The document describes the Antegrade Continence Enema (ACE) procedure, a bowel management technique for individuals with spina bifida, aimed at alleviating constipation and fecal incontinence. It outlines the surgical creation of a stoma, the process of conducting washouts, and potential complications, emphasizing the need for commitment and consistency in managing the routine. It also highlights alternative options and encourages consultations with healthcare professionals to determine the best approach.

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ACE Procedure
Antegrade Continence Enema
Many people who have spina bifida will suffer with problems
of constipation and faecal incontinence. The Antegrade
Continence Enema or ACE is a way of managing bowel
emptying at a convenient time each day, and should reduce
both constipation and soiling episodes.
The procedure involves sitting on a wall of the abdomen at the navel or
commode or toilet whilst a washout lower down below the level of most
is given through a small opening or underwear. This small opening or
stoma on the abdomen. stoma is used to pass a tube called
a catheter into the bowel so that
Because creating an ACE stoma fluid can be introduced to flush
requires an operation, the doctor faeces out through the anus. This is
will usually recommend it only called an ACE washout. For people
when all other efforts to manage who have previously had their
the bowel have been tried and appendix removed, there are other
have failed. ways of making an ACE stoma. For
example, a tiny segment of small
How does it work? bowel may be used.
To create an ACE stoma, the Before the operation, you may be
surgeon will cut off the appendix, admitted to the hospital for a few
still with its blood supply, and days. This is to make sure you are
connect one end to the large well enough to have the operation,
bowel and the other end to the and to empty the bowel.

2. ACE Procedure
Antegrade Continence Enema
Although you will not be able to if it is carried out regularly. Initially,
eat and drink immediately after this may need to be daily and the
surgery, you should be up and on whole process may take as little as
a normal diet after 1 or 2 days. This 30 minutes, or as long as 2 hours.
is when the washouts will begin. The average time though is an hour.
A soft catheter that is left in the Once you establish a good routine,
stoma from surgery will be used. A you should be clean between
solution is flushed along the bowel washouts. Remember that it takes
by gravity whilst you sit on the a little while for the system to settle
toilet. The solution and contents down, and the amount and/or type
will empty into the toilet. The of washout fluid may need to be
hospital stay will last 5 to 7 days. changed. Your nurse specialist will
After discharge from the hospital, help with this. For some people,
the catheter will stay in the stoma things seem to work out quickly and
for 4 to 6 weeks, to allow it to heal. they soon become accustomed to
You will then be asked to come doing the washouts.
back to the hospital, and will be
taught to catheterise the stoma so What complications can
you can do your washout and then occur?
be free of a catheter until the next
washout. Once the catheter has
There can be times when things
been removed, there is no leakage
do not go well, for instance if you
from the stoma as it is designed to
have to take antibiotics, or you get
be leak-proof.
a tummy upset. There are ways of
overcoming these problems and
Who is it for? with experience you will learn how
to cope with them.
This method of bowel management
is not a “quick fix”, and requires For a few people, complications
a great deal of commitment and do occur. Sometimes the stoma
hard work to establish a reliable becomes narrow (stenosed) and
washout routine. Once a good it is increasingly difficult to pass a
routine is achieved, it will work only catheter. This can be overcome

3. by passing a catheter every day
even if the washouts are not done Are there other options?
daily. Sometimes it is necessary to
have further surgery to solve these Some hospitals now offer a
difficulties. Some people choose to variation of this procedure that
wear a small soft plug or stopper in does not require a formal stoma
the stoma to prevent it from getting to be created. However, some
tight. Occasionally infections occur, form of small tube called a PEG or
and they may need to be treated Button device is left in place at all
with antibiotics. times. The tube is inserted under
general anaesthetic either using
Before choosing this method of a laparoscope or a colonoscope.
continence management, you This is a “pull through” method
should consider whether you could whereby a piece of the bowel is
give the time commitment, and pulled to the surface of the skin, and
have the motivation it takes to make the button or PEG tube is inserted.
it work for you. Generally, ACE is Once this has healed, washouts
not considered suitable for children can be given whilst sitting over
under the age of 5 years, as it can the toilet. The washouts work in
be very difficult to encourage them the same way. The big advantage
to sit on the toilet for the length of of this procedure is that it is easy
time required. to stop just by removing the tube.
For some patients, the tube can be
Talk to your doctor or continence placed into the left hand side of the
adviser and decide together if this bowel. This usually means shorter
is the way forward for you. Most washout times. This option will not
people who have chosen the ACE be suitable for everyone however,
procedure have gained immensely so it must be discussed with your
from it. They can do things they medical team.
thought were impossible before,
such as swimming and even having
sleepovers!

4. Help us
Shine relies on people’s generosity and support so we can help our clients
who depend on us for help and advice - people with hydrocephalus,
spina bifida, their families and carers. To donate to Shine please visit
www.shinecharity.org.uk or call 01733 421329.
This information has been produced by Shine’s medical advisers and
approved by Shine’s Medical Advisory Committee of senior medical
professionals.
Shine - Registered charity no.249338
To see our full range of information sheets and to find out how to donate
to Shine please visit www.shinecharity.org.uk