Trans-anal irrigation should be offered to patients with severe bowel dysfunction

Severe bowel dysfunction can present with faecal incontinence (FI), constipation, or both, and can have neurogenic and non-neurogenic aetiologies. The prevalence in the population for patients experiencing at least one episode of FI per month is high, with up to 12.4% affected.¹ The prevalence of severe functional constipation is less well documented, but together these patients present a significant health burden to primary and secondary care. Last year the National Institute for Health and Care Excellence (NICE) published medical technology guidelines supporting the use of trans-anal irrigation (TAI) in patients with bowel dysfunction as it can reduce the severity of constipation/incontinence, improve quality of life, and promote dignity and independence.² The benefits of TAI in patients with neurogenic bowel dysfunction secondary to spinal cord injuries are long established, and supported by the only randomised controlled trial by Christensen et al in 2006.³ The published body of evidence in support of TAI for non-neurogenic (functional) patients is slowly expanding, but consists only of case series, and therefore represents low-level evidence. In our experience, TAI is an effective treatment option that can significantly improve patients’ quality of life when assessed with the Manchester Health Questionnaire.

TREATMENT

Patients with non-neurogenic bowel dysfunction from primary and secondary care are often referred to consultant colorectal surgeons with a specialist interest in pelvic floor surgery. Once referred to the specialist service comprised of surgeons, gastroenterologists, radiologists, nurse specialists, and neurogastroenterology physiotherapists, treatment options available include medication, specialist non-surgical therapy, and surgery. TAI is one of the options available through specialist non-surgical treatment, where selected patients are trained to use home rectal washouts to help manage their symptoms.

TAI is therefore part of the armamentarium of treatments of the pelvic floor specialist. We at Manchester University NHS Foundation Trust assess and treat patients with severe bowel dysfunction often as tertiary referrals from across the North West of England. This entails taking a thorough history, clinical examination, and, where appropriate, investigations of anorectal anatomy and physiology (defaecating proctogram, endo-anal ultrasound, and anorectal manometry). An individualised management plan is provided, supported by a formal multidisciplinary team meeting (MDM). Our patients are all treated in a logical manner as per the algorithms provided by NICE guidelines for constipation⁴ and FI.⁵ Once the MDM has decided to offer TAI and the patient is motivated to accept, funding from the patient’s local CCG is sought.

A POSTCODE LOTTERY OF CARE

In the North West, the Greater Manchester Medicines Management Group (GMMMG) and the Lancashire Medicines Management Group (LMMG) are responsible for the decisions made with regards to medicines and, in particular, high-cost medicines for these regions. Both groups support the use of TAI but differ in their recommendations on when funding TAI will be initiated by GPs.

In Greater Manchester, GPs are approached to fund each case for TAI at the outset and are willing to do so according to the GMMMG guidance. The Lancashire patients, however, face different guidance that stipulates:

‘Treatment should be initiated and stabilised by specialist service providers for a period of 3 months. Treatment should be considered for transfer to primary care after the initial 3 month period only where there has been a demonstrable improvement in validated measures of bowel function such as the Cleveland Clinic constipation scoring system, St Mark’s faecal incontinence score or neurogenic bowel dysfunction score.’ ⁶

Specialist hospitals are unfortunately not funded to support the prescription of irrigation equipment, and so in essence this difference in support creates, what could be considered, a ‘postcode lottery’ for some patients in the North West of England. This leaves the healthcare professional and patient involved in a very difficult situation, where the only alternative treatment may be a stoma to relieve these significant symptoms.

IN LINE WITH NICE

In light of the 2018 NICE guidelines and the expanding evidence base for the use of TAI in non-neurogenic bowel dysfunction, we would encourage support for this treatment to be offered to the patients described who sometimes desperately need it to improve their symptoms and quality of life. Current sources of funding for TAI do not permit the specialist service to initiate treatment and there is no financial reimbursement to do so. We therefore sincerely hope that funding sources and medicines management guidance will be revised for these patients in light of the 2018 NICE guidance.