Adopting Peristeen and other transanal irrigation systems for people with functional bowel disorders

• Increase the choice of treatment options available for patients with bowel dysfunction
• Support patients in using transanal irrigation with specialist training, by experienced clinicians, for users and carers as recommended in the NICE medical technologies guidance
• Adopt the technology as part of a holistic structured multidisciplinary care pathway

The healthy bowel clinic at Aintree University Hospital, assesses and treats patients with functional bowel problems (including constipation, faecal incontinence and obstructed defecation) and pelvic floor conditions. It was established in 2003 and is led by a team of specialist physiotherapists. They accept referrals from Hospital Consultants and General Practitioners from the Liverpool are and also Tertiary referrals and more recently A and E (as part of a project to reduce admissions of people with a primary diagnosis of constipation who present to A and E – see findings).

The patients who present to the healthy bowel clinic are usually desperate. They may have had constipation, faecal incontinence or obstructed defecation for many years, even since childhood. These conditions can be debilitating and embarrassing. For the majority of patients presenting with functional bowel problems there is no surgical option. When surgery is indicated the results can be very variable therefore, for patients who have failed conservative treatment including diet / lifestyle and appropriate laxatives, rectal irrigation will often be trialled before surgery is considered.

Based on existing research where Peristeen was used to treat people with neurogenic bowel, the team believed that Peristeen TAI offered a better treatment option than failed conservative treatment and is less invasive than surgery. Therefore, in 2009 the team adopted Peristeen within a bowel care pathway (attached) to treat 3 main functional disorders; slow-transit constipation, faecal incontinence and obstructed defecation syndrome. As more TAI devices have become available, the team have expanded the choice of TAI systems available.

The clinic is supported by a range of healthcare professionals, including colorectal consultants, radiographers, physiologists, a gastroenterologist, a specialist nurse and a cognitive behavioural therapist.

Patients are triaged by a consultant to check the problem is functional. The physiotherapy team who lead the clinic can send patients for investigations such as transit marker studies, defecating proctograms, anorectal physiology or various blood tests. The team decide on the most appropriate treatment or management. Commonly less invasive conservative treatments such as diet / lifestyle and appropriate laxatives are started first. If these fail, after further assessment and a multidisciplinary team decision, Peristeen or other transanal irrigation (TAI) systems are tried.

Once TAI has been started the experienced clinicians provide ongoing training and support for patients in the long-term.

Training for the healthcare professional selecting TAI and teaching the patients how to use TAI is very important for the success of the intervention for the patient. Training for staff would vary depending upon their experience but the lead physiotherapist at the service organised for a Peristeen advisor to be in attendance at the irrigation clinics for the first 6 months until she felt competent. She also attended numerous training days provided by coloplast.

Following the successful use of Peristeen and other TAI systems and increased referrals to the service, general practitioners who are responsible for ongoing prescription of the systems are becoming aware of the costs. Aintree have found that explaining the benefits to GP’s of the systems and the potential for cost savings through reduced appointments and ongoing costs of someone who has had a stoma created has helped overcome these apprehensions.

Over an 8 year period the team undertook a retrospective evaluation of the effectiveness of Peristeen for the patients they had offered it to. 197 patients who had been using Peristeen for at least 12 weeks were identified and questionnaires sent to them. All had been treated in line with the clinics care pathways (attached). The findings were:

• 69% of responders were still using TAI. The drop out was 32% for those with constipation, 33% for those with faecal incontinence and 25% for responders with obstructed defecation syndrome. The majority stopped due to no improvement in perceived symptoms, followed by rectal or anal pain whilst using the irrigation system
• The median pre TAI visual analogue scale score (0 being no bowel problems at all and 10 being the worst they could be), for responders was 10. Post treatment the median was 4.

In 2016, a pilot study was established where patients with a primary diagnosis of constipation who present at A&E were referred directly to the AED bowel clinic and seen as outpatients within 24 hours. The majority of these patients are discharged but a small number with more chronic functional bowel symptoms may be seen within the Healthy Bowel Clinic and may require TAI after following the appropriate care pathway. So far, the new pathway has saved 231 bed days and cut costs by an estimated £92,400.

Based on their 8 years of experience they conclude that TAI is a viable, safe and effective treatment option for patients who present with functional bowel disorders.

The following comments have been received by the team from patients using TAI

• “Since using the irrigation I can now go out with comfort knowing I won’t be embarrassed by leakage”.
• “It has changed my life. I was more or less housebound previously. Now I have my social life back”.
• “Irrigation worked for me. I couldn’t cope without it”.
• “On most occasions it works very well. I would be lost without it”.
• “I feel more empty using this system and it is a good addition to my bowel management”.
• “Irrigation has been a great help to me even though I only use it when I’m bordering on hospital admission; it has been a really beneficial and reassuring treatment”.
• “Using irrigation has changed my daily life. I can eat and drink more after using it. Also I have less nausea, bloating and discomfort”.
• “Gaining weight happily. Peristeen has changed my life”.
• “I don’t suffer with constipation anymore and don’t have accidents at work. If going out in the evening I use it later in the day”.

• Adopt Peristeen in a dedicated clinic which takes a holistic approach to bowel management and includes thorough patient assessment and multidisciplinary team support.
• The team believe that because the patients follow an agreed care pathway, this enables patients to build a degree of trust with their clinicians which increases the patient’s motivation and belief that TAI will improve their symptoms.
• Training health care professionals and ensuring competence for those responsible for
  • selecting TAI as a treatment option
  • training patients in how to use the system
  • providing ongoing support to patients using the system is important for successful adoption of the system.
• When assessing the acceptability of Peristeen the team recommend measuring adherence to the therapy, optimal frequency of irrigation, the volume of irrigant used and the effect of TAI on the patient’s quality of life.

Contributors: Paul Skaife (Colorectal Consultant), Sandra Blythin (Specialist Physiotherapist) and Julie McAteer (Specialist Physiotherapist).