Neurogenic Bowel Management, Spina Bifida — Troubleshooting the Balloon Enema — Clinical Pathway: Outpatient Specialty Care

Neurogenic Bowel Management, Spina Bifida Clinical Pathway — Outpatient Specialty Care

Troubleshooting the Balloon Enema

The balloon enema is a gravity fluid delivery system using a 24 Fr. Foley catheter with a 30 ml balloon that accommodates patients with moderate anal-sphincter tone. Issues that most often arise are due to poor seal, leakage of fluid and hard stools related to poor anal-sphincter tone. Consider possible impaction when there is poor response to therapy or expulsion of balloon during the enema.

Troubleshooting the BALLOON
Problem Intervention
Meeting resistance
  • Check for impaction; may require digital disimpaction.
Impaction
  • Check placement of catheter (insert 4-6 inches before inflating balloon).
  • Check the temperature of water (warm, not cold or hot).
  • Adjust volume of irrigant; refer to Urology/General Surgery, spina bifida specialist to determine appropriate volume
  • Administer in small aliquots.
  • Adjust oral laxative to loosen stool.
  • Consider mineral-oil enema prior to irrigation.
Leakage during enema administration
  • Ensure no impaction, check position of catheter.
  • Add volume to balloon in 10 mL increments up to 60 ml max.
    • If still leaking, consult specialist.
  • Change position of patient on toilet (rear facing).
  • Check connection of tubing.
Leakage immediately after balloon catheter irrigation
  • Clear leakage: increase sit time, decrease volume of irrigant.
  • Feculent leakage: increase sit time, increase volume of irrigant, increase additives.
  • Non-latex catheter (22-24 Fr.) per rectum to allow for drainage.
Expulsion of balloon catheter
  • Deflate balloon, reinsert 4-6 inches, add more air to the balloon, gently retract to form seal.
  • Assess for impaction of stool.
  • Deliver irrigant in smaller volumes at first, then attempt to deliver full volume.
Hard daytime accidents
  • Assess diet: fiber, water, trigger foods.
  • Consider adjusting volume of irrigant.
  • Consider additives: glycerin, PEG, Castile soap.
Loose daytime accidents
  • Assess for impaction with resulting overflow incontinence .
  • Assess diet: fiber, water, trigger foods.
  • Consider adjusting additives: glycerin, PEG, Castile soap.
  • Consider adjusting irrigant volume.
Monthly accidents coinciding with menstruation
  • Decrease oral laxatives prior to menstruation.
  • Consider enema every 12 hours (morning and evening) at time of menstruation.
Abdominal pain/vomiting
  • Prime tubing prior to administration to eliminate air.
  • Check temperature of fluid (warm, not cold or hot).
  • Adjust volume of irrigant.
  • Adjust rate of administration (slow down or stop and rest then try again).
  • Review concentration of additives.
  • Ensure proper timing of last oral intake (> 30 minutes after meals is best).
  • Asses for viral illness.
Slow flow or stoppage of flow
  • Prime tubing prior to administration to eliminate air.
  • Check for clogging of tubing from additives (may require a flush with hot water when NOT connected to the patient).
  • May be related to impaction of stool.
Poor response
  • Repeat enema.
  • Consider abdominal X-ray.
Rectal bleeding, severe abdominal pain or back pain
  • Refer to emergency department.