Mary Wilson, PhD, MA, BSc, RGN, is nurse specialist in bladder and bowel health, Specialist Services for Bladder and Bowel Health, Westwood Hospital, East Yorkshire.
abstract Wilson, M. (2007) Guidelines for managing faecal incontinence. Nursing Times; 103: 42, 42–43.
In June 2007, NICE published the clinical guideline relating to the management of faecal incontinence (FI) in adults (NICE, 2007), providing guidance and recommendations for healthcare professionals (HCPs) who care for people with FI.
From the first paragraph of the introduction, the guideline identifies FI – a symptom of many diverse health problems – as a stigmatised condition. The guideline emphasises the need for HCPs to be aware not only of the physical consequences of FI but also of the emotional impact. Because many patients are reluctant to seek help, it stresses the need for HCPs to actively identify people who may experience FI. However, even after receiving treatment, many people may conceal some aspects of their symptoms from significant others (Chelvanayagam and Norton, 2000). The guideline highlights the importance of gaining agreement from those with FI before sharing sensitive information with those involved in their care.
Baseline assessment and initial management
NICE recommends a baseline assessment and initial management for all who present with, or are reported to have, FI. Although this is termed ‘baseline’ and ‘initial’, it is certainly not a cursory check-up. It comprises an assessment of the patient’s past medical history, a general and an anorectal examination and – if necessary – a cognitive assessment. Initially, the guideline advises that problems such as faecal loading and treatable diarrhoea should be dealt with, which alone may be sufficient to restore faecal continence. Other significant issues, including the warning signs of lower gastrointestinal cancer, rectal prolapse or third-degree haemorrhoids should also be addressed at this point.
Once these condition-specific causes have been eliminated, the baseline assessment can take place. NICE supplies a table of questions which constitute a comprehensive assessment.
It is recommended that in this initial treatment phase, HCPs investigate the individual’s bowel habit, aiming for an ideal stool consistency and a satisfactory bowel evacuation at a predictable time. Further tables are provided listing food, drink and drugs that may affect stool consistency, exacerbating FI. However, it is necessary – if the NICE guideline (rather than the full guideline with appendices) is used – to access the tables online.
Owing to feelings of embarrassment and shame, many people do not ask for help with FI, associating the condition with childhood or ageing (Khullar et al, 1998), or feel that they alone have the problem (Johanson and Laffery, 1996).
Initial management also includes practical lifestyle advice, including RADAR key access to locked toilets for people with disabilities and toilet ‘urgent’ cards. In addition, it relates to helping patients adopt a positive attitude and foster acceptance, which can lead to mastering the condition when cure may not be an option, or while it is being achieved (Wilson and McColl, 2007). This may include helping the individual interact with others – people many become reclusive as a result of FI and sometimes require referral for counselling or psychological help.
The guideline stipulates that those being treated for FI should be offered a choice of styles – and sufficient quantities – of body-worn pads and, where needed, disposable bedpads and gloves. In parts of the country where body-worn pads are prescribed in limited numbers and bedpads are not routinely provided, this guidance will necessitate reconsideration of local policies. Such discussion will encourage a proactive approach to continence promotion and encourage the use of alternative products, such as anal plugs which, while not universally
suitable, provide an alternative for those who can tolerate them.
Out of concern that ‘diagnosis overshadowing’ may take place (that is, simplistic assumptions made that FI is related to the primary diagnosis), the guideline stresses the need for a proactive approach, particularly if FI is experienced by an individual belonging to one of eight specified ‘special groups’ (Box 1).
Specialist management: integrated continence services
If initial management does not rectify FI, the guideline recommends that, providing the individual provides consent, referral should then be made for management by specialist integrated continence services. Specialist intervention may be in the form of pelvic floor training, specialist dietary management, biofeedback, electrical stimulation or rectal irrigation. Ideally, this would represent input from multidisciplinary continence teams combining, for example, nursing and physiotherapy input.
Access to such integrated services was described in the Department of Health publication Good Practice in Continence Services (DH, 2000). This document described how initial continence assessment and treatment should be the role of the primary care community team, where members of the team ‘who provide continence services as part of their main job’ would receive a basic level of continence training. Integrated continence services then accepted complex referrals from the primary care team. Likewise, the NICE FI guideline recommends that initial baseline assessment and treatment is carried out before referral to specialist services.
If faecal continence is not achieved by intervention involving specialised conservative management, the guideline recommends that specialist assessment – including anorectal physiology studies – is accessed. This would usually require hospital referral: tests would be carried out to assess the functioning of the bowel, and ultrasound used to identify, for example, the extent of anal sphincter damage, and could lead to surgical intervention.
The guideline recommends that the specialist surgeon should discuss possible options, both surgical and non-surgical, including potential benefits and limitations, long-term results and realistic expectations. The effectiveness of these interactions is of paramount importance. Recent research identified people who had misinterpreted or not taken in what they were told prior to their surgery, and were not adequately prepared for possible adverse consequences (Wilson and McColl, 2007). Nurses can help patients understand what the surgeon has told them, make them aware of possible untoward negative outcomes and, in addition, assume the role of advocate.
If patients do not wish to continue active treatment, long-term management is proposed. However, this does not indicate a discontinuation of care, but represents a change in focus, and is aimed at improving the quality of life with FI. It includes:
Six-monthly (or more frequent) review of symptoms;
The provision of continence products;
Advice regarding skincare and independence;
Help over interaction with friends and family;
Information regarding support groups;
Where necessary, the provision of specialised emotional/psychological support.
In the past patients with FI often received continence products without undergoing a thorough initial assessment and the necessary baseline treatment. Hopefully, with the introduction of continence care pathways and the decades of hard work by those intent in disseminating good practice in continence care, this is becoming less frequent. Nevertheless, current budget-driven reductions in staff numbers may cause continence promotion still to be placed on the back burner. This guideline recommends universal assessment and treatment of FI; perhaps, in years to come, proactive promotion of faecal continence will become the norm. n
Box 1: Special groups
Healthcare professionals should take a proactive approach to bowel management for specific groups of people:
People with faecal loading or constipation.
Patients with limited mobility.
Hospitalised patients who are acutely unwell and who develop acute faecal loading and associated incontinence.
People with cognitive or behavioural issues.
People with neurological or spinal disease/injury resulting in faecal incontinence.
People with learning disabilities.
Severely or terminally ill people.
People with acquired brain injury.
Chelvanayagam, S., Norton, C. (2000) Quality of life with faecal continence problems. Nursing Times Plus; 96: 31, 15–17.
Department of Health (2000) Good Practice in Continence Services. London: DH.
Johanson, J.F., Laffery, J. (1996) Epidemiology of faecal incontinence: the silent affliction. American Journal of Gastroenterology; 91: 1, 33–36.
Khullar, V. et al (1998) Prevalence of faecal incontinence among women with urinary incontinence. British Journal of Obstetrics and Gynaecology; 105: 11, 1211–1213.
NICE (2007) Faecal Incontinence: the Management of Faecal Incontinence in Adults. NICE Clinical Guideline 49. London: NICE.
Wilson, M., McColl, E. (2007) The experience of living with faecal incontinence. Nursing Times; 103: 14, 46–49.
Department of Health (1994) Hospital Discharge Workbook. London: DH.
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Pomfret, I. (2000) Catheter care in the community. Nursing Standard; 14: 27, 46–51.
Tierney, A. et al (1999) Information Needs Pre and Post-discharge: A Qualitative Study of the Perceptions and Experie