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

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

Troubleshooting the Cone Enema

The cone enema is a gravity fluid delivery system with a cone tip that accommodates patients with poor anal-sphincter tone or a patulous anus. Issues that most often arise are due to poor seal, leakage of fluid and hard stools. Consider possible impaction when there is poor response to therapy.

Troubleshooting with the CONE
Problem Intervention
Meeting resistance
  • Check placement, tighten seal of cone.
  • Check for impaction.
Impaction
  • Check placement, tighten seal of cone.
  • Assure warm water temperature.
  • Adjust volume of irrigant, refer to SB specialist.
  • Administer in small aliquots.
  • Add sodium phosphate (Fleet® enema) to cone or once weekly/prn.
  • Increase oral laxative to soften stool.
Leakage during enema administration
  • Ensure no impaction, check seal of cone.
  • Change position of patient on toilet (rear facing).
  • Check connection of tubing.
Leakage immediately after cone
  • Clear leakage: increase sit time, decrease volume of irrigant.
  • Feculent leakage: increase sit time, increase volume of irrigant.
Hard daytime accidents
  • Assess diet: high fiber, plenty of water, limit trigger foods.
  • Increase oral laxative.
  • Consider increasing volume of cone.
  • Consider adding sodium phosphate (Fleet) as needed for more thorough clean-out.
Loose daytime accidents
  • Assess diet: high fiber, plenty of water, limit trigger foods.
  • Increase oral laxative for overflow encopresis.
  • Decrease oral laxative for loose stools.
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.
  • Assure warm water temperature.
  • Adjust volume of irrigant.
  • Decrease rate of administration.
  • Review concentration of additives.
  • Ensure proper timing of last oral intake (> 30 minutes after meals is best).
Slow flow or stoppage of fluid
  • Prime tubing prior to administration.
  • Check for clogging of tubing.
Poor response
  • Repeat irrigation.
  • Consider abdominal X-ray.
Rectal bleeding, severe abdominal pain or back pain
  • Refer to emergency department.