If you cringe at the thought of using a rectal therapy in your ulcerative colitis treatment plan, you’re not alone. Most people consider them to be strange and icky, uncomfortable and unfamiliar and in many cases just plain embarrassing. But as much as we may despise the idea of using a suppository or enema, rectal therapies do have an important place in ulcerative colitis, and it’s time to get educated.

Oral vs. Rectal

If you’ve been prescribed medication to treat inflammatory bowel disease (IBD), you’re likely taking medications such as a 5-ASA, (Pentasa or Salofalk) and/or a steroid. While these therapies come in different forms – tablets, suppositories and enemas – most patients will opt for a systemic, oral therapy over the rectal type.

We’d rather pop something into our mouth than insert something into our rectum; oral tablets are quick, easy and mess-free, while suppositories and enemas tend to be more time-consuming, messier and all around more embarrassing. It makes sense!

But sometimes simple and tidy isn’t most effective. And the majority of physicians will agree that when it comes to treating IBD when the inflammation is in the colon – ulcerative colitis in particular – rectal therapy is the way to go (literally and figuratively speaking). Consider the following:

Inflammation from ulcerative colitis always extends from the anus up. This means an oral tablet must travel the whole digestive tract – almost 30 feet through the mouth, throat, stomach, small intestine – and stay intact before delivering the active agent to the affected area. A rectal therapy, on the other hand, has only a short distance to travel which guarantees that a large proportion of the medication reaches the site of inflammation.

(A) The human digestive tract, and (B) The human digestive tract with the small intestine straightened out. Note, the area in red is the inflammation you are trying to treat.

As a parallel situation, consider sunburn. If you needed to treat a burnt patch of skin, you’d probably use a cold compress or some sort of aloe vera cream directly on the affected area. Sure, you might take an oral pain medication – maybe an ibuprofen – in addition to the topical treatment, but by and large, the fastest, most effective treatments are the more direct options. Makes sense right?

Another reason rectal therapy is a better alternative to systemic relates to side effects. Consider a steroid like prednisone (which is available in both oral and rectal formulas). When prednisone is administered systemically via tablet, it’s absorbed into the bloodstream to travel to the site of inflammation.

But once it’s in the blood, prednisone is essentially interacting with the entire body, which means it has a number of associated side effects. These include elevated pressure in the eyes (glaucoma), fluid retention (swelling), increased blood pressure and weight gain. Steroids administered rectally don’t (directly) interact with the bloodstream, and therefore have fewer side effects.

But there’s a catch: rectal therapies are effective for treating inflammation in the rectum and connecting left colon, but they can only reach so high. Patients with more extensive inflammation – throughout the entire colon, small intestines and even higher into the stomach – might require an oral therapy, in addition to a rectal therapy, to target the inflammation from both ends.

Now you’re probably thinking…What about traveling? I don’t want to be leaking all over the sheets! What about my sex life? I can’t be intimate if I’m using suppositories and enemas all the time! And these are all legitimate concerns, but here’s the thing: Because IBD is characterized by flare-ups and remissions, suppositories and enemas need not be used on a regular basis.

During flare-ups, when inflammation is at its worst, rectal therapy should be used to induce remission. Once a patient is in remission, they may switch to an oral medication to maintain that state. So it’s essentially, rectal therapy for flare-ups and oral therapy for remission. Not so bad right?

The take away message is this: rectal therapies aren’t discreet or sexy or comfortable and they sure as heck aren’t fun. But when you’re experiencing an ulcerative colitis flare-up, they’re ultimately the most effective treatment option. Remember, you are your own best ulcerative colitis case manager, and as such, it’s important that you understand the full range of available alternatives – and how they might work independently and in unison – to optimize your treatment experience.

Tips for administering enemas

One common issue with liquid enemas is the urge to expel all or part of the enema shortly after administration. To avoid this issue, read the following tips from IBD patients.


  • Enemas should be administered right before bed, or in bed, so you don’t have to move after administration
  • Try going to the bathroom beforehand; if you have a bowel movement, wait 20 minutes for your body to relax before administration
  • Try having a hot bath before administration and relax as best you can

During administration:

  • Lay on your left side for a few minutes before and after administration. This might help you to pass gas without expelling the enema; ideally you will fall asleep and it stays put all night
  • While on your left side, try administering the enema with your thigh(s) pulled up to your torso or perpendicular to your torso
  • Try using half of the enema (for the first few times); this may help address the inflammation without causing you to immediately expel it. If you do expel the enema, your bowel will be empty and you can administer the other half of the dose
  • Take out the enema slowly, squeezing out the last bit of medicine, so it reaches the end of the rectum
  • Avoid talking and moving around after enema administration

If you are taking steroid enemas (i.e. Cortenema) and this advice doesn’t help, many people find that the foam type (i.e. Cortifoam) is easier to retain.

Keep in mind: if you allow your ulcerative colitis to fester for too long, the inflammation might make it harder to retain enemas when you do start administering them. So start treatment immediately!