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Definition
Faecal incontinence describes the inability to control the bowels (International Continence Society, 2015). Faecal incontinence is defined as:
- anal incontinence: the involuntary loss of flatus, liquid or solid stool, which is a social or hygienic problem
- passive soiling (liquid or solid), which occurs when an individual is unaware of liquid or solid stool leaking from the anus; this may be after a bowel movement, or at any time (Royal College of Nursing, (RCN) 2019)
Other definitions also include:
- urge faecal incontinence: contents of the bowel are discharged despite active attempts to retain contents
- faecal seepage: leakage of stool with normal continence and evacuation (Benezech et al, 2016)
The severity of the condition can range from the involuntary passage of flatus to complete involuntary evacuation of all stool.
Normally, the bowel and rings of muscle around the back passage (anal sphincters) work together to ensure that bowel contents are not passed
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Aetiology
The RCN (2019) and International Continence Society (2015) identified that faecal incontinence is mainly associated with the following:
Childbirth
The muscles of the anal sphincters can be stretched or even torn during vaginal birth. This can also cause nerve damage due to stretching of the nerve or a combination of direct muscle damage and nerve trauma. This usually occurs when the birth is difficult or when certain instruments have been used to assist delivery.
Anal sphincter damage
This may be caused by surgery, such as during treatment of cancer of the bowel or pelvic organs, or inadvertently during operations to remove haemorrhoids (piles).
Congenital malformations
Conditions such as spina bifida or anorectal malformations that affect the nerves may cause a person to experience faecal incontinence.
Chronic constipation or diarrhoea
Constant straining during defecation can gradually stretch the pelvic floor and rectal
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Symptoms
Any red-flag symptoms that indicate a potential underlying pathology should be investigated so these can be ruled out. Red-flag symptoms include :
- rectal bleeding
- a change of bowel habits for at least 6 weeks
- unintentional weight loss
- pain before, during or after defecation
- faecal leakage
- faecal urgency (National Institute for Health and Care Excellence (NICE), 2007; RCN, 2019)
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Diagnosis
A complete bowel assessment of an individual experiencing faecal incontinence should be undertaken by a competent health professional (McClurg et al, 2013). The assessment should be undertaken with sensitivity, as this can be embarrassing for the patient and may cause them to delay seeking medical care (Assmann et al, 2022).
The assessment should also involve taking a medical history, including:
- obstetric history
- medication
- onset
- duration
- timing
- nature of faecal incontinence (ie gas, solid or liquid stool)
- any associated triggers (eg particular foods)
- fluid and diet intake
An individual's mobility and dexterity should be assessed, as well as their proximity to a toilet and whether carers are required and available when needed (Emmanuel et al, 2019). Completion of a bowel diary to ascertain the duration of symptoms, pattern of leakage, type of leakage, frequency and consistency will assist in diagnosis.
An examination (vaginal, rectal, abdominal and/or neurological) by a competent professional
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Treatment
Faecal incontinence is a symptom, so it is important to diagnose the specific problem prior to initiating treatment (NICE, 2007; RCN, 2019). First-line treatments should always be conservative and will depend on an individual's symptoms. These may include supportive measures such as:
- improving wellbeing and nutritional status
- avoiding foods which can trigger faecal incontinence
- advice on hygiene maintenance
- implementation of defecation programmes (Shah et al, 2020)
Medications, such as loperamide, could be initiated, and pelvic floor rehabilitation and biofeedback are also valuable methods of treatment. If conservative treatments fail, then progression to surgery may be the only option.
Other treatment options can include:
Transanal irrigation
Patients can use transanal irrigation (TAI) as an effective long-term treatment option for faecal incontinence. There are different types of TAI that include high-volume irrigation, which can clear the transverse and descending colon, or low-volume irrigation, which clears the rectum only (Henderson
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Management
When it is not possible to treat faecal incontinence, it must be managed well. The aims of management are to provide respectful care that maintains the person's dignity and wellbeing, and to prevent complications of faecal incontinence, such as incontinence-associated dermatitis and the development of wounds.
Incontinence pads are often used to protect clothing and bedding from soiling. However, care must be taken to ensure that they do not leak and that they are changed regularly (Hurnauth, 2011; Woodward, 2012; Fader et al, 2018). It is important to ensure that incontinence pads are changed immediately after an episode of faecal incontinence to maintain skin health. If the person requires assistance, then community nurses may need to work with social services to ensure appropriate care and support is provided. Moisture-barrier creams are available to prevent irritated skin from having direct contact with faeces (Table 1).
| Table 1. Barrier creams and |
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
3.4 take appropriate action to ensure privacy and dignity at all times
6.4 assess bladder and bowel patterns to identify and respond to constipation, diarrhoea and urinary and faecal retention
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Resources
Assmann SL, Keszthelyi D, KleijnenJ et al. Guideline for the diagnosis and treatment of Faecal Incontinence – A UEG/ESCP/ESNM/ESPCG collaboration.United European Gastroenterol J. 2022;10(3):251–86. https://doi.org/10.1002/ueg2.12213
Benezech A, Bouvier M, Vitton V. Faecal incontinence: Current knowledge and perspectives. World J Gastrointest Pathophysiol. 2016;7(1):59-71. https://dx.doi.org/10.4291/wjgp.v7.i1.59
Emmanuel A, Collins B, Henderson M et al. Development of a decision guide for transanal irrigation in bowel disorders. Gastrointestinal Nursing. 2019;17(7):24–30
Fader M, Cottenden AM, Getliffe K. Absorbent products for moderate heavy urinary and/or faecal incontinence in women and men. Cochrane Database of Syst Rev. 2018;18(4):CD007408. https://doi.org/10.1002/14651858.CD007408
Henderson M, Tinkler L, Yiannakou Y. Transanal irrigation as a treatment for bowel dysfunction. Gastrointestinal Nursing. 2018;6(4)26–34
Herbert J. Use of anal plugs in faecal incontinence management. Nurs
Times. 2008;104(13):66–68
Hurnauth C. Management of faecal incontinence in acutely ill patients. Nurs Stand. 2011;25(22):48–56. https://doi.org/10.7748/ns2011.02.25.22.48.c8318
International Continence Society. ICS fact sheet: a background to urinary and faecal incontinence. 2015. https://www.ics.org/folder/news-and-publications/ics-factsheets/d/ics-fact-sheets-2015
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