A Malone, formally called the Malone Antegrade Continence Enema (MACE), is a surgical procedure that creates a small channel from the surface of the abdomen into the colon. This channel allows a person to flush saline or other solutions directly into the top of the large intestine, washing stool downward and out in a controlled, predictable bowel movement. The procedure is most common in children with conditions that prevent normal bowel control, though adults can have it too.
How the Malone Procedure Works
During surgery, a surgeon uses a small piece of the appendix (or, if the appendix isn’t available, a segment of intestine) to form a narrow tube. One end connects to the colon, and the other opens at the skin of the abdomen as a tiny, flat opening called a stoma. The stoma is small and discreet, often hidden by clothing.
To use it, the person or a caregiver inserts a thin catheter through the stoma and flushes a liquid solution into the colon. Because the fluid enters from the top of the colon and moves downward, it’s called an “antegrade” enema, meaning it flows in the same direction stool naturally travels. This washes the colon clean, producing a bowel movement that the person can schedule at a convenient time. The result is predictable emptying and, for many people, complete freedom from accidents for the rest of the day.
Who Needs a Malone
The Malone procedure is typically reserved for people with severe constipation or fecal incontinence that hasn’t responded to medications, dietary changes, or traditional enemas. The most common underlying conditions include:
- Spina bifida and other spinal cord problems: Roughly half of patients with a nerve-related bladder problem from spina bifida also have a nerve-related bowel problem, with chronic constipation or incontinence that doesn’t improve with conservative treatment.
- Anorectal malformations: Up to 50% of children born with structural abnormalities of the rectum or anus will have long-term fecal incontinence.
- Hirschsprung’s disease: A condition where nerve cells are missing from part of the colon, disrupting normal bowel motility.
- Sacral agenesis: Incomplete development of the lower spine, which can affect the nerves controlling the bowel.
The procedure is considered a step up when simpler bowel management programs have failed. Clinical guidelines from the Consortium of Spinal Cord Medicine position it alongside colostomy as a surgical option for severe bowel dysfunction, recommended only after thorough discussion of risks and benefits.
What Daily Life Looks Like
Most people with a Malone flush their channel once a day, though some need two flushes. The routine involves inserting a catheter, running a measured volume of fluid through, then sitting on the toilet and waiting for the colon to empty. The amount of fluid depends on the person’s size and bowel response, and it’s adjusted over time until it produces a complete bowel movement within about 20 minutes, with no accidents for the following 24 hours. Some people need up to 45 minutes after flushing before the process is finished.
If constipation persists despite regular flushes, doctors may recommend adding small amounts of mineral oil, a gentle laxative powder, or other mild additives to the flush solution. These adjustments are common and part of fine-tuning the routine to each person’s body.
For children and families dealing with unpredictable bowel accidents, the daily flush routine can feel like a major upgrade. Studies consistently show high satisfaction rates among families using the Malone, and some children are eventually able to stop using the channel altogether as their bowel function matures or responds to other treatments over time.
Success Rates
The Malone procedure has a strong track record. In studies of patients with neurogenic bowel dysfunction, about 85% of those who underwent MACE achieved full fecal continence. Published continence rates across the broader literature range from 57% to 100%, with most studies landing in the 80% to 90% range. These numbers mean the vast majority of patients go from daily or near-daily accidents to reliable bowel control.
Complications and Revisions
The most common issue after a Malone is narrowing of the stoma, called stomal stenosis. In one large study, nearly half of patients experienced some type of stoma-related complication, with stenosis being the most frequent. The average time to first stenosis was about 20 months after surgery, though it ranged from as early as 3 months to as late as 4 years. Stenosis is usually managed by dilating (gently stretching) the opening, but sometimes requires a second surgery.
Other possible complications include leakage from the stoma, prolapse (where tissue pushes outward), and rarely, perforation or fistula formation. About 25% of patients in one series needed a full surgical revision of their Malone channel, most often because of prolonged elimination times or recurring stenosis. The technique used to create the channel matters: approaches that leave the appendix attached to its blood supply in its natural position tend to have somewhat lower stenosis rates than techniques that fully detach and reposition it.
Despite these complication rates, most families and patients consider the trade-off worthwhile. The complications are generally manageable, and the alternative for many of these patients is ongoing, uncontrolled incontinence that limits school attendance, social activities, and independence.