An expert nurse advises on safe, effective care and when to contact a specialist nurse
The majority of patients with bowel dysfunction will have poor control of their bowels (faecal incontinence) or difficulty opening their bowels (constipation). Both require assessment and treatment.
While faecal incontinence in adults affects approximately 2% of the population (Perry et al, 2002), constipation is estimated to affect one third of people in westernised countries (Klaschik et al, 2003). Both conditions occur more frequently in women and can impair quality of life.
Bowel dysfunction is common in hospitals and the community for many reasons, including privacy and dignity issues, diet, poor fluid intake, medication, poor access to toilets, limited mobility and many others. With both conditions, the cause must be established before treatment is started.
Bowel dysfunction is a sign or symptom, not a diagnosis. It is important to avoid “diagnostic overshadowing”, for example when a patient with diarrhoea has impaction or a patient presumed to have bleeding haemorrhoids has bowel cancer.
Start with simple treatments such as dietary and fluid changes, correct toilet positioning, regular toilet use (often overlooked), skin care, medications to modify stool consistency and correct use of containment products. The incorrect use of such products can worsen a problem.
Most patients improve with conservative treatments, such as lifestyle and dietary changes, use of medications, biofeedback and behavioural interventions, but some go on to have surgery such as sacral nerve stimulation.
Wendy Ness is a colorectal nurse specialist at Croydon University Hospital
5 key points
1. Detailed assessment is crucial to establish the cause of the problem so that correct treatment is given
2. Treatment should have a structured approach; simple treatments first and steps should be taken to avoid diagnostic overshadowing
3. Medication could be the cause of constipation or faecal incontinence, and should be reviewed
4. Dietary and fluid changes can be used to modify the stool consistency which should ideally be between 3-4 on the Bristol stool form chart
5. Ensure that patients have access to private toilet facilities, best time for use ½ hour after meals especially after breakfast. Ensure correct toilet positioning
When to contact the nurse specialist
- If a cause of bowel dysfunction cannot be established
- If simple treatments have been tried but the patient’s symptoms of bowel dysfunction have not improved or been resolved
- If a patient needs more specialist management of their problems such as bowel retraining, pelvic floor muscle training, a course of biofeedback, electrical stimulation or rectal irrigation
- If further advice, support and education are required around bowel dysfunction, causes and treatments. These include digital rectal examination (see page 18) – which is not against the law as is commonly thought – and digital removal of faeces
Guidance and resources
- National Institute for Health and Clinical Excellence (2007) Faecal Incontinence: the Management of Faecal Incontinence in Adults. London: NICE. www.nice.org.uk/CG49
- National Occupational Standard (2008) Continence Care Suite. tinyurl.com/nos-contin-care
- Association for Continence Advice: www.aca.uk.com
- Bladder and Bowel Foundation: www.bladderandbowelfoundation.org
Klaschik E et al (2003) Constipation – modern laxative therapy. Support Care Cancer; 11: 679-685.
Perry S et al (2002) Prevalence of faecal incontinence in adults over 40 or more living in the community. GUT; 50: 480-484