Antegrade continence enema with appendicostomy (Malone Antegrade Continence Enema - MACE)

What is an enema?

An enema is a liquid that is poured into the intestine to flush out stool. An antegrade continence enema (ACE) is an enema that is given through a passage between your child’s abdomen and intestine. The enema is a saline solution, which is a mix of water, salt and, sometimes, other ingredients.

What is an appendicostomy?

An appendicostomy is a surgery (operation) to create a passage between the abdomen and the intestine. The surgery usually involves stitching your child’s appendix (located at the end of the large intestine) to their abdomen. Although the surgery is usually called an appendicostomy, it can also be called a Malone procedure or MACE (Malone Antegrade Continence Enema) procedure, after the surgeon who invented it.

Why your child needs an appendicostomy and antegrade continence enema

Your doctor may suggest an appendicostomy if your child is soiling their clothes because of a medical condition such as anorectal malformation or spina bifida or is experiencing trauma.

Having regular antegrade continence enemas (ACEs) will help your child stay “socially clean” so that they can wear underwear 24 hours a day. It will also ease the distress you or your child may feel about your child soiling their clothes.

What happens after an appendicostomy

After the appendicostomy, your child will have a stoma (opening) at or near their belly button. The stoma allows a tube to be inserted into your child’s intestine for your child’s daily ACE.

To help the stoma heal and keep its shape, your child will have a tube attached to their abdomen with sutures (small stitches) and medical tape. This tube is called a Foley catheter and will stay in place for two to three weeks, until your child’s first appointment with the surgeon after surgery.

When your child can go home after an appendicostomy

Children are usually ready to go home three to five days after surgery. Before discharging your child, the healthcare team will need to confirm that:

  • your child’s heart rate, breathing, blood pressure and temperature​ are normal
  • your child can eat without vomiting (throwing up)
  • your child is comfortable taking oral pain medicine (medicine taken by mouth)
  • you (and your child if they are old enough) have completed training in performing an ACE.

Taking care of your child at home after an appendicostomy

Care of the incision

  • Clean the area around the stoma and Foley catheter with soap and water every day and pat dry.
  • Keep the Foley catheter securely in place with tegaderm (a type of dressing) and tape.
  • Only remove the catheter according to the surgeon’s instructions.
  • Watch out for any signs of infection at the stoma (see below).


Your child should take part only in quiet supervised play for the first 24 to 48 hours. Do not allow your child to lift anything heavier than five pounds or take part in strenuous activity for one week after surgery.


Your child may need to change their diet to ease any difficulties with stool or with gas or bloating. Your child should eat regularly and not go more than 48 hours without a bowel movement. Remember to give them plenty of fluids to prevent constipation after surgery.


Your child may shower the day after surgery and swim or take a bath one week after surgery.

Pain medicine

Your child will need to take pain medicine for the first few days after surgery. Always follow the instructions from the surgical team.

When to get medical help

Call your nurse immediately if there is:

  • a crack in the Foley catheter
  • unusual discharge, irritation, redness or skin cracking at the stoma.

Call the surgeon’s office if:

  • your child has a fever of 38 °C (101°F) or higher
  • the tube has accidentally dislodged (come loose from the stoma)
  • you cannot flush out the tube or your child cannot pass stool through it
  • there is too much drainage from around the tube
  • your child is bleeding, red or swollen where the tube has been inserted
  • your child is uncomfortable or in more pain even after taking pain medicine (including abdominal, back or leg pain)
  • your child is vomiting​ (throwing up)
  • your child’s stomach is sore or distended (swollen or full)
  • your child is lethargic, very tired or drowsy.

Important phone numbers

My child’s nurse is:     __________________________________


Phone number:          __________________________________

My child’s doctor is:    __________________________________

Phone number:           _________________________________


When to start performing antegrade continence enemas

Your child’s surgeon will tell you when you can start performing antegrade continence enemas with the first Foley catheter in place. This is usually within a few days of the appendicostomy.

The nurses in the hospital will teach you how to give the antegrade continence enema. On the days that your child is not having an ACE, you should flush the Foley catheter with a mix of salt and water. Your child’s surgeon will tell you how much to use.

Follow-up appointment after an appendicostomy

After two to three weeks, your child will return to the clinic for a follow-up appointment. The surgeon will remove the Foley catheter that was fitted during the appendicostomy. A nurse will then teach you how to insert and remove the catheter that you will use for your child’s daily ACE from then on.

How to give an antegrade continence enema

Most children need to have the ACE performed every day, but the frequency is tailored to each child’s needs.

Gather your supplies

Get your supplies together before you start preparing the enema. You will need:

  • Zevex – 1200 Enteral Delivery Set (GR1200)
  • a Foley catheter (your doctor will tell you which size you need)
  • syringe, 5 mL, slip tip (BD #301603)
  • syringe, 60 mL, catheter tip (BD #309620)
  • water-based lubricant such as K-Y jelly or Muko.

You can buy these supplies from your local pharmacy or, if living in Ontario, from Ontario Ostomy Supply.

Most insurance companies cover the cost of supplies. Please ask your nurse if you qualify for any government programs, grants or tax credits that help with the cost.

Make up the saline solution

Mix 500 mL (2 cups) tap water (water you would drink) with 3/4 teaspoon table salt. This is a standard recipe for saline solution. Do not change it.

The amount of saline solution used in the enema depends on each child and their weight. You will be told how much to use for your child.

Prepare the enema

  1. Gather your equipment:
    • an enema bag and tubing (Zevex Enteral Delivery Set)
    • a Foley catheter with a 3 mL balloon
    • water-based lubricant
    • a 30 mL syringe (slip tip)
    • a 60 mL syringe (catheter tip - for cleaning catheter after the enema).
  2. Make up the saline solution.
  3. Clamp the tube of the enema bag and pour the saline into it. Mix well.
  4. Open the clamp and allow the fluid to flow out of the bag.
  5. Squeeze the drip chamber on the tubing until it is half filled with fluid. Then fill the entire tubing. This is called “priming the tubing”.

Give the enema to your child

  1. Have your child sit on the toilet.
  2. Lubricate the Foley catheter.
  3. Gently introduce the catheter into the appendicostomy and slowly insert 5-7cm. You may secure the Foley catheter to the skin with a piece of tape.
  4. Optional: If you have been told to inflate the balloon of the Foley catheter, attach the 5 mL syringe (filled with air) to the small port on the catheter. Fill the balloon with 3 mL of air. As soon as the balloon is inflated, take the syringe off the catheter to prevent the balloon from deflating.
  5. Tilt the enema bag to allow for a steady flow of saline solution into your child. If the saline solution is flowing too quickly, use the roller clamp on the tubing or lower the bag.
  6. After the enema is completed, simply remove the tape and remove the Foley catheter gently. If you had inflated the balloon, deflate it first by connecting the 5 mL syringe to the same port and removing the air. This will allow the Foley catheter to slip out.
  7. Have your child remain on the toilet for 45 minutes if possible. This will make the enema most effective. The timing of toilet sitting will vary for each child.
  8. When finished, rinse the enema bag with water and flush the Foley catheter with soapy water through the 60 mL syringe. You can reuse these supplies.

Tips for successful antegrade continence enemas

  • An ACE solution should take 15 minutes to flow through your child.
  • The higher you hold the bag, the faster the solution will flow. The lower you hold it, the slower the flow.
  • If your child starts to get cramps, it is a sign that the solution is flowing too quickly. Slow down the flow by lowering the enema bag or using the roller clamp.
  • Try to distract your child during the enema.
  • Try to involve your child in the ACE to increase their independence over time.
  • Check the results of the ACE by looking into the toilet. If there is no stool or only a tiny amount of stool, tell your child’s nurse. Your child may need a different ACE solution.
  • Replace the Foley catheter every two to three weeks or when it becomes clogged with stool.

What to do if the antegrade continence enema is not effective for 24 hours

If your child is still soiling, your nurse will help you adjust the amount of enema solution and timing of enemas.

If the ACE is not effective for 24 hours, your child might need more saline solution or you might need to add liquid glycerin. Please ask your healthcare team how much saline and glycerin to use.

How to protect your child’s stoma when they are not receiving an ACE

Your doctor may suggest that you place an ACE stopper in the passage when the ACE is not being given. The stopper can be secured to the abdomen with a bandage and should be replaced every month. Your child’s surgeon will tell you what size ACE stopper your child will need and where you can buy it.

Key points

  • An antegrade continence enema (ACE) is a saline solution that is given through a tube into a passage between the abdomen and the intestine.
  • Your child will need an appendicostomy to create the passage before receiving the ACE. After surgery, your child will have a stoma and be fitted with a tube to help the stoma keep its shape.
  • Call your nurse if there is a problem with the tube or if your child’s skin is irritated. Call the surgeon if your child has a fever, is vomiting or is in pain even after taking pain medicine or if the tube appears to be blocked.
  • Your child’s healthcare team will teach you how to give an enema and tell you when you can start. Follow their instructions carefully.
  • If an ACE is not effective, tell your nurse so that they can adjust the ACE solution or frequency.
​​Katharine Williams, RN (EC)
Division of Urology
Kimberley Colapinto, RN (EC), CETN
Division of General and Thoracic Surgery

​At SickKids

Supplies for antegrade continence enemas are sold at the Specialty Food Shop​ on the main floor of the hospital.


Cincinnati Children’s Hospital Medical Center (2014). Bowel Management Program​