Enema

Enema
Rectal bulb syringe to administer smaller enemas
Pronunciation /ˈɛnəmə/
Synonyms Clyster

An enema is the injection of fluid into the lower bowel by way of the rectum.[1]

In standard medicine, the most frequent uses of enemas are to relieve constipation and for bowel cleansing before a medical examination or procedure;[2] also, they are employed as a lower gastrointestinal series (also called a barium enema),[3] to check diarrhea, as a vehicle for the administration of food, water or medicine, as a stimulant to the general system, as a local application and, more rarely, as a means of reducing temperature,[1] as treatment for encopresis, and as a form of rehydration therapy (proctoclysis) in patients for whom intravenous therapy is not applicable.[4]

In other contexts, enemas are used as part of some alternative health therapies, as part of sexual activities, and to administer drugs for recreational or religious reasons.

Medical usage

The principal medical usages of enemas are:

Bowel cleansing

Soapsuds enemas, in a can with a nozzle typical for a cleansing enema, and in a contrast enema bag with a barium nozzle
A prepared, disposable enema

Acute treatments

As bowel stimulants, enemas are employed for the same purposes as orally administered laxatives: To relieve constipation; To treat fecal impaction; To empty the colon prior to a medical procedure such as a colonoscopy. A large volume or high enema[5] can be given to cleanse as much of the colon as possible of feces.[6][7] However, a low enema is generally useful only for stool in the rectum, not in the intestinal tract.[8]

Such enemas' mechanism consists of the volume of the liquid causing rapid expansion of the intestinal tract in conjunction with, in the case of certain solutions, irritation of the intestinal mucosa, resulting in powerful peristalsis and a feeling of extreme fecal urgency. The enema is retained until there is a uncontrollable urge to defecate, at which time the recipient may expel any fecal matter loosened by the instilled solution together with the solution itself. The procedure may cause uncomfortable bloating and cramping.

Water-based solutions

Plain water can be used, simply functioning mechanically to expand the colon, thus prompting evacuation.

Castile soap is commonly added because its irritation of the colon's lining increases the urgency to defecate.[9]

Likewise, mild hand soap can be dissolved in the water.[10] However, liquid handsoaps and detergents should not be used.[2]

Glycerol is a specific bowel mucosa irritant serving to induce peristalsis via a hyperosmotic effect.[11] It is used in a dilute solution, e.g., 5%.[12]

Buffered sodium phosphate solution draws additional water from the bloodstream into the colon to increase the effectiveness of the enema, but can be rather irritating to the colon, causing intense cramping or "griping."

Normal saline is least irritating to the colon, at the opposite end of the spectrum. Like plain water, it simply functions mechanically to expand the colon, but having a neutral concentration gradient, it neither draws electrolytes from the body, as happens with plain water, nor draws water into the colon, as occurs with phosphates. Thus, a salt water solution can be used when a longer period of retention is desired, such as to soften an impaction.

Likewise, baking soda (sodium bicarbonate) can be dissolved in the water.[10]

Other solutions

Equal parts of milk and molasses heated together to slightly above normal body temperature have been used.[13] Neither the milk sugars and proteins nor the molasses are absorbed in the lower intestine, thus keeping the water from the enema in the intestine. [14]

Mineral oil functions as a lubricant and stool softener, but often has the side effect of sporadic seepage from the patient's anus which can soil undergarments for up to 24 hours.

Chronic treatments

Transanal irrigation

TAI, also termed retrograde irrigation, is designed to assist evacuation using a water enema[15] as a treatment for persons with bowel dysfunction, including fecal incontinence or constipation, especially obstructed defecation. Its effectiveness varies considerably, some individuals experiencing complete control of incontinence but others reporting little or no benefit.[15]

The term retrograde irrigation distinguishes this procedure from the Malone antegrade continence enema, where irrigation fluid is introduced into the colon proximal to the anus via a surgically created irrigation port.

Bowel management

Patients who have a bowel disability, a medical condition which impairs control of defecation, e.g., fecal incontinence or constipation,[16] can use bowel management techniques to choose a predictable time and place to evacuate.[16] Without bowel management, such persons might either suffer from the feeling of not getting relief, or they might soil themselves.[16]

While simple techniques might include a controlled diet and establishing a toilet routine,[16] a daily enema can be taken to empty the colon, thus preventing unwanted and uncontrolled bowel movements that day.[17] By regularly emptying the bowel using transanal irrigation,[18] controlled bowel function is often re-established to a high degree, thus enabling development of a consistent bowel routine.[18] An international consensus on when and how to use transanal irrigation for people with bowel problems was published in 2013, offering practitioners a clear, comprehensive and simple guide to practice for the emerging therapeutic area of transanal irrigation.[18]

Contrast (X-ray)

A barium enema in a disposable bag manufactured for that purpose

In a lower gastrointestinal series an enema that may contain barium sulfate powder or a water-soluble contrast agent is used in the radiological imaging of the bowel. Called a barium enema, such enemas are sometimes the only practical way to view the colon in a relatively safe manner.[3] Following barium enema administration, patients often find that flushing the remaining barium with additional water, baking soda, or saline enemas helps restore normal colon activity without complications of constipation from the administration of the barium sulfate.

Medication administration

The administration of substances into the bloodstream. This may be done in situations where it is undesirable or impossible to deliver a medication by mouth, such as antiemetics given to reduce nausea (though not many antiemetics are delivered by enema). Additionally, several anti-angiogenic agents, which work better without digestion, can be safely administered via a gentle enema.

The topical administration of medications into the rectum, such as corticosteroids and mesalazine used in the treatment of inflammatory bowel disease. Administration by enema avoids having the medication pass through the entire gastrointestinal tract, therefore simplifying the delivery of the medication to the affected area and limiting the amount that is absorbed into the bloodstream.

Rectal corticosteroid enemas are sometimes used to treat mild or moderate ulcerative colitis. They also may be used along with systemic (oral or injection) corticosteroids or other medicines to treat severe disease or mild to moderate disease that has spread too far to be treated effectively by medicine inserted into the rectum alone.

Other

  • There have been a few cases in remote or rural settings, where rectal fluids have been used to rehydrate a person. Benefits include not needing to use sterile fluids.[19]
  • Enemas have been used around the time of childbirth however there is no evidence for this practice and it is now discouraged.[20]

Adverse effects

Improper administration of an enema can cause electrolyte imbalance (with repeated enemas) or ruptures to the bowel or rectal tissues resulting in internal bleeding. However, these occurrences are rare in healthy, sober adults. Internal bleeding or rupture may leave the individual exposed to infections from intestinal bacteria. Blood resulting from tears in the colon may not always be visible, but can be distinguished if the feces are unusually dark or have a red hue. If intestinal rupture is suspected, medical assistance should be obtained immediately.[21]

The enema tube and solution may stimulate the vagus nerve, which may trigger an arrhythmia such as bradycardia. Enemas should not be used if there is an undiagnosed abdominal pain since the peristalsis of the bowel can cause an inflamed appendix to rupture.

There are arguments both for and against colonic irrigation in people with diverticulitis, ulcerative colitis, Crohn's disease, severe or internal hemorrhoids or tumors in the rectum or colon, and its usage is not recommended soon after bowel surgery (unless directed by one's health care provider). Regular treatments should be avoided by people with heart disease or renal failure. Colonics are inappropriate for people with bowel, rectal or anal pathologies where the pathology contributes to the risk of bowel perforation.[22]

Recent research has shown that ozone water, which is sometimes used in enemas, can immediately cause microscopic colitis.[23]

A recent case series[24] of 11 patients with five deaths illustrated the danger of phosphate enemas in high-risk patients.

History

A normal clyster syringe (front) and the nozzle for a syringe designed for self-administration (rear). The latter avoided the need for a second party to attend an embarrassing procedure.

Enema comes from Greek ἔνεμα (énema), from ἐνίημι (eníēmi), "(I) inject".

Clyster (/ˈklɪstə(r)/), also spelled glister in the 17th century, rarely "cloister" or "clister" comes from Greek κλυστήρ (klystḗr), from κλύζω (klýzo), "(I) wash". It is an archaic word for enema, more particularly for enemas administered using a clyster syringe – that is, a syringe with a rectal nozzle and a plunger rather than a bulb. Clyster syringes were used from the 17th century (or before) to the 19th century, when they were largely replaced by enema bulb syringes, bocks, and bags.

The first mention of the enema in medical literature is in the Ancient Egyptian Ebers Papyrus (c. 1550 BCE). One of the many types of medical specialists was an Iri, the Shepherd of the Anus. Many medications were administered by enemas.[25] There was a Keeper of the Royal Rectum who may have primarily been the pharaoh's enema maker. The god Thoth, according to Egyptian mythology, invented the enema.[26]

The Olmec from their middle preclassic period (10th through 7th centeries BCE) through the Spanish Conquest used trance-inducing substances ceremonially, and these were ingested via, among other routes, enemas administered using jars.

The Maya in their late classic age (7th through 10th centuries CE) used enemas for, at least, ritual purposes, in the Xibalban court of the God D whose worship included ritual cult paraphernalia. It is hypothesized that these enemas were for ritual purification and the ingestion of intoxicants and hallucinogens. The Maya illustrated the use of a characteristic enema bulb syringe by female attendants administering clysters ritually.[27][28]

Pressure enema from an animal bladder (African wooden sculpture, 19th century)

In the first century BC the Greek physician Asclepiades of Bithynia wrote "Treatment consists merely of three elements: drink, food, and the enema".[29] Also, he contended that indigestion is caused by particles of food that are too big and his prescribed treatment was proper amounts of food and wine followed by an enema which would remove the improper food doing the damage.[30]

In the second century CE the Greek philosopher Celsus recommended an enema of pearl barley in milk or rose oil with butter as a nutrient for those suffering from dysentery and unable to eat[31] and Galen mentions enemas in several contexts.[32]

In medieval times appear the first illustrations of enema equipment, a clyster syringe consisting of a tube attached to a pump action bulb made of a pig bladder and the 15th century Simple piston syringe clysters came into use. Beginning in the 17th century enema apperatus was chiefly designed for self-administration at home and many were French as enemas enjoyed wide usage in France.[31]

When clyster syringes were in use in Europe, the patient was placed in an appropriate position (kneeling, with the buttocks raised, or lying on the side); a servant or apothecary would then insert the nozzle into the anus and press the plunger, resulting in the liquid remedy (generally, water, but also some other preparations) being injected into the colon.

Portable enema self-administration apparatus by Giovanni Alessandro Brambilla (18th century; Medical History Museum, University of Zurich)

Because of the embarrassment a woman might feel when showing her buttocks (and possibly her genitals, depending on the position) to a male apothecary, some contraptions were invented that blocked all from the apothecary's view except for the anal area. Another invention was syringes equipped with a special bent nozzle, which enabled self-administration, thereby eliminating the embarrassment.

Clysters were administered for symptoms of constipation and, with more questionable effectiveness, stomach aches and other illnesses. In his early-modern treatise, The Diseases of Women with Child, François Mauriceau records that both midwives and man-midwives commonly administered clysters to labouring mothers just prior to their delivery.

In the 16th century, satirists made physicians a favorite target, resembling Molière's caricature whose prescription for anything was "clyster, bleed, purge," or "purge, bleed, clyster."[33] Sir Thomas More's eldest daughter had fallen sick of the sweating sickness and could not be awakened by doctors. More prayed for her recovery, and then

where incontinent came into his mind, that a glister should be the only way to help her, which when he had told the physicians, they by-and-by confessed, that if there were any hope of health, that it was the very best help indeed, much marvelling of themselves, that they had not afore remembered it.[34]

19th century satirical cartoon of a monkey rejecting an old style clyster for a new design, filled with marshmallow and opium

In the 18th century tobacco smoke enemas were used to resuscitate drowned people. Tobacco resuscitation kits consisting of a pair of bellows and a tube were provided by the Royal Humane Society of London and placed at various points along the Thames.[31]

Clysters were a favourite medical treatment in the bourgeoisie and nobility of the Western world up to the 19th century. As medical knowledge was fairly limited at the time, purgative clysters were used for a wide variety of ailments, the foremost of which were stomach aches and constipation.

Molière, in several of his plays, introduces characters of incompetent physicians and apothecaries fond of prescribing this remedy, also discussed by Argan, the hypochondriac patient of Le Malade Imaginaire. More generally, clysters were a theme in the burlesque comedies of that time.

According to Claude de Rouvroy, duc de Saint-Simon, clysters were so popular at the court of King Louis XIV of France that the duchess of Burgundy had her servant give her a clyster in front of the King (her modesty being preserved by an adequate posture) before going to the comedy. However, he also mentions the astonishment of the King and Mme de Maintenon that she should take it before them.

In the 19th century many new types of enema administration equipment were devised, including the bulb enema. Later there came to be a device to allow gravity to infuse the solution into the recipient, consisting of a rubber bag or bucket connected to a hose with a nozzle at the other end to insert into the patient's anus, the bag or bucket being held or hung above the patient. These continue to be used, although rubber has been replaced by modern materials and the bags, at least in hospital use, as disposable.[31]

In the late 20th century the microenema was invented, this being a disposable squeeze bottle with contents that cause the body to draw water into the colon, e.g., sodium biphosphate (popular in the United States) or glycerin (popular in Japan).

Nutrient enemas were administered with the intent of providing nutrition when normal eating is not possible. Although this treatment is ancient, dating back at least to Galen, and commonly used in the Middle Ages,[35] and still a common technique in 19th century medicine,[36] Nutrient enemas have been superseded in modern medical care by tube feeding and intravenous feeding.

Society and culture

Alternative medicine

The term "colonic irrigation" is commonly used in gastroenterology to refer to the practice of introducing water through a colostomy or a surgically constructed conduit as a treatment for constipation.[37] The Food and Drug Administration has ruled that colonic irrigation equipment is not approved for sale for the purpose of general well-being[38] and has taken action against many distributors of this equipment, including a Warning Letter.[39]

Colon cleansing

The same term is also used in alternative medicine where it may involve the use of substances mixed with water in order to detoxify the body. Practitioners believe the accumulation of fecal matter in the large intestine leads to ill health.[40] This resurrects the old medical concept of autointoxication which was orthodox doctrine up to the end of the 19th century but which has now been discredited.[41][42][43]

Coffee enemas

Although well documented, the procedure of inserting coffee through the anus to cleanse the rectum and large intestines is considered by most medical authorities to be unproven, rash and potentially dangerous.[44][45]

Coffee enemas can cause numerous side effects, including infections, sepsis (including campylobacter sepsis), severe electrolyte imbalance, colitis, polymicrobial enteric septicemia, proctocolitis, salmonella,  brain abscess, and heart failure,[46][47][48][49][50][51][52][53][54] and deaths related to coffee enemas have been documented.[55]

In the Gerson therapy, coffee enemas are administered.[56]

Some proponents of alternative medicine have claimed that coffee enemas have an anti-cancer effect by "detoxifying" metabolic products of tumors[46] but there is no medical scientific evidence to support this.[45][47][57]

Kellogg's enemas

In the late 19th century Dr. John Harvey Kellogg made sure that the bowel of each and every patient was plied with water, from above and below. His favorite device was an enema machine ("just like one I saw in Germany") that could run fifteen gallons of water through a person's bowel in a matter of seconds. Every water enema was followed by a pint of yogurt—half was eaten, the other half was administered by enema "thus planting the protective germs where they are most needed and may render most effective service." The yogurt served to replace "the intestinal flora" of the bowel, creating what Kellogg claimed was a completely clean intestine.[58]

Recreational usage

An aluminium enema nozzle. Specialty nozzles, in a variety of sizes, styles, and materials, are common for non-medical usage.
An inflatable nozzle which, after insertion, is inflated to a size than can not be expelled, allowing administration of such an enema that could not otherwise be retained, either for pleasure or as part of BDSM activities. Shown here in an optional harness.

Pleasure

Enjoyment of enemas is known as klismaphilia, which medically is classified as a paraphilia.[59][60] A person with klismaphilia is a klismaphile.

Klismaphiles can gain satisfaction of enemas through fantasies, by actually receiving or giving one, or through the process of eliminating steps to being administered one (e.g., under the pretense of being constipated).[61] An enema can be an auxiliary to, or even a substitute for, genital sexual activity.[61]

Both women and men with the paraphilia enjoy sexual enema play, both heterosexually and homosexually, experiencing sexual arousal from enemas which they find gratifying or sensual.[62][61] Additionally, in men enemas can stimulate the prostate gland.

That some women use enemas while masturbating was documented by Kinsey, A. in "Sexual Behavior in the Human Female." H stated, :There still other masturbatory techniques which were regularly or occasionally employed by some 11 percent of the females in the sample ... enemas, and other anal insertions, ... were employed."[63]

Enemas are sometimes used in sadomasochistic activities[64][65] for erotic humiliation[66] or for physical discomfort.[67]

An enema can be employed prior to anal sexual activities such as anal sex, anilingus, and pegging to enhance sensation or remove feces, possibly reducing risk of infection.[68]

Intoxication

Noting that deaths have been reported from alcohol poisoning via enemas,[69] an alcohol enema can be used to very quickly instill alcohol into the bloodstream, absorbed through the membranes of the colon. However, great care must be taken as to the amount of alcohol used. Only a small amount is needed as the intestine absorbs the alcohol far more quickly than the stomach.

Preceding an enema for administration of drugs or alcohol, a cleansing enema may first be used for cleaning the colon to help increase the rate of absorption.[70]

Religious rituals

Enemas have been used for ritual rectal drug administration such as balché, alcohol, tobacco, peyote, and other hallucinogenic drugs and entheogens, most notably by the Maya and also some other American Indian tribes. Some tribes continue the practice in the present day.[71]

Called Basti or Vasti in Ayurveda, enemas are part of Panchakarma procedure in which herbal medicines are introduced rectally.[72]

Punitive usage

Enemas have also been forcibly applied as a means of punishment. In the vastly influential Latin American text Facundo, or Civilization and Barbarism, for example, Domingo Faustino Sarmiento describes the use of pepper and turpentine enemas by police forces as a way of discouraging political dissent in post-independence Argentina.[73]

The Senate Intelligence Committee report on CIA torture documented instances of enemas being used by the Central Intelligence Agency in order to ensure "total control" over detainees.[74]

Monument

A 365-kilogram (805-pound) brass statue of a syringe enema bulb held aloft by three angels stands in front of the "Mashuk" spa in the settlement of Zheleznovodsk in Russia. It is the only known monument to the enema.[75]

See also

References

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  2. 1 2 "Soapsuds enema". Biology-Online Dictionary. Biology-Online. Retrieved 6 August 2014.
  3. 1 2 "Barium enema". MedlinePlus. U.S. Department of Health & Human Services – National Institutes of Health (NIH). Retrieved 6 August 2014.
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  55. ↑ Eisele JW, Reay DT (October 1980). "Deaths related to coffee enemas". JAMA. 244 (14): 1608–9. doi:10.1001/jama.1980.03310140066036. PMID 7420666.
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  59. ↑ Paraphilias from Psychology Today
  60. ↑ Denko, JD. (April 1973). "Klismaphilia: enema as a sexual preference. Report of two cases". Am J Psychother. 27 (2): 232–50. doi:10.1176/appi.psychotherapy.1973.27.2.232. PMID 4704017.
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  63. ↑ Kinsey, Alfred Charles (1953), Sexual Behavior in the Human Female, Bloomington, Indiana, U.S.A.: Indiana University Press, ISBN 978-0-253-33411-4
  64. ↑ Brame et al., Different loving – The World of Sexual Dominance and Submission:513,516
  65. ↑ Agnew, Klismaphilia:74,77,78,79
  66. ↑ Brame et al., Different loving – The World of Sexual Dominance and Submission:515,516,520
  67. ↑ Brame et al., Different loving – The World of Sexual Dominance and Submission:513,517
  68. ↑ Agnew, Klismaphilia:76
  69. ↑ "The Enema Within". Darwin Awards. 2008. Retrieved 11 January 2008.
  70. ↑ de Boer AG, Moolenaar F, de Leede LG, Breimer DD (1982). "Rectal drug administration: clinical pharmacokinetic considerations". Clin Pharmacokinet. 7 (4): 285–311. doi:10.2165/00003088-198207040-00002. PMID 6126289.
  71. ↑ Diamond, Jared M. (1992). The Third Chimpanzee: The Evolution and Future of the Human Animal (P.S.). New York, N.Y: Harper Perennial. p. 432. ISBN 978-0-06-084550-6. ; pp. 201
  72. ↑ "Basti: Medicated Enema Therapy".
  73. ↑ "Ribbons and Rituals". In Problems in Modern Latin American History. Ed. Chasteen and Wood. Oxford, UK: Scholarly Resources, 2005. p. 97
  74. ↑ Rushe, Dominic; MacAskill, Ewen; Cobain, Ian; Yuhas, Alan; Laughland, Oliver (9 December 2014). "Rectal rehydration and waterboarding: the CIA torture report's grisliest findings". The Guardian. Retrieved 13 March 2015.
  75. ↑ "Enema monument unveiled in Russian resort". msn.com. 19 June 2008. Retrieved 2 October 2016.

Notes

  • Agnew, J. (2000). "Klismaphilia". Venereology. 13 (2): 75–79. ISSN 1032-1012. Retrieved 29 September 2018.
  • Brame, Gloria; Brame, William D.; Jacobs, Jon (1993). Different loving – The World of Sexual Dominance and Submission. Villard Books. ISBN 978-0-6797-6956-9.
  • Cullingworth, Charles James (1883). A Manual of Nursing, Medical and Surgical. Cambridge, England: Cambridge University Press (published 2009). ISBN 978-1-4590-1939-3.
  • Magner, Lois (1992). A History of Medicine. Boca Raton, Florida: CRC Press. ISBN 978-0-8247-8673-1.
  • Parsons, Lee Allen; Carlson, John B. (1988). The Face of Ancient America: The Wally and Brenda Zollman Collection of Precolumbian Art. Indianapolis, Indiana, United States: Indianapolis Museum of Art. ISBN 978-0-936260-24-2.
  • Scarborough, John (1975). "The Drug Lore of ASCLEPIADES of Bithynia". Pharmacy in History. 17 (2): 43–57. Retrieved 25 September 2018.

"A professional nursing instructional video demonstrating administering a cleansing enema". Taber's Medical Dictionary. K. A. Davis Company. Retrieved 17 July 2014.

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