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You can rest assured: Your doctor is absolutely doing the right thing—a mesalamine enema is the correct next step in therapy after Lialda. Steroids will come next if the enema fails. The idea is to use as gentle a treatment as possible, with the fewest side effects. This is the exact progression recommended by both the American Gastroenterological Association and the European Crohn’s and Colitis Organisation based on all medical and scientific evidence, research, and studies done to date.

Like Lialda, this type of enema (often called Rowasa) is just mesalamine, but it comes in “from the other end” so to speak. Mesalamine is a topical analgesic and works to stop inflammation directly where it is applied. Since ulcerative colitis starts at the rectum and works its way up the colon over time, an enema is the ideal way to get the mesalamine directly onto the inflamed area.

Personally, as someone who had never done anything like this at all before, the idea of an enema was a bit off-putting at first, as well. But I soon realized it was simple and it quickly became second nature.

Each disposable enema bottle consists of the bottle itself and a tapered neck a couple inches long, which is pre-lubricated and has a cap over it. You shake the bottle, lie down on your left side, remove the cap, fully insert the neck into your anus, squeeze the bottle, then discard it. The bottle has a one-way valve so that the bottle collapses as you squeeze it and it won’t pull anything back in.

Once you’re used to this, the entire process of the enema itself takes just seconds.

The first few times you do it, however, it will be difficult to get it in, to get the angle right, to get your anus to relax, etc. But very quickly it will become trivial and you’ll find yourself doing it perfectly and absolutely painlessly without thinking. It’s worthwhile. It really gets the mesalamine where it needs to be.

Here are some tips that I have discovered through the practical experience of doing these enemas occasionally over the past eight years:

1. Shake the bottle thoroughly before use, with the cap on. For the final shake, shake it downwards towards the base of the bottle. This moves any of the enema that was in the neck of the bottle downwards rather than towards the tip.
   
   
2. Be sure to evacuate your rectum as much as possible immediately beforehand (i.e. have a bowel movement) so that the mesalamine can better coat your rectum and descending colon.
   
   
3. Lay on your left side for at least 30 minutes afterwards. Have a phone, tablet, or book at hand before you start.
   
   
4. If you can elevate your butt higher than your head (with pillows or a memory foam wedge), the enema will get a bit farther into your descending colon. This may or may not be useful, depending on exactly where in your colon your ulcerative colitis is. Particularly if your ulcerative colitis reaches or passes your splenic flexure (ask your doctor), this is recommended.
   
   
5. After 30-60 minutes, you’ll be able to generally pass gas without any of the enema coming out. This can help with comfort. You’ll get better with this over time.
   
   
6. If you buy sanitary napkins (i.e. pads sold for women’s menstruation) you can put one towards the back of your underwear before lying down to make sure any mesalamine that gets out doesn’t stain your underwear. Mesalamine can permanently stain some things brown. Usually this doesn’t happen, but I like to be cautious.
   
   
7. Be sure to insert the enema bottle as far as you can, and even press a little more. If it’s only inserted part way, some can leak out and make a mess.
   
   
8. Because of the one-way valve, you don’t have to get everything out of the bottle in one big squeeze. Squeeze it repeatedly until the contents are emptied. You’ll know this happens when instead of liquid the bottle squeezes out air. You’ll both feel this and it will make a different noise, and you basically won’t be able to squeeze it any more.
   
   
9. Keep a trash can right next to your bed so you can toss the empty enema bottle in it when you’re done.
   
   
10. Since you’ll be lying down without moving afterwards, without the ability to wash your hands, you may want to wear a disposable latex or nitrile glove on the hand you use to hold the enema bottle. The process isn’t inherently messy, but after performing the enema, you may want to lightly dab or pat around your anus with a tissue in case a few drops of mesalamine got there when removing the bottle. I then tend to turn the glove inside out, over the bottle and tissue, and drop it in the trash. Another option is to keep some hand sanitizer on your nightstand. I’ve done both.
    
    
11. Try to hold the enema in as long as possible, i.e. don’t have a bowel movement for as long as you can, so the mesalamine can do its work. Ideally you want to hold it in for at least 8 hours. This is usually doable if you perform the enema right before bed, but depending on how bad your ulcerative colitis symptoms are it may be more difficult at first. If you can’t go for the full 8 hours, just do the best you can.
    
    Good luck, and don’t worry! This will be fine and isn’t a big deal. I do hope the enemas take care of your flare, and hopefully you never even need steroids. Please check in and let us know of your progress. All the best.