacuation of the bowel. Bowel irrigation may reduce digital interventions, oral laxatives and the need for suppositories. However bowel irrigation is not a common intervention/procedure within the acute hospital setting at this time. Therefore if a patient with a long term SCI is admitted and utilises bowel irrigation as part of their regime advice should be sought from relevant sources such as the patient, carers, district nurses and continence advisory service.

It is important to reiterate that SCI patients’ with established injuries should not have their essential routine interrupted regardless of the setting in which care is provided. Patients and/or their families remain the experts in the management of conditions such as spinal cord injury and the National Service Framework for long-term conditions (neurological) emphasises the importance of listening to their advice and suggestions.39 It may prove helpful to discuss any potential changes in bowel management regimes with the patient and local Spinal Injuries Centre to alleviate any unnecessary distress or implementation of new routines.55 If care is denied the nurse may be called into question by the NMC. Ultimately health care workers should be familiar with bowel care in patients with a SCI.

Unfortunately constipation and/or impaction of the bowel are a common complication in SCI patients outside of the spinal injury specialist setting, which can result in Autonomic Dysreflexia.27

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Autonomic Dysreflexia (AD)

Failure to perform ME in SCI patients may cause AD, which can be life threatening. However it must also be noted that rectal stimulation may also cause AD in patients with cervical or high thoracic SCI. Therefore if there is any indication of AD resulting from rectal stimulation lidocaine 2% gel should be utilised to reduce any potential side effects.66

AD can occur in any patient with a SCI at T6 or above. 24, 55, 63, 70 It occurs when there is irritation, pain or stimulus below the level of the SCI. This irritated area sends a signal to the brain so the stimulus can be removed or rectified. However in SCI patients the message is unable to reach the brain as it is blocked at the level of injury. A reflex action occurs including the release of noradrenaline and dopamine causing vasoconstriction, which in turn increases the patient’s blood pressure (BP) to potentially dangerous levels, which can cause myocardial infarction, seizures, cerebral haemorrhage and death.35, 63

Classic causes of AD are over distension of the bowel due to constipation and impaction and overstretching or irritation of the bladder including urinary tract infection and blocked catheter.63 however any irritant below the level of injury can initiate an episode of AD including pressure sores and tight clothing.35 Symptoms include, palpitations, sweating, headache, flushing and severe hypertension.  If AD does occur, the cause must be discovered and rectified immediately.27, 63 Implementing an appropriate bowel management programme can dramatically reduce the incidence of AD.3

It is important to note that patients with a SCI can be given sodium citrate micro-enema (Micollette, Microlax, Relaxit) but should not routinely be given phosphate enemas as they are difficult to retain and may cause AD.14 The use of lidocaine 2% gel as opposed to standard lubricating gel, for invasive bowel interventions and re-catheterisation is also indicated for this reason in patients who are already known to suffer with AD.

If interventions to determine the cause are ineffective and/or the patient’s BP remains elevated it should be treated with GTN spray 400 microgram, sub-lingual.7 If GTN spray is unavailable, a tablet form of GTN 500 microgram inserted under the tongue or a 5mg patch applied to the chest or upper arm can also be utilised. However it is important to note that the medication should be discontinued or the patch removed as soon as the BP is reduced. Prescribers need to be aware these are unlicensed indications for GTN.

If there is little or no effect on the patient’s BP in 5-10 minutes following administration, a second dose should be given. Up to three doses can be given in a 30-minute period.6, 35 If the BP remains elevated intravenous medication may be indicated including morphine and epidural anaesthesia. (Ibid). It is important to note that patients with SCI above the level of T6 may have a relatively low BP due to the actual SCI itself therefore assessment of the patient’s BP should be on an individual basis.6, 35However, AD should always be suspected in vulnerable SCI patients in whom the systolic BP increases 20-40mmHg above the individual’s normal resting level. 35

Also important to consider is whether the patient has had or recently taken medication for erectile dysfunction. The use of phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil) is contra-indicated in patients taking nitrates.

Patients who have recently taken phosphodiesterase inhibitors should be given Nifedipine 10mg capsules (not modified release tablets). These capsules should be swallowed, whole and it can take 15-20 minutes to be effective.35

An acute episode of AD can lead to increased susceptibility to further attacks in the next 24-72 hours and increases susceptibility to causes and/or irritants that were previously unproblematic.35

It is apparent that DRS and ME are vital aspects of care especially in patients with a SCI. However there are cautions and contra indications to these procedures in all patients.

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Cautions for patients requiring ME

Caution should be utilised if the following are present,

  • CHILDREN (Separate guidelines exist). (RCN. (2005) Digital Rectal Examination. Guidance for Nurses Working with Children and Young People.
  • Active inflammation of the bowel. E.g. Crohns Disease, Ulcerative Colitis.
  • Recent radiotherapy to the pelvic area.
  • Rectal surgery/trauma.
  • Abdominal, rectal and/or anal pain.
  • Tissue fragility due to age, radiation, loss of muscle tone due to neurological disease or malnourishment.
  • Obvious rectal bleeding.
  • SCI patients who are known to suffer with AD.
  • History of abuse.
  • History of allergies i.e. latex, lanolin. 52, 55, 69

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Contra indications for patients’ requiring ME

Contra indications include the following,

  • Lack of consent from the patient whether written, verbal or implied.
  • Patient’s doctor has given specific refusal for the procedure.
  • Patient gains sexual satisfaction from the procedure.
  • Abnormalities of the perineal and peri-anal region. (See further details below).55, 69

Prior to performing either DRS or ME the nurse must observe the perineal and peri-anal area. If any of the below are present, advice should be sought from a specialist nurse or medical practitioner. However DRS and ME can still be undertaken if the nurse feels confident and competent.55

  • Rectal prolaspe.
  • Haemorrhoids – note the number, position and condition.
  • Wounds/dressings/discharge.
  • Anal lesions.
  • Gaping anus.
  • Skin conditions including pressure sores of all grades and broken areas.
  • Bleeding – old/fresh.
  • Faecal matter.
  • Infestation.
  • Foreign bodies.
  • Anal fissure (small tear around the anal area) due to straining or trauma to the bowel lining and/or the actual procedure of ME. It can be very painful in patients who have sensation and increase spasm in SCIs' without sensation.44, 55

Throughout all aspects of bowel care it is vital that documentation is evident and complete. This promotes better patient care including early detection of any problems, improved communication, evidence of care delivered and may assist in improving accountability and addressing legal aspects of care.57

The guidelines provided overleaf for DRS and ME of faeces have been developed and adapted from Royal College of Nursing publications, Sheffield Teaching Hospitals, Southampton University Hospital Trust and East Lincolnshire Primary Care Trust bowel care guidelines.7,  21, 25, 26, 27, 31, 33, 34, 43, 38, 45,48, 55, 5769  Louise Dunsmure Advanced Pharmacist for Neurology and Neurosciences at Leeds General Infirmary has also provided advice and information. It is vital to note that all practitioners must check for allergies prior to utilising any of the recommended products in the procedures.

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Procedural Guidelines for Digital Rectal Stimulation

Materials required for the procedure;

  • Latex-free examination gloves.
  • Standard lubricating gel/anaesthetic gel (lidocaine 2% gel).
  • Disposable cleaning wipes.
  • Disposable protective pads/incontinence pads.
  • Skin cleansing materials.
  • Clinical waste bag.

Procedural Guidelines

  1. Ensure the appropriateness of the procedure including assessing the patients understanding and consent. Ask if the person would like a chaperone. Document in the nursing notes.
  2. Prepare equipment for the procedure to ensure it is performed with minimal disruption.
  3. Ensure privacy and dignity is maintained at all times including undertaking the procedure in an undisturbed area.
  4. If the procedure has not been performed previously or occurring in a ward base setting take the patient’s BP and pulse prior to the procedure as vagal stimulation can slow the heart rate. In SCI patients at risk of AD monitor BP and pulse in all health care settings.
  5. Wash and dry hands thoroughly. Apply an apron and two pairs of latex-free gloves to reduce the risk of cross-infection. (The patient may develop a latex allergy due to repeated contact during this procedure).
  6. Place the patient in a left lateral position with knees flexed. (If left lateral lying is ever contraindicated in a patient the procedure can be carried out with the patient lying on the right side. Practitioners need to be aware of the changed position of rectal anatomy in this position).
  7. Ensure sufficient protective pads are insitu to protect the bed sheets.
  8. Inform the patient of the imminent examination.
  9. Assess anal area for any abnormalities, which should be documented and reported to medical staff.
  10. Ensure the index finger is well lubricated which reduces surface friction thereby helping to prevent trauma to anal and rectal mucosa. Lubrication also facilitates easier insertion of the finger, reduces sensation and discomfort during the procedure. If the patient has previously suffered with AD anaesthetic gel (lidocaine 2% gel) must be utilised. It takes 5-10 minutes to take effect and can last up to 90 minutes.
  11. Insert the index finger gently through the anus with the finger pads facing towards the bowel wall 1-2 inches toward the belly button. The rationale for this is that the nail of the finger is furthest from the bowel wall and therefore less likely to cause any damage. Note any resistance or reflex contraction of the anal sphincter.
  12. If sensation is evident or the patient has previously suffered with AD utilise anaesthetic gel and wait 5 minutes for the anaesthetic to take effect.
  13. If stool is present in the rectum remove by pressing the stool towards the spine and remove with the finger.
  14. Use a circular motion following the bowel wall towards the spine to stretch/stimulate the wall and /internal anal sphincter for 15-20 seconds (no longer than 1 minute) or until you feel the internal/anal sphincter relax. NB; avoid pressure towards the prostate, vagina or bladder.
    * The circular motion originates from the wrist and forearm not the finger. Withdraw the finger and await a reflex evacuation. Wipe finger between insertions or remove one of the gloves and replace as necessary. When exiting the bowel, fingertip pad rotates to face the bowel wall again.
  15. Digital stimulation can be repeated every 5-10 minutes up to 3 times until evacuation is complete and the internal/anal sphincters tighten. Complete evacuation is indicated if two consecutive stimulations fail to produce any more stool or only mucous is passed.
  16. When the procedure has been completed ensure the patient is clean and dry. Dispose of utilised equipment and maintain strict hand hygiene measures.
  17. Practitioners must document the date, time and length of procedure, stool consistency and amount utilising the Bristol Form Stool Guide. The use of rectal stimulants (see below) and how many DRS’s were required to ensure complete evacuation should also be documented.

It is important to note that rectal stimulants can and may be necessary to ensure effective bowel evacuation. Absence of faeces in the rectum in SCI patients is not an indication to omit a rectal stimulant. If a rectal stimulant is utilised and left in position for 20-30 minutes the anal reflex may have developed enough strength and co-ordination to evacuate some stool onto the protective pad. However a digital examination should occur following this to ensure the bowel is empty, if not DRS may also be necessary. If an excessive amount of stool remains in the rectum a second dose of rectal stimulant can be utilised if necessary.

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Procedural Guidelines for the Manual Evacuation of Faeces

Materials required for the procedure;

  • Latex-free examination gloves.
  • Standard lubricating gel/anaesthetic gel (lidocaine 2% gel).
  • Disposable protective pads/incontinence pads.
  • Disposable cleaning wipes.
  • Skin cleansing materials.
  • Clinical waste bag.

Procedural Guidelines

  1. Ensure the appropriateness of the procedure including assessing the patients understanding and consent. Ask if the person would like a chaperone. Document in the nursing notes.
  2. Prepare equipment for the procedure to ensure it is performed with minimal disruption.
  3. Ensure privacy and dignity is maintained at all times including undertaking the procedure in an undisturbed area.
  4. If the procedure has not been performed previously or occurring in a ward base setting take the patient’s BP and pulse prior to the procedure as vagal stimulation can slow the heart rate. In SCI patients at risk of AD monitor BP and pulse in all health care settings.
  5. Wash and dry hands thoroughly. Apply an apron and two pairs of latex-free gloves to reduce the risk of cross-infection. (The patient may develop a latex allergy due to repeated contact during this procedure).
  6. Place the patient in a left lateral position with knees flexed.
  7. Ensure sufficient protective pads are insitu to protect the bed sheets.
  8. Assess anal area for any abnormalities, which should be documented and reported to medical staff.
  9. Inform patient of imminent examination.
  10. Ensure index finger is well lubricated to reduce surface friction, which helps to prevent trauma to anal and rectal mucosa. Lubrication also facilitates easier insertion of the finger, reduces sensation and discomfort during the procedure. If the patient has previously suffered with AD anaesthetic gel (lidocaine 2% gel) must be utilised. It takes 5-10 minutes to take effect and can last up to 90 minutes.
  11. Insert the index finger gently through the anus with finger pads facing towards the bowel wall.  The rationale for this is that the nail of the finger is furthest from the bowel wall and therefore less likely to cause any damage. The finger should be crooked slightly away from the bowel wall but still able to remove the stool away in a ‘beckoning’ back through the anal sphincter. The rationale for this is that the nail of the finger is furthest from the bowel wall and therefore less likely to cause any damage.
  12. Remove the faecal matter slowly in small amounts to reduce the risk of trauma and/or pain to the patient. If a solid mass is felt, gently push the index finger into the middle to split the stool and remove small pieces. When exiting the bowel, fingertip pads rotate to face the bowel wall again.
  13. A period of rest may be necessary to allow faecal matter to descend into the rectum.
  14. Repeat until the bowel is empty.
  15. If the patient becomes distressed and/or in pain or vagal activity occurs during the procedure, check the patients pulse again and STOP if the pulse rate has dropped or the patient is clearly distressed. Utilise anaesthetic gel and wait 5 minutes before continuing. Over time the ano-rectal area can become de-sensitised to this procedure and almost all patients with an established SCI utilise standard lubricating gel.
  16. Wipe the finger of the glove clean between insertions or change the top glove as necessary.
  17. When the procedure has been completed ensure the patient is clean and dry. Dispose of utilised equipment and maintain strict hand hygiene measures.
  18. Practitioners must document the date, time and length of procedure, stool consistency and amount utilising the Bristol Form Stool Guide. The use of rectal stimulants (see below) should also be documented.

During the procedure the person delivering the care may carry out abdominal massage 57. If the rectum is full of soft stool continuous gentle circling of the finger may be used to remove the stool and is still classed as digital removal of faeces. 57 If this is ineffective the patient may be left for a further 24 hours to allow re-absorption of water content.

If faeces are hard and dry the use of rectal stimulants may be necessary utilising either 2 glycerine suppositories (4g) or a sodium citrate micro-enema (Micollette, Microlax, Relaxit) (5ml volume). Phosphate enemas should not be utilised in SCI patients as this may cause an episode of AD.

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Provenance

Record: 1481
Objective:
  • To provide guidance for health care professionals regarding digital rectal stimulation and manual evacuation of faeces.
  • To provide evidence based recommendations for these procedures.
  • To provide insight into patients who may require the procedures.
  • To provide insight into the legal and professional aspects of care.
  • To ensure patients receive essential care in a safe and skilled manner.
Clinical condition:

Patients with neurogenic bowel especially those individuals who have sustained a spinal cord injury (both acute or established).

Target patient group: Adult patients
Target professional group(s): Secondary Care Nurses
Allied Health Professionals
Adapted from:

Royal College of Nursing publications;
Digital Rectal Examination and Manual Removal of Faeces (2006)
Bowel Care, including Digital Rectal Examination and Manual
Removal of Faeces. (2008)
Management of Lower Bowel Dysfunction, including DRE and DRF (2012)


Evidence base

  1. Addison, R. (1996) The last resort. Journal of Community Nursing. 10:8:18-20.
  2. Addison, R. & White, M. (2002) Spinal injury and bowel management. Nursing Times. 98:4. www.nursingtimes.net. Accessed January 2007.
  3. Adsit, P. & Bishop, C. (1995) Autonomic Dysreflexia: don’t let it be a surprise. Orthopaedic Nursing. 14:3:17-20.
  4. An Bord Altranais. (2006) Scope of Practice. http://www.nursingboard.ie/elearning/scope. Accessed January 2007.
  5. Ash, D. Harrison, P. Slater, W. (2006) Bowel Management. In: Harrison P (Ed) (2006) Managing Spinal Cord Injuries: Continuing Care. Spinal Injury Association, Milton Keynes: 60-67.
  6. Australian & New Zealand Spinal Cord Society (ANZSCOS). (2006) http://ciap.health.nsw.gov.au/downloads/speciality/SCI_auto_dys_algorithm.pdf. Accessed November 2008.
  7. Bhattacharjee, S. & Poonnoose, P. (2003) Management of paraplegia in palliative care. Indian Journal of Palliative Care. 9:1:14-18.
  8. Bryant, G. (2000) When spinal cord injury affects the bowel. RN. 63:2:26-30.
  9. Burke, A. (1994) The management of constipation in end stage disease. Australian Family Physician. 23:7:1248-1253.
  10. Care Quality Commission. (2010) Assessing and Monitoring the Service Provision. Essential Standards of Quality. 
  11. Christensen, P. et al. (2006) A randomised controlled trial of transanal irrigation versus conservative bowel management in spinal cord injured patients. Gastroenterology. 131:3:738-347.
  12. Coggrave, M. (2007b) Transanal irrigation for bowel manag88ement. Nursing Times. 2:103:26
  13. Coggrave, M. (2008) Neurogenic continence. Part 3: Bowel management strategies. British Journal of Nursing. 17:11:706-710
  14. Coggrave, M. et al. (2009) (on behalf of spinal cord injury centres of UK and Ireland). Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury. Peterborough: Coloplast.
  15. Consortium for Spinal Cord Medicine (1998): Neurogenic Bowel Management in Adults with SCI: Clinical Practice Guidelines. Paralyzed Veterans of America, Washington.
  16. Correa, G. & Rotter, K. (2000) Clinical evaluation and management of neurogenic bowel after spinal cord injury. Spinal Cord. 38:5:301-308.
  17. Cosgrove, S. (2005) Southport & Ormskirk NHS Trust: Policy for Manual Evacuation of Faeces for the Spinal Cord Injured Patient. Southport & Ormskirk NHS Trust.
  18. Department of Health. (2003) Essence of Care Benchmarks for Privacy & Dignity. London, DH.
  19. Department of Health. (2005) National Service Framework for Long Term Conditions. London, DH.
  20. Department of Health. (2007) Essence of Care: Benchmark for the Care Environment. London, DH.
  21. Doyle, J. & Patel, J. (2006) Bowel Care Guidelines. South Worcestershire Primary Care Trust. http://www.worcestershirehealth.nhs.uk/Intranet1_Library/foi_internet/foi_files/class_9/Clinical_Policies/250406BowelCareGuidelinesfinal. Accessed January 2007.
  22. East Lincolnshire Primary Care Trust. (2005) Guideline for Manual Evacuation. http://www.eastlincs-pct.nhs.uk/foi/data/09 Policies and Procedures/G-M/Manual Evacuation Clinical Guidelines Oct 05.pdf. Accessed January 2007.
  23. Fader, M. (1997) The Promotion and Management of Continence in Neurological Disabilities. In Dolman, M, & Getliffe, K. Promoting Continence. Bailliere Tindall, London.
  24. Halm, M. (1990) Elimination concerns with acute spinal cord trauma. Assessment and nursing interventions. Critical Care Nursing Clinics of North America. 2:3:385-398.
  25. Harrison, P. (2000) HDU/ICU. Managing Spinal Injury: Critical Care. Spinal Injury Association, London.
  26. Harrison, P. & Thomas, S. (2000) Bowel management problems outside the specialist units. Forward (Spinal Injury Association Newsletter). 35:6-7.
  27. Harrison P, Lamb A, Mackay K, Fletcher A (2007) Autonomic Dysreflexia. In: Harrison P (Ed) (2007) Managing Spinal Cord Injuries: The First 48 Hours. Spinal Injury Association, Milton Keynes: 75-77.
  28. Irwin, K. (2001) Managing adult faecal incontinence. Journal of Community Nursing. 15:2:25-29.
  29. Irwin, K. (2002) Digital rectal examination/manual removal of faeces in adults. JCN Online. www.jcn.co.uk. Accessed January 2007.
  30. Irwin, K. (2008) Digital Rectal Examination & Manual Removal of Faeces Supporting Information. Bolton Primary Care Trust.
  31. Kyle G, Oliver H, & Prymm P (2003): The procedure for the digital removal of faeces. NHS/Thames Valley University/Norgine, Uxbridge.
  32. Kyle, G. (2008) Digital Removal of faeces by acute sector nurses. Nursing Times. 104:25:40
  33. Lavender, R. & Raven, D. (2004) Digital Rectal Examination and Manual Evacuation of faeces (Adult). East Elmbridge and Mid Surrey NHS Primary Care Trust. http://www.eeandms-pct.nhs.uk/pdf/DigRectalExam.pdf. Accessed January 2007.
  34. Mallet, J. & Dougherty, L. (2000) Bowel Care in Royal Marsden Hospital Manual of Clinical Nursing Procedures. 4th edition. Pp 131-145. London, Blackwell Scientific Publications.
  35. Middleton, J. (2005) Treatment of Autonomic Dysreflexia for Adults with Spinal Cord Injuries. http://www.paraquad.nsw.asn.au. Accessed November 2008.
  36. Multidisciplinary Association of Spinal Cord Injury Professionals (MASCIP) (2004) Guidelines for Bowel Management after Spinal Cord Injury: Overview available from: www.mascip.co.uk. (See reference 13 for the updated document).
  37. Multidisciplinary Association of Spinal Cord Injury Professionals (MASCIP). (2012) Guidelines for the Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions.
  38. National Patient Safety Agency. (2004) Improving the safety of patients with established spinal injuries in hospital. London, NPSA.
  39. National and Reporting and Learning Agency. (2012) Patient Safety Information: Spinal Cord Lesion and Bowel Care. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59790 Accessed January 2014.
  40. Nelson, A. & Fine, C. (2001). Chapter 16. 203-223. In Nelson, A, Zejdlik, C & Love, L. (2001) Nursing Practice Related to Spinal Cord Injury and Disorders: A Core Curriculum. Demos Medical Publishing.
  41. Ness, W. (2013) Management of Lower Bowel Dysfunction. Primary Health Care. 23:5:27-30.
  42. NHS Clinical Governance Support Team. (2005) Guidance on the Role & use of Chaperones in Primary & Community Care Settings. London, NHS CGST.
  43. NICE (2007) Faecal Incontinence. NICE clinical guideline 49. London, NICE.
  44. Noon, C. (2002) Digital Rectal Examination and Manual Removal of Faeces for the Spinal Injury Patient. The Mid Yorkshire Hospital Trust. Wakefield.
  45. Norton, C. & Chelvanayagam, S. (2004) Bowel Continence Nursing. Beaconsfield Publishers Ltd, Buckinghamshire.
  46. Nursing & Midwifery Council. (2002) Code of Professional Conduct. NMC, London.
  47. Nursing & Midwifery Council. (2002) Practitioner-Client Relationships and the Prevention of Abuse.
  48. Nursing & Midwifery Council. (2004) Guidelines for Records and Record Keeping. NMC, London.
  49. Nursing & Midwifery Council. (2007) Record Keeping & Guidance. London, NMC.
  50. Oozier, B., et al. (1998) Fundamentals of Nursing. California, Addison Wesley.
  51. Porter, P. & Perry, A. (1989) Fundamentals of Nursing Care. 3rd Edition. London, Mosby.
  52. Powell, M & Rigby, D. (2000) Management of bowel dysfunction: Evacuation difficulties. Nursing Standard. 14:47-51.
  53. Royal College of Nursing. (2000) Digital rectal Examination and Manual Removal of Faeces. London, RCN.
  54. Royal College of Nursing. (2004) Digital Rectal Examination and Manual Removal of Faeces, Guidance for Nurses. London, RCN.
  55. Royal College of Nursing. (2006) Digital Rectal Examination and Manual Removal of Faeces. Guidance for Nurses. London, RCN.
  56.  Royal College of Nursing. (2008) Bowel Care, including Digital Rectal Examination and Manual Removal of Faeces.  Guidance for nurses. London, RCN.
  57. Royal College of Nursing. (2012) Management of Lower Bowel Dysfunction, including DRE and DRF. Guidance for Nurses. London. RCN.
  58. Royal College of Physicians. (2008) Chronic Spinal Cord Injury: management of patients in acute hospital settings. National Guidelines. http://www.mascip.co.uk/default.ihtml?itep=48pid=73 Accessed July 2008.
  59. Sheffield Teaching Hospitals (2006) Procedural Guideline for Digital Rectal Examination (DRE) in Patients with Established Spinal Cord Lesions. Sheffield Teaching Hospitals.
  60. Sheffield Teaching Hospitals. (2006) Procedural Guideline for the Digital Removal of Faeces (DRF) in Patients with Established Spinal Cord Lesions. Sheffield Teaching Hospitals.
  61. Sheffield Teaching Hospitals (2006) Procedural Guideline for the Reflex Evacuation of Faeces and the use of Digital Rectal Stimulation (DRS) in Patients with Established Spinal Cord Lesions. Sheffield Teaching Hospitals.
  62. Shepherd, E. (2000) Editorial. Nursing Times Continence Supplement. Nursing Times. 96:6:1.
  63. Spinal Injury Association. (2007) Autonomic Dysreflexia. http://www.spinalcord.org/news.php?dep=17&page=94&list=1178. Accessed November 2008.
  64. Southampton University Hospital Trust. (2005) Bowel Care Guidelines for Patients with a Spinal Cord Lesion. Southampton University Hospital Trust.
  65. United Kingdom Central Council for Nursing, Midwifery & Health Visiting. (1992) Scope of Professional Practice. London, UKCC.
  66. United Spinal Association. (2005) SCI Neurogenic bowel care: Nursing guidelines. American Association of Spinal Cord Injury Nursing. 
  67. Wiesel, P. McKee, J. & Norton, C. (2006) Bowel Management. Spinal Injury Association.
  68. Williams, C. (2010) Managing bowel function after spinal cord injury using anal irrigation. Nursing Times. 106:24
  69. Young, K. (2004) Policy for Nurses undertaking Digital Rectal Examination in Adults. Bury Primary Care Trust. www.burypct.nhs.uk/fileadmin/user_upload/services/hospital_services/commissioning_matrix.pdf. Accessed January 2007.
  70. Zejdlik, C. (1992) Management of Spinal Cord Injury. 2nd Ed. Chapter 19. Jones & Bartlett, Boston.

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Definitions

Digital Rectal Examination (DRE)
DRE is performed to assess if faecal matter is present in the rectum including, the amount and consistency of stool and whether rectal medication, DRS or ME is required.52, 55

DRE also allows for assessment of anal tone and sensation (this is the ability to initiate a voluntary contraction and to what degree). It can also be used to trigger defecation in patients with an UMN bowel by stimulating the recto-anal reflex. 55

Digital Rectal Stimulation (DRS)
DRS stimulates the rectum to contract and enable evacuation by gently rotating a well-lubricated gloved finger just inside the anus.42 This might follow an episode of constipation and then become an integral part of defecation. In SCI patients with a UMN bowel it is usually possible to stimulate a defecation reflex voluntarily.

Manual Evacuation of Faeces (ME)
ME is the digital removal of faecal matter from the rectum to prevent a build up of stool in the rectum, which may lead to incontinence, increased constipation and impaction of faeces.45, 52, 55

ME may only be required once in a person’s lifetime but more commonly it is a long-term management in the presence of neurological dysfunction. It may be required for faecal impaction, incomplete defecation and/or when other bowel emptying techniques have failed.55

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Glossary of Abbreviations

AD – Autonomic Dysreflexia.
BP – Blood Pressure.
DRE – Digital Rectal Examination.
DRS – Digital Rectal Stimulation.
LMN – Lower Motor Neurone.
ME – Manual Evacuation.
NMC – Nursing and Midwifery Council.
NPSA – National Patient Safety Agency.
RCN – Royal College of Nursing.
SCI – Spinal Cord Injury.
SIA – Spinal Injury Association.
UMN – Upper Motor Neurone.

For any information and/or advice regarding these guidelines please contact Sister Janette Fleetwood on Neuro Intensive Care (L6), Leeds General Infirmary on (0113) 392 7406.
Sister Janette Fleetwood will review these guidelines in January 2016 unless new evidence and/or national guidelines are published which may indicate an earlier review.

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Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.