# Transanal irrigation for incomplete evacuation



## JMH91 (Apr 16, 2014)

I wanted to explain in more detail how I use this treatment and seems to be keeping me odor free for most of the working day. I am also thinking aloud about ways to make it more effective, and if anyone else has experience of it please let me know if you have any other tips.

Doctors are getting keen on this treatment because it avoids any surgery and it is very safe (only rare complications are perforation and electrolyte imbalance). Water is not an stimulant laxative like e.g miralax, so it is impossible for the gut to become dependent upon it.

https://en.wikipedia.org/wiki/Transanal_irrigation

Some say that one treatment with transanal irrigation can empty out the the bowel so much that there new feces does not arrive in the rectum for 2 days. For me it seems more like half a day. I think it was Intothewild who is saying that they have had no luck with transanal irrigation because of leakage of water afterwards. I do agree that the claims made about this treatment probably do not apply for people with obstructed defecation, who have a tendency to retain any bowel contents, for whatever reason (in my case, this is probably because of nerve damage stopping the muscles from performing normal evacuation). Since I believe one main type of odor here is incomplete evacuation combined with reduced seal, fluid is harder to keep inside than solid, so there is definately potential for transanal irrigation to make odor worse. You need to get to know the system over some time. I was actually prescribed it over a year ago. I had v high hopes for it at first and then I was v disappointed at how uncomfortable it was and how poorly it was working for me compared to the claims. So I just stopped using it, but I have come back to in recent months and now I think that I know how to use it better it is having some good results.

Those days when I don't use it I seem to get odor complaints/reactions really early on in the day and then for the rest of the day. Of course, it could be a psychological thing, and I am performing some safety ritual which gives me a sense of control and has no impact on odor, or indeed there is no odor even without (i.e. olfactory reference syndrome). It is so difficult to tell when your mind has been raped by odor paranoia and plays tricks on you constantly.

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Here is what I am doing at the moment each morning, starting v early:

Natural bowel movement, which comes easily and quickly as soon as I wake up. Because of psyllium, diet and squatting posture, there is never any straining needed.

Then I have breakfast, drink hot water and wait a while for these gastrocolic stimulae to work. Something that is v potent for me is caffeine (but it gives me palpitations, so I avoid) and cigarette (I don't smoke, but when I have tried it in the past, I often cannot finish one cigarette before I feel the need to go... ofc v bad for health so I would not smoke even one cigarette per day).

Then about 1 hour before leaving home, I do first transanal irrigation. The container goes up to 1000ml. I get severe cramping pain at about 300 - 400 so I cannot use this much water (probably why I am getting poor results). I even lie in some yoga like position with pelvis raised above abdomen, so the water can flow with gravity inside rather than press down immediately on the sphincters. This makes it more comfortable and allows more water inside. So letting out the fluid, there is much more feces which comes out compared to just the normal bowel movement. It is the difference between 2-3 bm per day and continuous odor compared to no odor for most of the day. The feces is also softer and eventually just fluid. Which is a good sign that it is feces from higher up the colon which would otherwise be descending throughout the day. Letting out the majority of the first fluid can take up to 30 mins, trying to avoid straining again.

Just before shower and finally leaving, I wash out with the rest of the container. Since I am mostly empty at this point, there is more water that can go in, and the evacuation is mostly water with a few small specs of fecal matter.

I arrive early at work so it is pretty quiet. I can make sure there is any last bit of water/mucus to let out before the day here. Often there is nothing, but it helps give me confidence. Sometimes no matter how long you sit to try and let all the fluid out, it is walking around that causes the last bit to come out.

Combined with this is importantly, TENS for anal sphincter and pelvic floor. So even if some fluid is left, there is more bulky muscles to resist leaking. And ofc low FODMAP. I find low FODMAP also reduces the mucus, as well as gas.

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So I am thinking, now that my bowels are no longer working normally, without transanal irrigation, my normal rythmn would be main bm first thing, then perhaps mid-morning and lunch further bms of decreasing size. So maybe things would work better if I did the irrigation the night before, and then again in the morning. So the night before becomes the main evacuation session, and the morning is cleaning out any residue. Will try this new approach this week and report if there is any difference.


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## tummyrumbles (Aug 14, 2005)

"&#8230; it is important to be aware that even in experienced individuals who are properly trained, TAI can cause rectal perforation, which always has to be borne in mind."

Rectum perforation during transanal irrigation: a case story

http://www.nature.com/sc/journal/v47/n3/full/sc200895a.html

" ... other authors have stated that side-effects include nausea, diarrhoea, nervous disturbances<a>[16]</a> as well as cramps and irritations.<a>[19]</a> Moreover, the documented risks include electrolyte depletion,<a>[20,21]</a> water intoxication,<a>[22,23]</a> bowel perforation<a>[24-27]</a> and infection.<a>[28"]</a>

Colonic Irrigation: Therapeutic Claims by Professional Organisations, a Review

http://www.medscape.com/viewarticle/717410_4

How can you advise this treatment to others when you say that it only "seems to be keeping you odour free"?

This is a potentially dangerous procedure on many levels. If the patient has olfactory reference syndrome, as you claim to have, then the risks increase. Someone with ORS doesn't seem to experience symptoms of retained gas, from what I can make out from asking people with this condition. So how do you know whether or not it's working if you just rely on reactions from other people.

A better bet would be to try to analyse your condition in greater depth. Do you experience the chronic flatulence that other leaky gassers have? Are you aware of gas build-up / pain generally, especially a few hours or so after eating? Does this gas awareness just "switch off" when you go to work?

There have been people here with ORS who eat a highly flatulogenic diet, but claim not to experience much gas at all. It's highly unlikely that someone posting here would have less gas than the general population, especially on a high fibre diet. It could be that in ORS there is a very low pain threshold, and the sphincter opens involuntarily in response. So gas gradually escapes during the day. As there's no build up there's no bloating or perception of gas.

The risk is that ORS has a lot to do with perception. My form of leaky gas at least tells me whether or not a particular diet is working as I'm very aware of the gas I produce. For someone with ORS who doesn't seem to have direct knowledge of their gas the risk is that they keep topping up the dose or taking shortcuts out of frustration, particularly if people are still making comments. Despite claims the procedure isn't addictive, anything that evacuates the bowel artificially can lead to a lazy, ineffective colon which is the last thing we need.


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## JMH91 (Apr 16, 2014)

Tummyrumbles, whatever your motives are (I'm sure you mean well), you are creating unnecessary concern about a very safe treatment. People with incomplete evacuation should try it and see if it helps them.

Bowel perforation is exceedingly rare with transanal irrigation. Probably those persons affected have absence of sensation due to spinal disease, and therefore have no warning from their body that there is too much fluid going inside. Or, persons with diverticulitis, etc. In someone without diverticulitis, such as myself who is using under 50% of the recommended volume, I think it is negligible. According to some sources, people with diverticulitis should not be using this treatment anyway. The potential complications are all case reports. When there are only a handful of case reports about complications with such a common treatment which is used all over the world, you can conclude that the intervention is very safe.

I don't claim to have ORS, I'm acknowledging it as a possibility that there is no genuine odor. This is because I understand how reality is subjective and how powerful the brain is in shaping our experience of the world around us. I would like to carry around a electronic nose to tell me straight if I smelled at certain times or not, but the portable ones tend to be so poor at what they are supposed to do that they are not worth the expense. Until I have such hard proof, the possibility that there is no real odor has not been ruled out.

I'm not understanding your comment about increased risks of transanal irrigation in people with ORS.

My problem is not too much gas, provided I am behaving with low FODMAP diet. I have awareness of when I am passing even small quantities of gas. Actually it is pretty difficult to pass sometimes because of the TENS. Ofc, all odors are odorant volatiles, so actually my problem *is* gas, but you know what I mean. No, I feel my problem is related to incomplete evacuation and imperfect resting seal of the anal canal. Inocmplete evacutaion in presence of normal sphincter will only give intermittent odor. Vast majority of constipated, obstructed defecation, incomplete evacuation people do not seem to report odor. This leads me to believe that the "seal is the deal". It determines if the odor is continuous or not.

I tend not to want to pass gas when around my work colleagues. If I have not been behaving with my diet and there is some gas, on the way home, and then I realize I have been holding a fart in without an real conscious thought.



> My form of leaky gas


This is at least some progress. Yes you are still using the made up term, but you seem to hint that yes there are more than one cause of an odor symptom

So I am not a "leaky gasser", because there is no such condition...

I would guess my particular situation is nerve damage (perhaps caused from too much straining, stretching the pudendal nerve, or perhaps some spinal disease which is affecting the nerves which contribute fibers to the pudendal nerve) causing decreased resting tone of the anal canal and incomplete evacuation. There is more mucus for me than there used to be. Perhaps this is simply the body responding to incomplete evacuation, or perhaps it is a symptom of sibo, which hydrogen lactulose breath test suggested I had a long time ago. Since then I have been on low FODMAP diet intermittently, so hopefully the breath test would be different if I retook it today.



> Despite claims the procedure isn't addictive, anything that evacuates the bowel artificially can lead to a lazy, ineffective colon which is the last thing we need.


.

No evidence... just superstition. Water is not a stimulant drug, it has no intrinsic pharmacologic mechanism. It simulates a large amount of gut contents (which is what it is), which triggers what the body does normally. Actually according to some sources a TAI routine brings normal rhythm back to a dysfunctioning colon. I agree people should be wary taking stimulant laxatives for extended periods as the gut becoming "lazy" is a recognized possibility in that scenario.


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## tummyrumbles (Aug 14, 2005)

Are you saying that you don't generally get much gas if your diet is right, but incomplete evacuation causes your odour? So your problem isn't so much gas on it's own, but the volatile compounds from stool which your sphincter is allowing through? I'm just trying to clarify this. Mucus can be a sign of SIBO. The bacteria can lodge into the epithelial lining. Mucus can be an immune response defense to the bacterial overgrowth. If you tested positive for SIBO you might need to limit starches as well as FODMAPs. For me, starches are worse than FODMAPs but I have to limit both.

When I said "my form of leaky gas" I just meant that I'm always aware of trying to hold the gas in if I have LG. Whether the gas is isolated pockets of gas, or whether the gas is gassy stool, the gas itself exerts a pressure on the colon, which is painful for most of us. Some people refer to the gas from stool as volatile compounds but it's still gas. If we were constipated with non-gassy stool, which most normal people probably have, then maybe this wouldn't cause LG. For normal people there's no gas build-up from maldigestion so there's no pressure on the colon and sphincters, apart from the weight of the stool itself. Most normal people admit to constipation because there's no embarrassing IBS symptoms attached.

But even if your LG is mainly from stool rather than gas, you would still feel the stool in your lower colon at work. Well I used to anyway. That alone could be enough to open sphincters if you have IBS. We have an overly sensitive colon, and it's quite possible the sphincters open in sympathy as stool descends even further. Then again maybe there's a time limit to how long the sphincters can remain closed so it might not even be IBS related. Maybe "normal" constipation is when the stool is higher up in the colon. Our form of constipation is that stool is lower down, exerting a pressure on the sphincters, whether from gas or the stool itself.


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## JMH91 (Apr 16, 2014)

> Are you saying that you don't generally get much gas if your diet is right, but incomplete evacuation causes your odour?


Possibly, or possibly it's mucus coming through. I used to ge t a mucus leak which would stain the underwear a little. Before PTQ implant, which stopped this. Now there is no more marking of the underwear. Sometimes if I stop taking psyllium/ misbehave with diet/ do not complete evacuate, then there is wet sensation when walking around. However when I go to check the paper is always dry and odorless. Someone once said this wet feeling was because the sphincter was partially open, and therefore the mucous membranes were exposed to the air, which gives a wet and cold sensation. I have no sure answer, maybe it is just another facet of nerve damage sending my brain false sensations. Possibly it is body odor, in addition to this odor or body odor alone; or ORS ofc.

I've struggled to find a proper scientific source which lists mucous discharge as a symptom of sibo.



> But even if your LG is mainly from stool rather than gas


Seriously? You seem to be wanting to create your own branch of (pseudo) science with a whole raft of new terms like "gassy stool", "leaky gas", etc. Just don't go around pretending that you have solved some mystery illness, because most of what you say has absolutely no evidence. Your explanation of the mechanism of your made up condition honestly sounds like a child made it up. Again, I stress that what is wrong with you (what is actually wrong with you), is not necessarily the same as other people.


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