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Rectal bulb syringe to administer smaller enemas
An enema is the injection of fluid into the lower bowel by way of the rectum. The most frequent use of an enema is to relieve constipation or for bowel cleansing before a medical examination or procedure. In standard medicine an enema may also be employed as a lower gastrointestinal series (also called a barium enema), to check diarrhea, as a vehicle for the administration of food, water or medicine, as a stimulant to the general system, as a local application and, more rarely, as a means of reducing temperature, as treatment for encopresis, and as a form of rehydration therapy (proctoclysis) in patients for whom intravenous therapy is not applicable.
- 1 Medical usage
- 2 Adverse effects
- 3 History
- 4 Society and culture
- 5 See also
- 6 References
- 7 External links
The main medical usages of enemas are:
TAI, also termed retrograde irrigation, is designed to assist the evacuation of feces from the bowel by introducing water into the rectum and colon via the anus as a treatment for persons with bowel dysfunction, including fecal incontinence or constipation, especially obstructed defecation. Its effectiveness varies considerably, some individuals experiencing complete control of incontinence but others reporting little or no benefit.
The term retrograde irrigation distinguishes this procedure from the Malone antegrade continence enema, where irrigation fluid is introduced into the colon proximal to the anus via a surgically created irrigation port.
Patients who have a bowel disability, a medical condition which impairs control of their defecation, e.g., fecal incontinence or constipation. can use bowel management techniques to choose a predictable time and place to evacuate. Without bowel management, such persons might either suffer from the feeling of not getting relief, or they might soil themselves.
A daily enema can be taken to empty the colon, thus preventing unwanted and uncontrolled bowel movements that day. By regularly emptying the bowel using transanal irrigation, which is designed to assist the evacuation of faeces from the bowel by introducing water into colon via the anus, controlled bowel function is often re-established to a high degree, thus enabling development of a consistent bowel routine. An international consensus on when and how to use transanal irrigation for people with bowel problems was published in 2013. The article offers practitioners a clear, comprehensive and simple guide to practice for the emerging therapeutic area of transanal irrigation.
Enemas are employed as bowel stimulants, for the same purposes as orally administered laxatives: To relieve constipation; To treat fecal impaction; To empty the colon prior to a medical procedure such as a colonoscopy.
The volume of the liquid causes rapid expansion of the intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis and a feeling of extreme urgency.
Once the injection is complete, the enema is retained until there is a strong urge to defecate, at which time the recipient may expel any fecal matter loosened by the instilled solution together with the solution itself.
Bowel stimulating enemas usually consist of water, which works primarily as a mechanical stimulant, or they may be made up of water with baking soda (sodium bicarbonate)  or water with a mild hand soap dissolved in it. Buffered sodium phosphate solution draws additional water from the bloodstream into the colon to increase the effectiveness of the enema, but can be rather irritating to the colon, causing intense cramping or "griping." Mineral oil functions as a lubricant and stool softener, but often has the side effect of sporadic seepage from the patient's anus which can soil undergarments for up to 24 hours. Glycerol is a specific bowel mucosa irritant and when introduced in very dilute solution serves to induce peristalsis. Also used are equal parts of milk and molasses heated together to slightly above normal body temperature. In the past, castile soap was a common additive in an enema, but it has largely fallen out of use because of its irritating action in the rectum and because of the risk of chemical colitis as well as the ready availability of other enema preparations that are more effective than soap in stimulating a bowel movement. At the opposite end of the spectrum, an isotonic saline solution is least irritating to the rectum and colon, having a neutral concentration gradient. This neither draws electrolytes from the body – as can happen with plain water – nor draws water into the colon, as will occur with phosphates. Thus, a salt water solution can be used when a longer period of retention is desired, such as to soften an impaction.
In the U.S. and some other parts of the world, their use has been replaced in most professional health-care settings by oral laxatives and laxative suppositories. In-home use of enemas for constipation is somewhat harder to measure.
In a lower gastrointestinal series an enema that may contain barium sulfate powder or a water-soluble contrast agent is used in the radiological imaging of the bowel. Called a barium enema, such enemas are sometimes the only practical way to view the colon in a relatively safe manner. Following barium enema administration, patients often find that flushing the remaining barium with additional water, baking soda, or saline enemas helps restore normal colon activity without complications of constipation from the administration of the barium sulfate.
The administration of substances into the bloodstream. This may be done in situations where it is undesirable or impossible to deliver a medication by mouth, such as antiemetics given to reduce nausea (though not many antiemetics are delivered by enema). Additionally, several anti-angiogenic agents, which work better without digestion, can be safely administered via a gentle enema.
The topical administration of medications into the rectum, such as corticosteroids and mesalazine used in the treatment of inflammatory bowel disease. Administration by enema avoids having the medication pass through the entire gastrointestinal tract, therefore simplifying the delivery of the medication to the affected area and limiting the amount that is absorbed into the bloodstream.
Rectal corticosteroid enemas are sometimes used to treat mild or moderate ulcerative colitis. They also may be used along with systemic (oral or injection) corticosteroids or other medicines to treat severe disease or mild to moderate disease that has spread too far to be treated effectively by medicine inserted into the rectum alone.
- There have been a few cases in remote or rural settings, where rectal fluids have been used to rehydrate a person. Benefits include not needing to use sterile fluids.
- Enemas have been used around the time of childbirth however there is no evidence for this practice and it is now discouraged.
Improper administration of an enema can cause electrolyte imbalance (with repeated enemas) or ruptures to the bowel or rectal tissues resulting in internal bleeding. However, these occurrences are rare in healthy, sober adults. Internal bleeding or rupture may leave the individual exposed to infections from intestinal bacteria. Blood resulting from tears in the colon may not always be visible, but can be distinguished if the feces are unusually dark or have a red hue. If intestinal rupture is suspected, medical assistance should be obtained immediately.
The enema tube and solution may stimulate the vagus nerve, which may trigger an arrhythmia such as bradycardia. Enemas should not be used if there is an undiagnosed abdominal pain since the peristalsis of the bowel can cause an inflamed appendix to rupture.
There are arguments both for and against colonic irrigation in people with diverticulitis, ulcerative colitis, Crohn's disease, severe or internal hemorrhoids or tumors in the rectum or colon, and its usage is not recommended soon after bowel surgery (unless directed by one's health care provider). Regular treatments should be avoided by people with heart disease or renal failure. Colonics are inappropriate for people with bowel, rectal or anal pathologies where the pathology contributes to the risk of bowel perforation.
A recent case series of 11 patients with five deaths illustrated the danger of phosphate enemas in high-risk patients.
Enema comes from Greek ἔνεμα (énema), from ἐνίημι (eníēmi), "(I) inject".
Clyster (/ˈklɪstə(r)/), also spelled glister in the 17th century, rarely "cloister" or "clister" comes from Greek κλυστήρ (klystḗr), from κλύζω (klýzo), "(I) wash". It is an archaic word for enema, more particularly for enemas administered using a clyster syringe – that is, a syringe with a rectal nozzle and a plunger rather than a bulb. Clyster syringes were used from the 17th century (or before) to the 19th century, when they were largely replaced by enema bulb syringes, bocks, and bags.
The first mention of the enema in medical literature is in the Ancient Egyptian Ebers Papyrus (c. 1550 BCE). One of the many types of medical specialists was an Iri, the Shepherd of the Anus. Many medications were administered by enemas. There was a Keeper of the Royal Rectum who may have primarily been the pharaoh's enema maker. The god Thoth, according to Egyptian mythology, invented the enema.
The Olmec from their middle preclassic period (10th through 7th centeries BCE) through the Spanish Conquest used trance-inducing substances ceremonially, and these were ingested via, among other routes, enemas administered using jars.
The Maya in their late classic age (7th through 10th centuries CE) used enemas for, at least, ritual purposes, in the Xibalban court of the God D whose worship included ritual cult paraphernalia. It is hypothesized that these enemas were for ritual purification and the ingestion of intoxicants and hallucinogens. The Maya illustrated the use of a characteristic enema bulb syringe by female attendants administering clysters ritually.
In the second century CE the Greek philosopher Celsus recommended an enema of pearl barley in milk or rose oil with butter as a nutrient for those suffering from dysentery and unable to eat and Galen mentions enemas in several contexts.
In medieval times appear the first illustrations of enema equipment, a clyster syringe consisting of a tube attached to a pump action bulb made of a pig bladder and the 15th century Simple piston syringe clysters came into use. Beginning in the 17th century enema apperatus was chiefly designed for self-administration at home and many were French as enemas enjoyed wide usage in France.
When clyster syringes were in use in Europe, the patient was placed in an appropriate position (kneeling, with the buttocks raised, or lying on the side); a servant or apothecary would then insert the nozzle into the anus and depress the plunger, resulting in the liquid remedy (generally, water, but also some other preparations) being injected into the colon.
Because of the embarrassment a woman might feel when showing her buttocks (and possibly her genitals, depending on the position) to a male apothecary, some contraptions were invented that blocked all from the apothecary's view except for the anal area. Another invention was syringes equipped with a special bent nozzle, which enabled self-administration, thereby eliminating the embarrassment.
Clysters were administered for symptoms of constipation and, with more questionable effectiveness, stomach aches and other illnesses. In his early-modern treatise, The Diseases of Women with Child, François Mauriceau records that both midwives and man-midwives commonly administered clysters to labouring mothers just prior to their delivery.
In the 16th century, satirists made physicians a favorite target, resembling Molière's caricature whose prescription for anything was "clyster, bleed, purge," or "purge, bleed, clyster." In Roper's biography of his father-in-law Sir Thomas More, he tells of Thomas More's eldest daughter falling sick of the sweating sickness. She could not be awakened by doctors. After praying, it came to Thomas More:
There straightway it came into his mind that a clyster would be the one way to help her, which when he told the physicians, they at once confessed that if there were any hope of health, it was the very best help indeed, much marveling among themselves that they had not afore remembered it.
In the 18th century tobacco smoke enemas were used to resuscitate drowned people. Tobacco resuscitation kits consisting of a pair of bellows and a tube were provided by the Royal Humane Society of London and placed at various points along the Thames.
Clysters were a favourite medical treatment in the bourgeoisie and nobility of the Western world up to the 19th century. As medical knowledge was fairly limited at the time, purgative clysters were used for a wide variety of ailments, the foremost of which were stomach aches and constipation.
Molière, in several of his plays, introduces characters of incompetent physicians and apothecaries fond of prescribing this remedy, also discussed by Argan, the hypochondriac patient of Le Malade Imaginaire. More generally, clysters were a theme in the burlesque comedies of that time.
According to Claude de Rouvroy, duc de Saint-Simon, clysters were so popular at the court of King Louis XIV of France that the duchess of Burgundy had her servant give her a clyster in front of the King (her modesty being preserved by an adequate posture) before going to the comedy. However, he also mentions the astonishment of the King and Mme de Maintenon that she should take it before them.
In the 19th century many new types of enema administration equipment were devised, including the bulb enema. Later there came to be a device to allow gravity to infuse the solution into the recipient, consisting of a rubber bag or bucket connected to a hose with a nozzle at the other end to insert into the patient's anus, the bag or bucket being held or hung above the patient. These continue to be used, although rubber has been replaced by modern materials and the bags, at least in hospital use, as disposable.
In the late 20th century the microenema was invented, this being a disposable squeeze bottle with contents that cause the body to draw water into the colon, e.g., sodium biphosphate (popular in the United States) or glycerin (popular in Japan).
Nutrient enemas were administered with the intent of providing nutrition when normal eating is not possible. Although this treatment is ancient, dating back at least to Galen, and commonly used in the Middle Ages, and still a common technique in 19th century medicine, Nutrient enemas have been superseded in modern medical care by tube feeding and intravenous feeding.
Society and culture
The term "colonic irrigation" is commonly used in gastroenterology to refer to the practice of introducing water through a colostomy or a surgically constructed conduit as a treatment for constipation. The Food and Drug Administration has ruled that colonic irrigation equipment is not approved for sale for the purpose of general well-being and has taken action against many distributors of this equipment, including a Warning Letter. The use of enemas for reasons other than the relief of constipation is currently regulated in some parts of the United States while practitioners in other states may go through a voluntary certification process.
The same term is also used in alternative medicine where it may involve the use of substances mixed with water in order to detoxify the body. Practitioners believe the accumulation of fecal matter in the large intestine leads to ill health. This resurrects the old medical concept of autointoxication which was orthodox doctrine up to the end of the 19th century but which has now been discredited.
Although well documented, the procedure of inserting coffee through the anus to cleanse the rectum and large intestines is considered by most medical authorities to be unproven, rash and potentially dangerous. Coffee enemas can cause numerous side effects, including infections, sepsis (including campylobacter sepsis), severe electrolyte imbalance, colitis, polymicrobial enteric septicemia, proctocolitis, salmonella, brain abscess, and heart failure, and deaths related to coffee enemas have been documented.
Some proponents of alternative medicine have claimed that coffee enemas have an anti-cancer effect by "detoxifying" metabolic products of tumors but there is no medical scientific evidence to support this.
In the late 19th century Dr. John Harvey Kellogg made sure that the bowel of each and every patient was plied with water, from above and below. His favorite device was an enema machine ("just like one I saw in Germany") that could run fifteen gallons of water through an unfortunate bowel in a matter of seconds. Every water enema was followed by a pint of yogurt -- half was eaten, the other half was administered by enema "thus planting the protective germs where they are most needed and may render most effective service." The yogurt served to replace "the intestinal flora" of the bowel, creating what Kellogg claimed was a squeaky clean intestine.
Both women and men can find enemas gratifying or sensual. Additionally, in men enemas can stimulate the prostate gland and so, even when a recipient perceives his enema as unpleasant, as can happen in medical settings, an unexpected erection is common.
Klismaphiles can gain satisfaction of enemas through fantasies, by actually receiving or giving one, or through the process of eliminating steps to being administered one (e.g., under the pretense of being constipated).
An enema can be an auxiliary for genital sexual activity, possibly as a regular sexual activity for one or both partners. Sexual enema play is practiced both heterosexually and homosexually.
There still other masturbatory techniques which were regularly or occasionally employed by some 11 percent of the females in the sample ... enemas, and other anal insertions, ... were employed.
An enema can be employed prior to anal sexual activities such as anal sex, anilingus, and pegging for several reasons: In order to enhance the sensation of intercourse; to remove feces prior to sex, possibly reducing bacterial transmission and risk of infection; or to reduce the possibility of fecal material or detritus from sexual activity adhering to the genitals or sex toys used during the subsequent activity.
Enemas have also been used for ritual rectal drug administration such as balché, alcohol, tobacco, peyote, and other hallucinogenic drugs and entheogens, most notably by the Maya and also some other American Indian tribes. Some tribes continue the practice in the present day.
Noting that deaths have been reported from alcohol poisoning via enemas, an alcohol enema can be used to very quickly instill alcohol into the bloodstream, absorbed through the membranes of the colon. However, great care must be taken as to the amount of alcohol used. Only a small amount is needed as the intestine absorbs the alcohol far more quickly than the stomach.
Preceding an enema for administration of drugs or alcohol, a cleansing enema may first be used for cleaning the colon to help increase the rate of absorption.
Enemas have also been forcibly applied as a means of punishment. In the vastly influential Latin American text Facundo, or Civilization and Barbarism, for example, Domingo Faustino Sarmiento describes the use of pepper and turpentine enemas by police forces as a way of discouraging political dissent in post-independence Argentina.
The Senate Intelligence Committee report on CIA torture documented instances of enemas being used by the Central Intelligence Agency in order to ensure "total control" over detainees.
A 365-kilogram (805-pound) brass statue of a syringe enema bulb held aloft by three angels stands in front of the "Mashuk" spa in the settlement of Zheleznovodsk in Russia. It is the only known monument to the enema.
- Cullingworth, A Manual of Nursing, Medical and Surgical:155
- "Soapsuds enema". Biology-Online Dictionary. Biology-Online. Retrieved 6 August 2014.
- "Barium enema". MedlinePlus. U.S. Department of Health & Human Services – National Institutes of Health (NIH). Retrieved 6 August 2014.
- Bruera, E; Pruvost, M; Schoeller, T; Montegjo, G; Watanabe, S (April 1998). "Proctoclysis for Hydration of Terminally Ill Cancer Patients". Jour Pain Symptom Management. 15 (4): 216–9. doi:10.1016/S0885-3924(97)00367-9. PMID 9601155.
- Emmanuel, A V; Krogh, K; Bazzocchi, G; Leroi, A-M; Bremers, A; Leder, D; van Kuppevelt, D; Mosiello, G; Vogel, M; Perrouin-Verbe, B; Coggrave, M; Christensen, P (20 August 2013). "Consensus review of best practice of transanal irrigation in adults" (PDF). Spinal Cord. 51 (10): 732–738. doi:10.1038/sc.2013.86. PMID 23958927.
- "Bowel Management After Spinal Cord Injury". www.sci-info-pages.com.
- Peña A, Guardino K, Tovilla JM, Levitt MA, Rodriguez G, Torres R Bowel management for fecal incontinence in patients with anorectal malformations Pediatr. Surg. 33:1 133–7 1998
- , Consensus review of best practice of transanal irrigation in adults A V Emmanuel et al. Spinal Cord 2013.
- Chaurasia, Gita; Patil, Amruta; Dighe, Shweta (2015). "A REVIEW ON THERAPEUTIC ASPECTS OF HYDROTHERAPY". International Journal of Pharmaceutical Sciences and Research.
- Nicholls, Pam Hufford; Metules, Terri J (April 2001). "Some old-fashioned enemas still work and are still used". RN. 64: 80 – via Ebsco.
- MarileeSchmelzer, Lawrence R.Schiller, Richard Meyer, Susan M.Rugari, PattiCase (November 2004). "Safety and effectiveness of large-volume enema solutions". Applied Nursing Research. Elsevier B.V., Amsterdam, The Netherlands. 17: 265–274. doi:10.1016/j.apnr.2004.09.010. Retrieved July 22, 2017. CS1 maint: Multiple names: authors list (link)
- Tremayne V (2009). "Proctoclysis: emergency rectal fluid infusion" (PDF). Nurs Stand. 24 (3): 46–8. doi:10.7748/ns2009.09.24.3.46.c7271. PMID 19856644.
- "Enemas during labour". Cochrane Database of Systematic Reviews: Plain Language Summaries. National Institutes of Health (NIH). 4 July 2013. Retrieved 14 June 2016.
- Martelli, ME. "Encyclopedia of Nursing and Allied Health". FindArticles. Archived from the original ( – Scholar search) on 23 January 2008. Retrieved 11 January 2008.
- "Colon Hydrotherapy". Aetna IntelliHealth. 1 July 2005. Archived from the original on 7 August 2007. Retrieved 23 April 2007.
- Eliakim R, Karmeli F, Rachmilewitz D, Cohen P, Zimran A (4 January 2004). "Ozone Enema: A Model of Microscopic Colitis in Rats". Digestive Diseases and Sciences. 46 (11): 2515–20. doi:10.1023/A:1012348525208. PMID 11713963.
- Ori Y, Rozen-Zvi B, Chagnac A, Herman M, Zingerman B, Atar E, Gafter U, Korzets A (2012). "Fatalities and Severe Metabolic Disorders Associated With the Use of Sodium Phosphate Enemas". Archives of Internal Medicine. 172 (3): 263–5. doi:10.1001/archinternmed.2011.694. PMID 22332159.
- Magner, A History of Medicine:31
- Magner, A History of Medicine:26
- Parsons and Carlson:92
- de Smet PA, Hellmuth NM (1986). "A multidisciplinary approach to ritual enema scenes on ancient Maya pottery". J Ethnopharmacol. 16 (2–3): 213–62. doi:10.1016/0378-8741(86)90091-7. PMID 3528674.
- "Information Sheet:21 Enemas" (PDF). Information Sheets. Museum of the Royal Pharmaceutical Society, London. Retrieved 26 July 2014.
- Mattern, Susan P. (2008), Galen and the Rhetoric of Healing, Johns Hopkins University Press, Maryland, USA: Johns Hopkins University Press, pp. 31, 145, 149, ISBN 978-0-8018-8835-9
- Magner, A History of Medicine:218
- Short AR, Bywaters HW (June 1913). "Amino-Acids and Sugars in Rectal Feeding". Br Med J. 1 (2739): 1361–7. doi:10.1136/bmj.1.2739.1361. JSTOR 25302025. PMC . PMID 20766702.
- Mackenzie JW (March 1943). "The nutrient enema". Arch. Dis. Child. Archives of Disease in Childhood. 18 (93): 22–7. doi:10.1136/adc.18.93.22. PMC . PMID 21032242.
- Locke GR, Pemberton JH, Phillips SF (2000). "AGA technical review on constipation". Gastroenterology. 119 (6): 1766–78. doi:10.1053/gast.2000.20392. PMID 11113099.
- "Subpart F—Therapeutic Devices Sec. 876.5220 Colonic irrigation system". Code of Federal Regulations, Title 21 Food and Drugs, Subchapter H – Medical Devices, Part 876 – Gatroenterology-Urology Devices. FDA. 1 April 2007.
- Department of Health and Human Services (21 July 1999). "Warning letter to Dotolo Research Corp" (reprint by Casewatch). FDA. Retrieved 31 December 2007.
- Whorton J (2000). "Civilisation and the colon: constipation as the "disease of diseases"". BMJ. 321 (7276): 1586–9. doi:10.1136/bmj.321.7276.1586. PMC . PMID 11124189.
- Ernst E (June 1997). "Colonic Irrigation and the Theory of Autointoxication". Journal of Clinical Gastroenterology. 24 (4): 196–198. doi:10.1097/00004836-199706000-00002. PMID 9252839.
- Kaiser (1985). "The Case Against Colonic Irrigation". California Morbidity (38).
- Chen TS, Chen PS (1989). "Intestinal autointoxication: a medical leitmotif". Journal of Clinical Gastroenterology. 11 (4): 434–41. doi:10.1097/00004836-198908000-00017. PMID 2668399.
- Ernst E (June 1997). "Colonic irrigation and the theory of autointoxication: a triumph of ignorance over science". J. Clin. Gastroenterol. 24 (4): 196–8. doi:10.1097/00004836-199706000-00002. PMID 9252839.
- Shils ME, Hermann MG (April 1982). "Unproved dietary claims in the treatment of patients with cancer". Bull N Y Acad Med. 58 (3): 323–40. PMC . PMID 7052177.
- Lee CJ, Song SK, Jeon JH, Sung MK, Cheung DY, Kim JI, Kim JK, Lee YS (2008). "Coffee enema induced acute colitis". The Korean Journal of Gastroenterology = Taehan Sohwagi Hakhoe chi. 52 (4): 251–254. PMID 19077527.
- "Colon Therapy". American Cancer Society. 11 January 2008. Retrieved 13 May 2011.
- Margolin KA, Green MR (1984). "Polymicrobial enteric septicemia from coffee enemas". The Western Journal of Medicine. 140 (3): 460. PMC . PMID 6710988.
- Eisele JW, Reay DT (1980). "Deaths related to coffee enemas". JAMA: The Journal of the American Medical Association. 244 (14): 1608–1609. doi:10.1001/jama.1980.03310140066036. PMID 7420666.
- Keum B, Jeen YT, Park SC, Seo YS, Kim YS, Chun HJ, Um SH, Kim CD, Ryu HS (2010). "Proctocolitis Caused by Coffee Enemas". The American Journal of Gastroenterology. 105 (1): 229–230. doi:10.1038/ajg.2009.505. PMID 20054322.
- "Livingston-Wheeler Therapy". Memorial Sloan Kettering Cancer Center. 9 May 2011. Retrieved 13 May 2011.
- William T. Jarvis, Ph.D., National Council Against Healthcare Fraud, "Cancer Quackery". Accessed 11 July 2012.
- Centers for Disease Control (CDC) (1981). "Campylobacter sepsis associated with "nutritional therapy"--California". MMWR Morb. Mortal. Wkly. Rep. 30 (24): 294–5. PMID 6789105.
- Keum B, Jeen YT, Park SC, Seo YS, Kim YS, Chun HJ, Um SH, Kim CD, Ryu HS (2010). "Proctocolitis caused by coffee enemas". Am. J. Gastroenterol. 105 (1): 229–30. doi:10.1038/ajg.2009.505. PMID 20054322.
- Eisele JW, Reay DT (October 1980). "Deaths related to coffee enemas". JAMA. 244 (14): 1608–9. doi:10.1001/jama.1980.03310140066036. PMID 7420666.
- "The Gerson Institute — Alternative Cancer Treatment". Archived from the original on 1 April 2003.
- Cassileth B (February 2010). "Gerson regimen". Oncology (Williston Park, N.Y.). 24 (2): 201. PMID 20361473.
- "Dr. John Harvey Kellogg". Great American Quacks. Museum of Quackery. Retrieved 12 February 2018.
- Paraphilias from Psychology Today
- Denko, JD. (April 1973). "Klismaphilia: enema as a sexual preference. Report of two cases". Am J Psychother. 27 (2): 232–50. PMID 4704017.
- Denko, JD. (April 1976). "Amplification of the erotic enema deviance". Am J Psychother. 30 (2): 236–55. PMID 937588.
- Agnew, J. (October 1982). "Klismaphilia--a physiological perspective". American journal of psychotherapy. United States: Association for the Advancement of Psychotherapy. 36 (4): 554–66. ISSN 0002-9564. PMID 7158678.
- Kinsey, Alfred Charles (1953), Sexual Behavior in the Human Female, Bloomington, Indiana, U.S.A.: Indiana University Press, ISBN 978-0-253-33411-4
- Diamond, Jared M. (1992). The Third Chimpanzee: The Evolution and Future of the Human Animal (P.S.). New York, N.Y: Harper Perennial. p. 432. ISBN 0-06-084550-3. ; pp. 201
- "The Enema Within". Darwin Awards. 2008. Retrieved 11 January 2008.
- de Boer AG, Moolenaar F, de Leede LG, Breimer DD (1982). "Rectal drug administration: clinical pharmacokinetic considerations". Clin Pharmacokinet. 7 (4): 285–311. doi:10.2165/00003088-198207040-00002. PMID 6126289.
- "Ribbons and Rituals". In Problems in Modern Latin American History. Ed. Chasteen and Wood. Oxford, UK: Scholarly Resources, 2005. p. 97
- Rushe, Dominic; MacAskill, Ewen; Cobain, Ian; Yuhas, Alan; Laughland, Oliver (9 December 2014). "Rectal rehydration and waterboarding: the CIA torture report's grisliest findings". The Guardian. Retrieved 13 March 2015.
- "Enema monument unveiled in Russian resort". msn.com. 19 June 2008. Retrieved 2 October 2016.
- Cullingworth, Charles James (1883). A Manual of Nursing, Medical and Surgical. Cambridge, England: Cambridge University Press (published 2009). ISBN 978-1-4590-1939-3.
- Magner, Lois (1992). A History of Medicine. Boca Raton, Florida: CRC Press. ISBN 978-0-8247-8673-1.
- Parsons, Lee Allen; Carlson, John B. (1988). The Face of Ancient America: The Wally and Brenda Zollman Collection of Precolumbian Art. Indianapolis, Indiana, United States: Indianapolis Museum of Art. ISBN 978-0-936260-24-2.
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"A professional nursing instructional video demonstrating administering a cleansing enema". Taber's Medical Dictionary. K. A. Davis Company. Retrieved 17 July 2014.