This post was written by Michelle Henderson, Clinical Education Manager, MacGregor Healthcare.

This study was undertaken whilst Michelle was Clinical Lead in the Durham Bowel Dysfunction service, with Professor Yan Yiannakou (Consultant Neurogastroenterologist) as the Chief Investigator. She has since joined MacGregor Healthcare as Clinical Education Manager.

PERSPECTIVE ^*(Patient pERSPective of functional bowel disorders: Effects on lifestyle, experienCe of Transanal Irrigation and effects of the COVID-19 pandEmic) was sponsored by County Durham & Darlington NHS Trust and funded by MacGregor Healthcare.

Background

Functional bowel disorders (FBDs) are a group of medical conditions that affect the normal functioning of the gastrointestinal (GI) tract without any apparent structural or biochemical abnormalities. These disorders are common, affecting over 25% of UK adults¹. The term “functional” means that the disorder is primarily related to how the GI tract functions rather than any specific physical damage or disease.

Some common functional bowel disorders include:

• Irritable Bowel Syndrome (IBS) – IBS causes abdominal pain or discomfort, along with changes in bowel habits, such as diarrhoea (IBS-D) constipation (IBS-C) or alternating between the two (mixed IBS).
• Functional Constipation – infrequent bowel movements, difficulty passing stools, and a feeling of incomplete emptying.
• Functional Diarrhoea – frequent loose or watery stools without any identifiable cause.
• Evacuatory Dysfunction – difficulty in passing stools, often associated with excessive straining and a feeling of incomplete evacuation.
• Faecal incontinence – the accidental passage of stool from the rectum.

In clinical practice, symptom overlap is common among patients. They frequently speak of the considerable burden these conditions have on various aspects of their lives, including relationships, overall health, and ability to work. These insights led to the development of the PERSPECTIVE study.

The PERSPECTIVE study has explored the impact of the aforementioned FBDs on patient’s lifestyle, including their real-world experience of using transanal irrigation (TAI) to manage these symptoms. This study differs from previous studies as it has explored a wider range of FBDs. This article will discuss the results regarding TAI usage.

Method

A total of 4,794 individuals were invited to participate in the study from two existing cohorts of people, sourced from two existing databases:

1.  ContactME-IBS – a dedicated national registry (NHS owned) for individuals who self-identify as having any type of IBS. People sign up to receive information about research opportunities, without any obligation to participate. This provided access to over 4,000 individuals from both primary and secondary care.
2. Durham Transanal Irrigation database, which had over 200 TAI users, all seen in secondary care.

Data from 933 respondents were captured through a single online questionnaire. Among them, 183 (20%) had experience of using TAI, and 110 (60%) continue to use it.

Results

In the study, females were primarily irrigating for constipation-related symptoms (43, 44%), while males used it predominantly for diarrhoea or mixed-type symptoms (9, 82%).

Respondents often faced delays in starting TAI, with 48 (44%) reporting symptoms for 10 or more years before beginning treatment. This delay could be attributed to various factors such as the time it takes to access specialist services. There is a need to increase awareness around bowel dysfunction and the benefits of treatments to address this issue.

Respondents were asked to rate how effective TAI was for them at 3, 6, and 12 months using a scale of 0 (no benefit) to 10 (excellent). At 3 and 6 months there was a positive correlation, meaning that if TAI was effective at 3 months, it was likely to still be relieving symptoms at 6 months. In fact, the trend for effectiveness continued up to 12 months. So, TAI being effective at 3 months is a good indicator of longer-term effectiveness.

In fact, the findings suggest long -term effectiveness way beyond the 12- month period explored. The majority of respondents (58, 53%) had been irrigating for 3 or more years and 33 (30%) had been irrigating for even longer (5-10 years). Since TAI requires time and commitment, it is reasonable to conclude that patients will continue to use it if they are finding it beneficial in relieving their bowel symptoms. Hence, long -term use suggests long-term effectiveness.

TAI is an effective treatment for all types of FBDs. The 60% success rate in PERSPECTIVE is similar to that of other studies^3,4.

Interestingly, when we examined the data around those who continued irrigating and those who had stopped, we discovered that respondents with diarrhoea-related symptoms (IBS-D, functional diarrhoea, or faecal incontinence) were the highest proportion which continued using TAI (74%, 26). Among this group, a considerable percentage (77%) also reported faecal incontinence. Perhaps the burden of faecal incontinence contributes to the continued use of irrigation as a treatment option.

Implications for practice

The PERSPECTIVE results have significant implications for both patients and healthcare professionals:

• Patients with a wide range of FBDs can benefit from irrigation.
• Patients with IBS-D, diarrhoea, and faecal incontinence in particular, find irrigation beneficial.
• Reassurance for patients – that the therapeutic effects of TAI will not diminish over time, as observed with other treatments such as laxatives.
• Effective TAI can create clinical capacity – longer term efficacy means that healthcare professionals can confidently discharge patients back to GP care. Thereby freeing up valuable clinical resources and capacity, enabling more patients to be treated.
• Encourage patients to persevere with irrigation for up to 3 months, as per the follow up regime proposed by Emmanuel et al². After which time, if it’s beneficial continue, if not then stop.
• If irrigation does not give satisfactory results after the initial 3 month-period, refer back to the multidisciplinary team for further advice, aligning with the follow-up recommendations proposed by Emmanuel et al².
• These approaches streamline what is currently a convoluted journey for patients to access specialist treatment.

This post was written by Michelle Henderson, Clinical Education Manager, MacGregor Healthcare.