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Injection of fluid into rectum, typically en route to the colon From Wikipedia, the free encyclopedia
An enema, also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum.[1] The word enema can also refer to the liquid injected,[2][3] as well as to a device for administering such an injection.[4]
In standard medicine, the most frequent uses of enemas are to relieve constipation and for bowel cleansing before a medical examination or procedure;[5] also, they are employed as a lower gastrointestinal series (also called a barium enema),[6] to treat traveler's diarrhea,[7] 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 body temperature,[1] as treatment for encopresis, and as a form of rehydration therapy (proctoclysis) in patients for whom intravenous therapy is not applicable.[8]
The principal medical usages of enemas are:
As bowel stimulants, enemas are employed 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. When oral laxatives are not indicated or are not sufficiently effective, enemas may be a sensible and necessary measure.[9]
A large volume enema[10] can be given to cleanse as much of the colon as possible of feces.[11][12] However, a low enema is generally useful only for stool in the rectum, not in the intestinal tract.[13]
Such enemas' mechanism consists of the volume of the liquid causing a rapid expansion of the intestinal tract in conjunction with, in the case of certain solutions, irritation of the intestinal mucosa which stimulates peristalsis and lubricates the stool to encourage a bowel movement.[14] An enema's efficacy depends on several factors including the volume injected and the temperature and the contents of the infusion.[9] In order for the enema to be effective the patient should retain the solution for five to ten minutes, as tolerated.[5][14] or, as some nursing textbooks recommend, for five to fifteen minutes or as long as possible.[15]
For emptying the entire colon as much as feasible[12] deeper and higher enemas are utilized to reach large sections of the colon.[9] The colon dilates and expands when a large volume of liquid is injected into it, and the colon reacts to that sudden expansion with general contractions, peristalsis, propelling its contents toward the rectum.[5]
Soapsuds enema is a frequently used synonym for a large volume enema (although soap is not necessary for effectivity).[5]
For relieving occasional constipation, a large volume enema may be used in a home setting, although for recurring or severe cases of constipation medical care may be required.[5]
Plain water can be used, simply functioning mechanically to expand the colon, thus prompting evacuation.
Normal saline is least irritating to the colon. Like plain water, it simply functions mechanically to expand the colon, but having a neutral concentration gradient, it neither draws electrolytes from the body, as happens with plain water, nor draws water into the colon, as occurs with phosphates. Thus, a salt water solution can be used when a longer period of retention is desired, such as to soften an impaction.
Castile soap is commonly added because its irritation of the colon's lining increases the urgency to defecate.[15] However, liquid handsoaps and detergents should not be used.[5]
Glycerol is a specific bowel mucosa irritant serving to induce peristalsis via a hyperosmotic effect.[16] It is used in a dilute solution, e.g., 5%.[17]
Equal parts of milk and molasses heated together to slightly above normal body temperature have been used.[18] Neither the milk sugars and proteins nor the molasses are absorbed in the lower intestine, thus keeping the water from the enema in the intestine.[19] Studies have shown that milk and molasses enemas have a low complication rate when used in the emergency department[20] and are safe and effective with minimal side effects.[21]
Mineral oil functions as a lubricant and stool softener, but may have side effects including rectal skin irritation and leakage of oil.[22]
ATC code A06 Drugs for constipation is a therapeutic subgroup of the Anatomical Therapeutic Chemical Classification System, a system of alphanumeric codes developed by the World Health Organization (WHO) for the classification of drugs and other medical products.[23][24][25] Subgroup A06 is part of the anatomical group A Alimentary tract and metabolism.[26]
Codes for veterinary use (ATCvet codes) can be created by placing the letter Q in front of the human ATC code: for example, QA06.[27]
National issues of the ATC classification may include additional codes not present in this list, which follows the WHO version.
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In alphabetical order
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In alphabetical order of the original brand names
Klyx contains docusate sodium 1 mg/mL and sorbitol solution (70%)(crystallising) 357 mg/mL and is used for faecal impaction or constipation or for colon evacuation prior medical procedures,[44] developed by Ferring B.V.
Micralax (not to be confused with MICROLAX®)[45]
MICROLAX® (not to be confused with Micralax) combines the action of sodium citrate, a peptidising agent which can displace bound water present in the faeces, with sodium alkyl sulphoacetate, a wetting agent, and with glycerol, an anal mucosa irritant and hyperosmotic. However, also sold under the name "Micralax", is a preparation containing sorbitol rather than glycerol;[46] which was initially tested in preparation for sigmoidoscopy.[47]
Micolette Micro-enema® contains 45 mg sodium lauryl sulphoacetate, 450 mg per 5 ml sodium citrate BP, and 625 mg glycerol BP[48] and is a small volume stimulant enema suitable where large-volume enemas are contra-indicated.[28]
TAI, also termed retrograde irrigation, is designed to assist evacuation using a water enema[49] as a treatment for persons with bowel dysfunction, including fecal incontinence or constipation, especially obstructed defecation. By regularly emptying the bowel using transanal irrigation,[50] controlled bowel function is often re-established to a high degree, thus enabling development of a consistent bowel routine.[50] Its effectiveness varies considerably, some individuals experiencing complete control of incontinence but others reporting little or no benefit.[49]
An international consensus on when and how to use transanal irrigation for people with bowel problems was published in 2013, offering practitioners a clear, comprehensive and simple guide to practice for the emerging therapeutic area of transanal irrigation.[50]
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.[51]
Patients who have a bowel disability, a medical condition which impairs control of defecation, e.g., fecal incontinence or constipation,[52] can use bowel management techniques to choose a predictable time and place to evacuate.[52] Without bowel management, such persons might either suffer from the feeling of not getting relief, or they might soil themselves.[52]
While simple techniques might include a controlled diet and establishing a toilet routine,[52] a daily enema can be taken to empty the colon, thus preventing unwanted and uncontrolled bowel movements that day.[53]
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.[6]
Failure to expel all of the barium may cause constipation or possible impaction[54] and a patient who has no bowel movement for more than two days or is unable to pass gas rectally should promptly inform a physician and may require an enema or laxative.[55]
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.
Improper administration of an enema can cause electrolyte imbalance (with repeated enemas) or ruptures to the bowel or rectal tissues which can be unnoticed as the rectum is insensitive to pain,[66] 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.[14] Frequent use of enemas can cause laxative dependency.[67]
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 kidney failure. Colonics are inappropriate for people with bowel, rectal or anal pathologies where the pathology contributes to the risk of bowel perforation.[68]
Recent research has shown that ozone water, which is sometimes used in enemas, can immediately cause microscopic colitis.[69]
A recent case series[70] of 11 patients with five deaths illustrated the danger of phosphate enemas in high-risk patients.
Enema entered the English language c. 1675 from Latin in which, in the 15th century,[3] it was first used in the sense of a rectal injection,[2] from Greek ἔνεμα (énema), "injection", itself from ἐνιέναι (enienai) "to send in, inject", from ἐν (en), "in" + ἱέναι (hienai), "to send, throw".[71]
Clyster entered the English language in the late 14th century from Old French or Latin, from Greek κλυστήρ (klyster), "syringe", itself from κλύζειν (klyzein), "to wash out",[72] also spelled glister in the 18th century,[73] is a generally archaic word used more particularly for enemas administered using a clyster syringe.
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 a Nery-Pehuyt, the Shepherd of the Anus. Many medications were administered by enemas.[74] There was a Keeper of the Royal Rectum[75] who may have primarily been the pharaoh's enema maker. The god Thoth, according to Egyptian mythology, invented the enema.[76]
In parts of Africa the calabash gourd is used traditionally to administer enemas. On the Ivory Coast the narrow neck of the gourd filled with water is inserted the patient's rectum and the contents are then injected by means of an attendant's forcible oral inflation, or, alternatively, a patient may self-administer the enema by using suction to create a negative pressure in the gourd, placing a finger at the opening, and then upon anal insertion, removing the finger to allow atmospheric pressure to effect the flow. In South Africa, Bhaca people used an ox horn to administer enemas.[77] Along the upper Congo River an enema apparatus is made by making a hole in one end of the gourd for filling it, and using a resin to attach a hollow cane to the gourd's neck. The cane is inserted into the anus of the patient who is in a posture that allows gravity to effect infusion of the fluid.[78]
The Olmec from their middle preclassic period (10th through 7th centuries BCE) through the Spanish Conquest used trance-inducing substances ceremonially, and these were ingested via, among other routes, enemas administered using jars.
As further described below in religious rituals, the Maya in their late classic age (7th through 10th centuries CE) used enemas for, at least, ritual purposes, Mayan sculpture and ceramics from that period depicting scenes in which, injected by syringes made of gourd and clay, ritual hallucinogenic enemas were taken.[79] In the Xibalban court of the God D, whose worship included ritual cult paraphernal, the Maya illustrated the use of a characteristic enema bulb syringe by female attendants administering clysters ritually.[80][81]
For combating illness and discomfort of the digestive tract, the Mayan also employed enemas, as documented during the colonial period, e.g., in the Florentine Codex.[79]
The indigenous peoples of North America employed tobacco smoke enemas to stimulate respiration, injecting the smoke using a rectal tube.[82][83]
A rubber bag connected with a conical nozzle, at an early period, was in use among the indigenous peoples of South America as an enema syringe,[84] and the rubber enema bag with a connecting tube and ivory tip remained in use by them while in Europe a syringe was still the usual means for conducting an enema.[85]
In Babylonia, by 600 BCE, enemas were in use, although it appears that initially they were in use because of a belief that the demon of disease would, by means of an enema, be driven out of the body.[86] Babylonian and Assyrian tablets c. 600 BCE bear cuneiform inscriptions referring to enemas.[87]
In China, c. 200 CE, Zhang Zhongjing was the first to employ enemas. "Secure a large pig's bile and mix with a small quantity of vinegar. Insert a bamboo tube three or four inches long into the rectum and inject the mixture" are his directions, according to Wu Lien-teh.[88]
In India, in the fifth century BCE, Sushruta enumerates the enema syringe among 121 surgical instruments described. Early Indian physicians' enema apparatus consisted of a tube of bamboo, ivory, or horn attached to the scrotum of a deer, goat, or ox.[86]
In Persia, Avicenna (980–1037 A. D.) is credited with the introduction of the "clyster-purse" or collapsible portion of an enema outfit made from ox skin or silk cloth and emptied by squeezing with the hands.[87]
Hippocrates (460–370 BCE) frequently mentions enemas, e.g., "if the previous food which the patient has recently eaten should not have gone down, give an enema if the patient be strong and in the prime of life, but if he be weak, a suppository should be administered, should the bowels be not well moved on their own accord."[89]
In the first century BCE the Greek physician Asclepiades of Bithynia wrote "Treatment consists merely of three elements: drink, food, and the enema".[90] Also, he contended that indigestion is caused by particles of food that are too big and his prescribed treatment was proper amounts of food and wine followed by an enema which would remove the improper food doing the damage.[91]
In the second century CE the Greek physician Soranus prescribed, among other techniques, enemas as a safe abortion method,[92] and the Greek philosopher Celsus recommended an enema of pearl barley in milk or rose oil with butter as a nutrient for those with dysentery and unable to eat,[93] and also Galen mentions enemas in several contexts.[61]
In medieval times appear the first illustrations of enema equipment in the Western world, a clyster syringe consisting of a tube attached to a pump action bulb made of a pig bladder.[citation needed] A simple piston syringe clyster was in use from the 15th through 19th centuries. This device had its rectal nozzle connected to a syringe with a plunger rather than to a bulb.[citation needed]
Beginning in the 17th century enema apparatus was chiefly designed for self-administration at home and many were French as enemas enjoyed wide usage in France.[93]
In 1694 François Mauriceau in his early-modern treatise, The Diseases of Women with Child, records that both midwives and man-midwives commonly administered clysters to labouring mothers just prior to their delivery.[94]
Clysters were administered for symptoms of constipation and, with more questionable effectiveness, stomach aches and other illnesses.[when?][citation needed][95]
In 1753 an enema bag prepared from a pig's or beef's bladder attached to a tube was described by Johann Jacob Woyts as an alternative to a syringe.[96]
In the 18th century Europeans began emulating the indigenous peoples of North America's use of tobacco smoke enemas to resuscitate drowned people.[97] 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.[93] Furthermore, these enemas came to be employed for headaches, respiratory failure, colds, hernias, abdominal cramps, typhoid fever, and cholera outbreaks.[97]
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.[9]
According to the 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.[98]
In the 19th century many new types of enema administration equipment were devised. Devices allowing gravity to infuse the solution, like those mentioned above used by South American indigenous people and like the enema bag described by Johann Jacob Woyts, came into common use. These consist of a nozzle at the end of a hose which connects a reservoir, either a bucket or a rubber bag, which is filled with liquid and held or hung above the recipient.[93]
In the early 20th century the disposable microenema, a squeeze bottle, was invented by Charles Browne Fleet.[99]
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.[100] The Food and Drug Administration has ruled that colonic irrigation equipment is not approved for sale for the purpose of general well-being[101] and has taken action against many distributors of this equipment, including a Warning Letter.[102]
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.[103] 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.[104][105][106]
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 a person's 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 completely clean intestine.[107]
Chlorine dioxide enemas have been fraudulently marketed as a medical treatment, primarily for autism. This has resulted, for example, in a six-year-old boy needing to have his colon removed and a colostomy bag fitted,[108][109] complaints to the FDA reporting life-threatening reactions,[110] and even death.[111]
Proponents falsely claim that administering autistic children these enemas results in the expulsion of parasitic worms ("rope worms"), which actually are fragments of damaged intestinal epithelium that are misinterpreted as being human pathogens.[112][113] Oral and rectal use of the solution has also been promoted as a cure for HIV, malaria, viral hepatitis, influenza, common colds, acne, cancer, Parkinson's, and much more.
Chlorine dioxide is a potent and toxic bleach[114] that is relabeled for "medicinal purposes" to a variety of brand names including, but not limited, to MMS, Miracle Mineral Supplement, and CD protocol.[115] For oral use, the doses recommended on the labeling can cause nausea, vomiting, diarrhea, and potentially life-threatening dehydration.[116]
No clinical trials have been performed to test the health claims made for chlorine dioxide, which originate from former Scientologist Jim Humble[117] in his 2006 self-published book, The Miracle Mineral Solution of the 21st Century[118] and from anecdotal reports. The name MMS was coined by Humble. Sellers sometimes describe MMS as a water purifier so as to circumvent medical regulations.[119] The International Federation of Red Cross and Red Crescent Societies rejected "in the strongest terms" reports by promoters of MMS that they had used the product to fight malaria.[120]
Well documented as having no proven benefits and considered by medical authorities as rash and potentially dangerous is an enema of coffee.[104][121]
A coffee enema can cause numerous maladies including infections, sepsis (including campylobacter sepsis), severe electrolyte imbalance, colitis, polymicrobial enteric sepsis, proctocolitis, salmonella, brain abscess, and heart failure,[122][123][124][125][126][127][128][129][130] and deaths related to coffee enemas have been documented.[131]
Gerson therapy includes administering enemas of coffee,[132] as well as of castor oil and sometimes of hydrogen peroxide or of ozone.[133]
Some proponents of alternative medicine have claimed that coffee enemas have an anti-cancer effect by "detoxifying" metabolic products of tumors[122] but there is no medical scientific evidence to support this.[121][123][134]
Enjoyment of enemas is known as klismaphilia, which medically is classified as a paraphilia.[135][136] A person with klismaphilia is a klismaphile.
Both women and men may enjoy sexual enema play, heterosexually and homosexually, experiencing sexual arousal from enemas which they find gratifying or sensual[137][138] and which can be an auxiliary to, or even a substitute for, genital sexual activity.[137][138]
Klismaphiles may perceive pleasure from a large, water-distended belly, or the feeling of internal pressure. An enema fetish may include sexual attraction to the involved equipment, processes, environments, situations, or scenarios,[139] 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 pretence of being constipated).[138]
That some women use enemas while masturbating was documented by Alfred Kinsey in Sexual Behavior in the Human Female: "There were still other masturbatory techniques which were regularly or occasionally employed by some 11 percent of the females in the sample... Douches, streams of running water, vibrators, urethral insertions, enemas, other anal insertions, sado-masochistic activity, and still other methods were occasionally employed, but none of them in any appreciable number of cases."[140]
Besides klismaphilia, the intrinsic enjoyment of enemas, there are other uses of enemas in sexual play.[141]
Enemas are sometimes used in sadomasochistic activities[142][143] for erotic humiliation[144] or for physical discomfort.[145]
Another sexual use for enemas is to empty the rectum as a prelude to other anal sexual activities such as anal sex,[146] possibly reducing risk of infection.
This is different from klismaphilia, in which the enema is enjoyed for itself and as a part of sexual arousal and gratification.[146]
Rectal douching is a common practice among people who take a receptive role in anal sex[147] although rectal douching before anal sex may increase the risk of transferring HIV,[148] hepatitis B,[149] and other diseases.[150]
Noting that deaths have been reported from alcohol poisoning via enemas,[151] 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.[152]
All across Mesoamerica ritual enemas were employed to consume psychoactive substances, e.g., balché, alcohol, tobacco, peyote, and other hallucinogenic drugs and entheogens, most notably by the Maya, thus attaining more intense trance states more quickly, and Mayan classic-period sculpture and ceramics depict hallucinogenic enemas used in rituals.[79] Some tribes continue the practice in the present day.[153]
With historical roots in the Indian subcontinent, enemas in Ayurveda, called Basti or Vasti, form part of Panchakarma procedure in which herbal medicines are introduced rectally.[154]
Enemas have also been forcibly applied as a means of punishment.
Political dissenters in post-independence Argentina were given enemas of chili pepper and turpentine. [155] Turpentine enemas are very harsh purgatives.[156]
In the Guantanamo Bay Detention Camp, 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.[157] Enemas, officials said, are uncomfortable and degrading,[158] The CIA forced nutrient enema on detainees who attempted hunger strikes, documenting "With head lower than torso … sloshing up the large intestines … [what] I infer is that you get a tube up as you can … We used the largest Ewal [sic] tube we had" wrote an officer,[159] and "violent enemas" is how a detainee described what he received.[160]
In the Dionysus' satyr play Limos, Silenus attempts to give an enema to Heracles.[161]
In Cervantes' Don Quixote, a narrative to Sancho includes “The Knight of the Sun ... bound hand and foot ... was administered a clyster of snow water and sand that almost disracted him"[162]
In the 17th century, satirists made physicians a favorite target, resembling Molière's caricature whose prescription for anything was "clyster, bleed, purge," or "purge, bleed, clyster".[163]
In Molière's play The Imaginary Invalid, Argan, a severe hypochondriac, is addicted to enemas as indicated by such lines as when Bĕralde asks, "Can't you be one moment without a purge?"[164]
In Grace Metalious's novel Peyton Place, the town doctor tells of "a young boy with the worst case of dehydration I ever saw. It came from getting too many enemas that he didn't need. Sex, with a capital S-E-X.".[165] As a teenager, the boy enjoys receiving enemas from his mother.[166]
In Flora Rheta Schreiber's book Sybil, Sybil's psychiatrist asks her "What's Mama been doing to you, dear?...I know she gave you the enemas."[167]
In The Right Stuff, during flight training astronaut Alan Shepard retains a barium enema,[168] given two floors away from a toilet, embarrassedly riding a public elevator wearing a hospital gown and holding the enema bag with its tip still inserted in him.[169][170]
Water Power is a film loosely based on the real-life exploits of Michael H. Kenyon, an American criminal who pleaded guilty to a decade-long series of armed robberies of female victims, some of which involved sexual assaults in which he would give them enemas.[171]
The lyrics of Frank Zappa's song The Illinois Enema Bandit are concerned with Michael H. Kenyon's sexual assaults which included administering involuntary enemas.[172]
A 365-kilogram (805-pound) brass statue of a syringe enema bulb held aloft by three cherubs stands in front of the "Mashuk" spa in the settlement of Zheleznovodsk in Russia. Inspired by the 15th century Renaissance painter Botticelli, it was created by a local artist who commented that "An enema is an unpleasant procedure as many of us may know. But when cherubs do it, it's all right." When unveiled on 19 June 2008, posted on one of the spa's wall was a banner declaring "Let's beat constipation and sloppiness with enemas." The spa lying in the Caucasus Mountains region, known for dozens of spas that routinely treat digestive and other complaints with enemas of mineral spring water, the director commented "An enema is almost a symbol of our region."[173][174] It is the only known monument to the enema.[175]
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