1. Starting a Patient on Peristeen

2. Indications for use
Neurogenic bowel disfunction eg spinal cord injury, spina bifida, muliple sclerosis
Chronic constipation,including both evacuation difficulties and slow transit constipation
Chronic faecal incontinence
(cauda equina syndrome, idopathic faecal incontinence, sphincter disruption, anal, rectal and colonic surgery and rectal prolapse)

3. Use with care and close monitoring
• Spinal cord injury above T6 - monitor for autonomic dysreflexia until it is clear that the technique is well tolerated and does not provoke autonomic dysreflexia
• Unstable metabolic conditions - frail, known renal disease or liver disease:
may need to monitor electrolytes and possibly use saline rather than water for
irrigation if there are problems with salt depletion
Under 18 years old - consult paediatric consultant, consider safeguarding
issues, and consider use of saline for younger children over 3 years old
• Inability to perform the procedure independently or comply with the protocol in the absence of close involvement of carers
• Anorectal conditions that could cause pain or bleeding during the procedure (e.g. third degree haemorrhoids, anal fissure)

4. Relative contra-indications
• Pregnant or planning pregnancy - There is no evidence to suggest whether irrigation can or cannot be used during pregnancy. Prior to commencing or continuing irrigation the patient should be assessed on an individual basis in consultation with her midwife obstetrician and/or General Practitioner. Bear in mind that continuing effective evacuation of stool regularly throughout pregnancy must be maintained by some method. • Children under 3 years of age • Inflammatory bowel disease (e.g. ulcerative colitis or Crohn’s disease) • Active perianal sepsis (fistula or abscess) • Rectal or colonic surgical anastomosis within the last 3-6 months

5. Relative contra-indications
• Faecal impaction – rectal impaction should be cleared (using suppositories, enemas and/or digital evacuation of stool as appropriate) prior to introducing irrigation • Past pelvic radiotherapy which has caused bowel symptoms or recent pelvic radiotherapy • Long term steroid medication (rare risk of diverticular perforation, reported with steriod use, however not related to irrigation • Anticoagulant medication (bleeding risk) • Colonic biopsy during endoscopy in the past 3 months • Use of rectal medications for other diseases which may be diluted by irrigation

6. Relative contra-indications
• Congestive cardiac failure
• Anal surgery within the past 6 months
• Diarrhoea of unknown aetiology
• Known diverticular disease
• Low blood sodium
• Pelvic malignancy

7. Absolute contraindications
• Acute active inflammatory bowel disease
• Known obstructing rectal or colonic mass or stricture
• Diverticulitis or complex diverticular disease (diverticular abscess or rupture)
• Anal surgery in the past 3 months or haemorrhoid banding within
the past 4-6 weeks
• Severe cognitive impairment (unless carer available to
supervise/administer)

8. Risk and Long Term Use of Irrigation
Trans-anal irrigation using Peristeen Anal Irrigation is a safe intervention : adverse events are rare
Very small risk of bowel damage (perforation), less than 1 per 100,000 irrigations
Discuss with patient, informed consent
Long term use not thought to impact bowel function
Continuing support for patients
Trouble shooting tips – ‘If you have a sudden major bleed (especially with sudden pain at the same time) seek urgent medical attention’