Approximately 2% of the adult population get daily or weekly episodes. Studies of healthy independent adults aged over 65 years have detected a prevalence of 7% and one third of elderly in retirement homes or hospital have been found to be suffering from faecal incontinence.
By virtue of the nature of the condition, faecal incontinence remains largely a hidden problem - active but sensitive case finding may be required, particularly in high-risk groups:
- Add notes to any clinical page and create a reflective diary
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- Any patients with diarrhoea
- Patients with anal problems:
- women with third- and fourth-degree obstetric injury
- Patients with rectal or pelvic organ prolapse
- Patients with pelvic radiotherapy or colonic resection
- Patients with perianal itching, soreness or pain or anal surgery
- Patients with urinary incontinence
- Frail elderly patients
- Patients with neurological problems or spinal disease (eg CVE, MS, spina bifida or spinal injury)
- Patients with severe cognitive impairment or learning difficulties
When asking questions, always be aware of the physical and emotional impact that faecal incontinence can have on patients and carers.
Be aware that faecal incontinence is a symptom or sign rather than a disease and that there are often multiple contributory factors. One study found that nearly 40% of men with faecal incontinence report it in the absence of a definable functional or structural sphincter abnormality. Professionals should not concentrate on one specific diagnosis to the total exclusion of all other factors.
A baseline assessment should include relevant medical history, a general examination, an anorectal examination and an assessment of cognitive function if appropriate.
Recognised associations with faecal incontinence include:
Incontinence is common after the use of forceps, a large baby, occipitoposterior position and a long second stage of labour. 13% of women develop incontinence after their first vaginal delivery and 30% have structural damage as evidenced by anal endosonography. Of 0.5 to 1% of women with a recognised third-degree tear, 85% have residual structural sphincter damage and over half of this group have symptoms despite primary repair at the time of delivery. One study, however, of primiparous women during pregnancy and in the postpartum period found a low prevalence of faecal incontinence and, when it did occur, the condition was sporadic.
This is the most common cause after obstetric trauma. Incontinence may be inevitable after complex anal fistula surgery, or may occur as an unexpected complication after haemorrhoidectomy or surgery for chronic anal fissure. The incidence is reducing with advances in surgical techniques.
Degeneration of the internal anal sphincter
After structural damage, this is the most common cause of sphincter dysfunction. Most cases are due to primary isolated degeneration of the smooth muscle of the internal anal sphincter. The condition is most common in middle age and affects both men and women. Endosonography is a useful investigation to identify surgically correctable sphincter defects. It often shows that the anal sphincter is fibrotic and thin and resting anal pressure is low. Degeneration is occasionally seen secondary to progressive systemic sclerosis, radiotherapy for cervical or other pelvic neoplasms, or chronic idiopathic intestinal pseudo-obstruction.
Faecal incontinence is a feature of many neurological diseases and may be aggravated by non-neurological factors such as the side-effects of drugs or childbirth. One study reported that 50% of MS patients had faecal incontinence, with a weekly occurrence in 25%.  It can also be a feature of diabetic autonomic neuropathy.
90% of spina bifida patients report faecal incontinence, with 50% soiling regularly. It can also occur as a consequence of surgery for congenital disorders. 50-80% of patients treated for anal atresia reported some incontinence and one study of 60 patients with Hirschprung's disease identified that 53% subsequently had severe soiling. More recent studies suggested that persistence of incontinence after surgery in patients with Hirschprung's disease may be related to poor technique.
Children with a normal sphincter can pass stools inappropriately as part of a behavioural disorder (encopresis), or can suffer from faecal impaction with overflow. In some children the condition is due to a poorly defined neuromuscular disorder of the distal gut which can persist into adulthood. Other conditions that can be associated with faecal incontinence include rectal prolapse, inflammatory bowel disease (IBD) and unwanted anal penetration.
Management should be tailored to the needs of the individual. Information should be provided in a format which they can understand, so that they can participate in decisions about their care. Family and carers should be involved in this process, unless the individual deems this inappropriate.
The following potentially reversible conditions should be excluded and, if present, treated with condition-specific interventions before other initial management is instituted:
- Faecal loading
- Potentially treatable causes of diarrhoea (for example, infective, IBD and irritable bowel syndrome (IBS))
- Warning signs for lower GI cancer
- Rectal prolapse or third-degree haemorrhoids
- Acute anal sphincter injury including obstetric and other trauma
- Acute disc prolapse/cauda equina syndrome (CES)
Basic initial interventions
Interventions should promote ideal stool consistency and predictable bowel emptying.
- Existing therapeutic diets should be taken into account.
- Overall nutrient intake should be balanced.
- A food and fluid diary might be helpful.
- Advise patients to modify one food at a time.
- Patients with hard stools and/or dehydration should be encouraged to aim for at least 1.5 litres' intake of fluid per day (unless contra-indicated).
- Consider screening for malnutrition, or risk of malnutrition.
- Bowel and toileting habits
- Bowel emptying should be encouraged after a meal.
- Toilet facilities should be private, comfortable and used safely with sufficient time allowed.
- The patient should adopt a sitting or squatting position to avoid straining.
- Locations of toilets should be made clear and any equipment or help needed to access the toilet provided.
- Advice should be offered on easily removable clothing.
- Refer for home and mobility assessment if appropriate.
- Consider alternatives to drugs contributing to faecal incontinence.
- Anti-diarrhoeal drugs should be prescribed, in accordance with the summary of product characteristics, for people with loose stools and associated incontinence once other causes have been excluded.
- Loperamide hydrochloride should be first drug of choice. Consider loperamide hydrochloride syrup for doses less than 2 mg.
- Codeine phosphate or co-phenotrope may be tried for those unable to tolerate loperamide hydrochloride.
- Loperamide hydrochloride should not be offered to people with hard or infrequent stools, acute diarrhoea without a diagnosed cause, or an acute flare-up of ulcerative colitis.
- Loperamide hydrochloride should be introduced at a very low dose and increased as tolerated until desired stool consistency is reached. Subsequent doses can be adjusted according to stool consistency and lifestyle.
- Coping strategies People with faecal incontinence should be offered advice on:
- Continence products.
- Emotional and psychological support.
- Talking to friends and family.
- Planning travel and carrying a toilet access card or RADAR key.
- Disposable body-worn pads and disposable bed pads.
- Anal plugs.
- Skin-care, odour control and laundry advice.
- Disposable gloves.
- Reusable absorbent products - these are not generally recommended.
- People with faecal loading
- Offer a rectally administered treatment to clear the bowel satisfactorily, or a potent oral laxative if this is not appropriate. Often treatment will need to be repeated daily for a few days.
- Recommend a combination of initial management options to reduce recurrence (see Specialist management below).
- Consider the use of orally administered laxatives if rectal treatments fail.
- People with limited mobility
- Consider a combination of oral or rectal laxatives and/or constipating agents.
- Review toilet access,
- Advise concerning appropriate disposable products (see Coping strategies above).
- Advise re timing of toileting - ie stool needs to be in the rectum at the time of the planned bowel action.
- People using enteral tube feeding and reporting faecal incontinence
- Modify the type and timing of feed on an individual basis to establish the most effective way to manage faecal incontinence.
- People with severe cognitive impairment
- Refer for a behavioural and functional analysis to determine if there is any behavioural reason for faecal incontinence.
- If behavioural aspects are identified that contribute to faecal incontinence, offer cause-specific interventions founded on structured goal planning that aim to resolve them.
- In cases of severe cognitive impairment, further specialist management of faecal incontinence may be inappropriate.
- People with neurological or spinal disease/injury
- Offer, until satisfactory bowel habit is established, a bowel management programme which:
- Ascertains the person's preferences and premorbid bowel habit.
- Maximises the person's understanding of normal bowel function and how it has been altered.
- Modifies diet and/or administers rectal evacuants and/or oral laxatives, adjusted to individual response, to establish a predictable pattern of bowel evacuation.
- Considers digital anorectal stimulation for people with spinal cord injuries or other neurogenic bowel disorders.
- Considers manual/digital removal of faeces, particularly for people with a lower spinal injury.
- For those unable to achieve reliable bowel continence after a neurological bowel management programme offer:
- Coping and long-term management strategies (see 'Coping strategies' above and 'Long-term strategies' below).
- Rectal irrigation.
- Electrical stimulation of the sacral roots has been used with some success in patients with partial CES.
- Other surgical options (including stoma) if faecal incontinence or the time taken for bowel emptying imposes major limits on their lifestyle.
- Offer, until satisfactory bowel habit is established, a bowel management programme which:
- People with learning disabilities
- It is essential that these people follow the same initial care pathway as other people with faecal incontinence, regardless of when their faecal incontinence started.
- Severely or terminally ill people
- Consider a faecal collection device.
This should be considered for people who continue to have episodes of faecal incontinence despite initial management. Such management may include:
- Pelvic floor muscle training.
- Bowel retraining.
- Specialist dietary assessment and management.
- Electrical stimulation.
- Rectal irrigation.
- The use of anal bulking agent injections, currently being explored as an alternative to surgery.
- Surgery - the benefits and limitations should be discussed, as follows:
- Sphincter repair should be considered for people with a full-length external anal sphincter defect that is 90° or greater and faecal incontinence that restricts quality of life. The effectiveness of procedure decreased in people with internal sphincter defects, pudendal nerve neuropathy, multiple defects, external sphincter atrophy, loose stools or IBS.
- One ten-year follow up study found a gradual deterioration in continence, especially people who were older at the time of surgery or who had more than two births.
- People undergoing anal sphincter repair should not:
- Routinely receive a temporary defunctioning stoma.
- Receive constipating agents in the postoperative period.
- Consider a trial of temporary sacral nerve stimulation if sphincter surgery is inappropriate and proceed to implantation if successful.
- Consider a neosphincter (stimulated graciloplasty or an artificial anal sphincter) if a trial of sacral nerve stimulation is unsuccessful. Advise patients that they may experience evacuatory disorders and/or serious infection, which may necessitate removal of the device.
- Antegrade irrigation via appendicostomy, neo-appendicostomy or continent colonic conduit should be offered to selected people with constipation and colonic motility disorders associated with faecal incontinence.
- A stoma for people with faecal incontinence that severely restricts lifestyle should only be considered once all appropriate non-surgical and surgical options, including those at specialist centres, have been considered. Refer to a stoma care service.
Symptomatic people, who do not want to persevere with active treatment or who have intractable faecal incontinence, should be offered:
- Advice on preservation of dignity and, where possible, independence.
- At least six-monthly review of symptoms.
- Discussion of other management options (including specialist referral).
- Contact details for relevant support groups.
- Advice on coping strategies and skin care.
Further reading & references
- Kamm MA; Faecal incontinence. BMJ. 1998 Feb 14;316(7130):528-32.
- Faecal incontinence, NICE Clinical Guideline (2007)
- Maeda Y, Vaizey CJ, Hollington P, et al; Physiological, psychological and behavioural characteristics of men and women with faecal incontinence. Colorectal Dis. 2009 Nov;11(9):927-32. Epub 2008 Oct 21.
- Sultan AH, Kamm MA, Hudson CN, et al; Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993 Dec 23;329(26):1905-11.
- Kamm MA; Obstetric damage and faecal incontinence. Lancet. 1994 Sep 10;344(8924):730-3.
- Brincat C, Lewicky-Gaupp C, Patel D, et al; Fecal incontinence in pregnancy and post partum. Int J Gynaecol Obstet. 2009 Sep;106(3):236-8. Epub 2009 May 29.
- Khubchandani IT, Reed JF; Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg. 1989 May;76(5):431-4.
- Tocchi A, Mazzoni G, Miccini M, et al; Total lateral sphincterotomy for anal fissure. Int J Colorectal Dis. 2004 May;19(3):245-9. Epub 2003 Sep 9.
- Mousavi SR, Sharifi M, Mehdikhah Z; A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg. 2009 Jul;13(7):1279-82. Epub 2009 May 5.
- Vaizey CJ, Kamm MA, Bartram CI; Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence. Lancet. 1997 Mar 1;349(9052):612-5.
- Pinsk I, Brown J, Phang PT; Assessment of sonographic quality of anal sphincter muscles in patients with faecal incontinence. Colorectal Dis. 2009 Nov;11(9):933-40. Epub 2008 Oct 31.
- Hinds JP, Eidelman BH, Wald A; Prevalence of bowel dysfunction in multiple sclerosis. A population survey. Gastroenterology. 1990 Jun;98(6):1538-42.
- Vinik AI, Maser RE, Mitchell BD, et al; Diabetic autonomic neuropathy. Diabetes Care. 2003 May;26(5):1553-79.
- Malone PS, Wheeler RA, Williams JE; Continence in patients with spina bifida: long term results. Arch Dis Child. 1994 Feb;70(2):107-10.
- Hassink EA, Rieu PN, Severijnen RS, et al; Adults born with high anorectal atresia--how do they manage? Dis Colon Rectum. 1996 Jun;39(6):695-9.
- Catto-Smith AG, Coffey CM, Nolan TM, et al; Fecal incontinence after the surgical treatment of Hirschsprung disease. J Pediatr. 1995 Dec;127(6):954-7.
- Levitt MA, Martin CA, Olesevich M, et al; Hirschsprung disease and fecal incontinence: diagnostic and management strategies. J Pediatr Surg. 2009 Jan;44(1):271-7; discussion 277.
- Reid H, Bahar RJ; Treatment of encopresis and chronic constipation in young children: clinical results from interactive parent-child guidance. Clin Pediatr (Phila). 2006 Mar;45(2):157-64.
- Loening-Baucke VA; Factors responsible for persistence of childhood constipation. J Pediatr Gastroenterol Nutr. 1987 Nov-Dec;6(6):915-22.
- Di Giorgio A, Biacchi D, Sibio S, et al; Abdominal rectopexy for complete rectal prolapse: preliminary results of a new technique. Int J Colorectal Dis. 2005 Mar;20(2):180-9. Epub 2004 Nov 20.
- Engel AF, Kamm MA, Bartram CI; Unwanted anal penetration as a physical cause of faecal incontinence. Eur J Gastroenterol Hepatol. 1995 Jan;7(1):65-7.
- Referral for Suspected Cancer CG27; NICE Guidance
- Vande Velde S, Van Biervliet S, Van Renterghem K, et al; Achieving fecal continence in patients with spina bifida: a descriptive cohort study. J Urol. 2007 Dec;178(6):2640-4; discussion 2644. Epub 2007 Oct 22.
- Gstaltner K, Rosen H, Hufgard J, et al; Sacral nerve stimulation as an option for the treatment of faecal incontinence in patients suffering from cauda equina syndrome. Spinal Cord. 2008 Sep;46(9):644-7. Epub 2008 Mar 4.
- Altomare DF, Rinaldi M, Cuccia F, et al; Fecal incontinence: up to date on pathophysiology and treatment. Minerva Gastroenterol Dietol. 2009 Sep;55(3):379-84.
- Zutshi M, Tracey TH, Bast J, et al; Ten-year outcome after anal sphincter repair for fecal incontinence. Dis Colon Rectum. 2009 Jun;52(6):1089-94.
- Stimulated graciloplasty for faecal incontinence, NICE (2006)
- Sacral nerve stimulation for faecal incontinence, NICE Interventional Procedure Guideline (2004)
- Artificial anal sphincter implantation, NICE Interventional Procedure Guideline (2004)
|Original Author: Dr Laurence Knott||Current Version: Dr Laurence Knott|
|Last Checked: 21/05/2010||Document ID: 2131 Version: 22||© EMIS|
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