Constipation and faecal incontinence are symptoms associated with major impairment of quality of life. Such bowel dysfunction can arise from a variety of causes, neurological diseases, spinal cord injury, multiple sclerosis, spina bifida and Parkinson’s. Constipation complicates opioid use in up to 60% of cases, and with the increased prescribing of these agents, opioid induced constipation is an increasingly prevalent problem. As well as these aetiologies there remains a problem associated with idiopathic constipation and faecal incontinence. Increased age is correlated with idiopathic causes and with an aging population, the prevalence of such symptoms is ever increasing. Effective treatment options for these conditions are therefore essential. For many years conservative management with lifestyle, laxatives and in more recent years the advent of novel pharmacological agents have been available treat constipation and faecal incontinence. Despite this, there remain many patients with refractory symptoms. 
Transanal irrigation has emerged as a treatment solution for some of these patients. The technique assists the evacuation of faeces by introducing water into the bowel via the anus in order to induce a reflex colorectal voiding. The water is introduced using a single-use device, cone or catheter. After the device is removed, the contents of the rectum and some of the proximal colon is emptied. By regularly emptying the bowel in this manner, TAI is intended to help control of bowel function and enable the user to choose the time and place of evacuation.
In recent years, a range of TAI systems has emerged, intended to make the treatment available to a wider range of patients as well as optimising long-term adherence. Whilst there exists a best practice review of how to initiate therapy, this was written prior to the advent of the newer systems now available. In addition, following the NICE guidance there are likely to be an increasing range of healthcare professionals who use the technique. For that reason and because decision making on which system to use has been challenging, an expert consensus group has developed a decision guide to help the clinician determine the optimal equipment to use for each individual patient when initiating TAI.

The rapid evolution of the therapy means that there is little Grade A evidence available to develop formal guidance, and so a consensus review of best practice was thought to represent the best means of arriving at clinically meaningful advice. The review covers practice in adults only. It encompasses all the systems, without this being company biased, of TAI available at the time of writing. The consensus group had a detailed and structured round-table discussion during which the pathway of care presented was developed, and a manuscript arose from that process, which was serially revised by each member individually until a group consensus was agreed. This review is presented in a deliberately pictorial way in order to make it as user friendly as possible.  Information is presented in box text and tables in order to allow novice and experienced clinicians to have access to a handy summary guide to assist consultations and practical discussions. The intention is to have an evidence-informed and expert consensus guide (on one page) to optimise safe practice of transanal irrigation in a climate that sees both increasing availability of the systems and an expanding potential patient population.

The first part of the manuscript gives a treatment pathway for bowel dysfunction. As set out in Figure 1.  A critical first step in establishing a service is to set up a pathway of care according to local practice and service availability. This in turn requires setting up or working with a local multi-disciplinary group of healthcare professionals. 
Education: At the same time clinicians should have appropriate TAI training, education with follow up training as deemed appropriately for example twice a year. This is especially important given the rapid evolution of systems and studies investigating the use of TAI in different patient groups. The box below summarises the aspects that need to be considered as part of maintaining competency, which can be included in a pack for initial training and follow up.
Patient assessment: A careful assessment of the patient is needed before undertaking therapy. This will help to confirm the indication for TAI. it is important to document the patient’s primary reason for needing escalation of therapy (failure of conservative therapy, complications of that therapy, unpredictability of bowel function, dependence on carer). Patient related outcome measures can be used initially, and once treatment has commenced to ensure success or failure and deem continuation of treatment.
Equipment choice: It is important that clinicians training patients should have access to a range of systems – both catheter and cone systems, low and high-volume systems, manual and electronic pump systems. The key is to have a discussion between the clinician and patient about types of equipment, and to make a best fit choice. To help with this a table will highlight types of systems available (without specific brand names) and the type of patient that will be suitable for a particular system.

A practical pathway and decisions making process was arrived it through consensus building.

Transanal irrigation is now an established treatment to manage bowel dysfunction. As the technique becomes more widespread, and more complicated with a greater range of products available, it becomes ever more essential for the clinician to have up to date information and guidelines to help make the decision on using the right system for the right reason. Making this a choice based on theory and practicalities for each individual patient.