VOL: 103, ISSUE: 28, PAGE NO: 23
NICE has published guidance on managing faecal incontinence in adults (NICE, 2007). The guidance highlights the gro…
NICE has published guidance on managing faecal incontinence in adults (NICE, 2007). The guidance highlights the groups most at risk and the approaches that should be used for managing this distressing condition.
Faecal incontinence is a sign or a symptom, not a diagnosis, so it is important to diagnose the cause or causes for each person affected. Depending on the definition used, 1-10% of adults experience it at some point, and up to 1% have regular episodes. Degeneration of the delicate muscle of the internal anal sphincter is the most common factor implicated in anal leakage (Vaizey et al, 1997).
For most people faecal incontinence is the result of a complex interplay of contributing factors, some of which are relatively simple to reverse. Specialised options and investigations are available if this fails to restore continence.
Patients in whom faecal incontinence is suspected should be assessed to identify contributing factors (NICE, 2007). This should comprise a medical history, a general examination, an anorectal examination and a cognitive assessment if appropriate.
Many people are embarrassed or ashamed to admit they have the problem, so nurses need to actively yet sensitively enquire about symptoms in high-risk groups (see box, p24).
There are many conditions associated with faecal incontinence that need to be excluded before treatment as incontinence is likely to improve with condition-specific treatment. These include: faecal loading; potentially treatable causes of diarrhoea, including inflammatory bowel disease and irritable bowel syndrome; warning signs for lower gastrointestinal cancer; rectal prolapse or third-degree haemorrhoids; acute injury to the anal sphincter by obstetric or other trauma; and acute disc prolapse or cauda equina syndrome.
In the absence of one of these conditions, a combination of interventions is usually required and these should be selected based on the assessment findings and according to the patient’s preference.
The aim of management is to attain ideal stool consistency and satisfactory bowel emptying at a predictable time, and dietary changes are likely to aid this. It is important that in recommending changes, existing therapeutic diets are taken into account and that the overall nutritional intake is balanced and that there is no malnutrition (NICE, 2006). When looking for foods that prompt faecal incontinence, changing one food item at a time is recommended.
Faecal incontinence can be associated with fibre supplements and wholegrain cereals, including bread, porridge and oats. Artificial sweeteners, alcohol and spicy food, particularly chilli, may also increase bowel movements, as can excessive caffeine intake and excessive doses of vitamin C, magnesium, phosphorus and/or calcium supplements.
Reducing consumption of fruit and vegetables might also be helpful. Rhubarb, figs, prunes and plums are best avoided as they contain natural laxative compounds, and limiting consumption of beans, pulses, cabbage and sprouts can help. Milk may cause diarrhoea in patients with any degree of lactase deficiency.
Encouraging patients to keep a food and fluid diary will help monitor intake of food and fluids and identify any problem foods.
Patients with faecal incontinence should be encouraged to empty their bowels after a meal to utilise the gastrocolic response. A sitting or squatting position is recommended when defecating. Techniques for facilitating bowel evacuation can be taught.
Toilet facilities may need to be accessed quickly so patients should be advised to wear easy-to-remove clothes. Where a patient needs help to access the toilet, this help needs to be readily available. There is also equipment available to help people reach the toilet and, where appropriate, patients should be referred for assessment of their home and/or mobility.
Nurses should help patients with journey planning so that they are aware of public conveniences available en route and the use of toilet access cards and keys. Cards to help gain access to toilets not usually available to the public can be obtained from the National Association for Colitis and Crohn’s disease (NACC) or the Continence Foundation, and keys allowing access to ‘disabled’ toilets in the National Key Scheme are available from disability network RADAR.
Continence products, including disposable bed and body pads, should be offered to patients who require them, and no limitation should be put on the amount supplied. Body-worn pads exist in a choice of styles and designs, and anal plugs are also available. Patients will also need advice about skincare cleansing and barrier products, odour control and laundry needs, and a supply of disposable gloves.
A variety of drugs can contribute to faecal incontinence and it is recommended that the use of these is reviewed so that they are replaced by alternatives if possible.
Patients with loose stools should be offered antidiarrhoeal medication for faecal incontinence after excessive laxative use, dietary factors and other medication have been excluded. Loperamide hydrochloride 0.5mg to 16mg per day is the drug of first choice and can be used long term. It should be started at a very low dose and the dose increased until the desired stool consistency has been achieved. Patients should then adjust the dose and/or frequency up or down in response to stool consistency.
Loperamide hydrochloride syrup should be considered for doses under 2mg per day, and codeine phosphate or co-phenotrope for patients unable to tolerate loperamide hydrochloride.
People who continue to have episodes of faecal incontinence may need to be considered for referral to a specialist service for specialised conservative management. This may include pelvic floor muscle training, bowel retraining, specialist dietary assessment and management, biofeedback, electrical stimulation and rectal irrigation.
Some treatments, such as pelvic floor re-education programmes, might not be appropriate for people who are unable to understand and/or comply with instructions, such as those with neurological disease.
Patients whose incontinence persists may be considered for specialist assessment, including anorectal physiology studies, endoanal ultrasound and proctography.
Surgical options exist for patients who still experience faecal incontinence affecting their quality of life despite medical management. The first option is sphincter repair for patients with a full-length external anal sphincter defect that is 90 degs or greater. An alternative for patients for whom this procedure is inappropriate is neosphincter, of which there are two options - a stimulated graciloplasty or an artificial anal sphincter. Antegrade irrigation via appendicostomy, neo-appendicostomy or continent colonic conduit may be used in selected people with constipation and colonic motility disorders associated with faecal incontinence.
A stoma should be considered only for those with faecal incontinence that severely restricts their lifestyle, once all non-surgical and surgical options have been ruled out.
The patient’s perception is the most important basis for assessing the success of management. Patients should be involved in decisions about their care as treatment should take account of their preferences.
Where possible carers and relatives should also be involved in decisions about the patient’s care and treatment but only if the patient agrees, as in some cultures disclosure of faecal incontinence could lead to the person being ostracised.
People with faecal incontinence can have their quality of life vastly improved once they have been identified, and taking a sensitive approach to this delicate subject will encourage more patients to admit to the problem.
HIGH-RISK GROUPS FOR FAECAL INCONTINENCE
- Frail older people
- People with loose stools or diarrhoea from any cause
- Women following childbirth (especially following third and fourth- degree obstetric injury)
- People with neurological or spinal disease/injury (for example, spina bifida, stroke, multiple sclerosis, spinal cord injury)
- People with severe cognitive impairment
- People with urinary incontinence
- People with pelvic organ prolapse and/or rectal prolapse
- People who have had colonic resection or anal surgery
- People who have undergone pelvic radiotherapy
- People with perianal soreness, itching or pain;
- People with learning disabilities