NICE guidance on faecal incontinence in adults

The recent guideline from NICE covers initial, specialised and long-term management of faecal incontinence, as well as management of specific groups and specialist referral.

Current data suggest that up to 10 per cent of adults are affected with faecal incontinence. However, the majority of patients’ condition can be improved, and in many instances symptoms can be resolved, by identifying the interaction of causative factors.


KEY RECOMMENDATIONS FOR PRIMARY CARE:

Good practice

  • Be aware that faecal incontinence is a symptom, often with multiple contributory factors; avoid simplistic assumptions that causation is related to a single primary diagnosis.
  • Be aware of both the physical and the emotional impact this condition can have on patients and carers.

Baseline assessment and initial management

  • Actively, yet sensitively, enquire about symptoms of faecal incontinence in high-risk groups (see below).

High-risk groups 
 - Frail older people. 
 - Patients with loose stools or diarrhoea from any cause. 
 - Women following childbirth (especially following third- and fourth- degree obstetric injury). 
 - Patients with neurological or spinal disease/injury (e.g. spina bifida, stroke, multiple sclerosis, spinal cord injury). 
 - Patients with severe cognitive impairment or learning difficulties. 
 - Patients with urinary incontinence; pelvic organ prolapse and/or rectal prolapse; perianal soreness, itching or  - pain. 
 - Patients who have had colonic resection, anal surgery or pelvic radiotherapy.

  • Perform a baseline assessment comprising: relevant medical history, general and anorectal examination, and cognitive assessment, if appropriate.
  • Assess and treat the following before progressing:
     - faecal loading.
     - potentially treatable causes of diarrhoea, eg, infective, inflammatory bowel disease and irritable bowel syndrome.
     - warning signs for lower gastrointestinal cancer, rectal prolapse or third-degree haemorrhoids.
     - acute anal sphincter injury.
     - acute disc prolapse/cauda equina syndrome.
  • Once the above conditions have been excluded or treated, address the patient's bowel habit, aiming for ideal stool consistency and satisfactory bowel emptying at a predictable time.
     

Lifestyle and dietary intervention

  • Assess diet; ensure overall nutrient intake is balanced; encourage patients with hard stools to aim for at least 1.5 litres intake of fluid per day; advise patients to modify one food at a time.
  • Encourage bowel emptying after a meal, and encourage patients to adopt a sitting or squatting position while emptying the bowel and to avoid straining. Equipment to help patients gain access to a toilet should also be provided if needed. 
  • Advise on coping strategies including the use of continence products – pads, plugs and skin care – and where to get emotional and psychological support.
     

Medication

  • Review medication and consider alternatives to drugs that might be a contributing factor.
  • Offer antidiarrhoeal drugs once other causes, e.g. excessive laxative use, dietary factors and other medication – have been excluded.
  • Loperamide is the antidiarrhoeal of first choice:
     - Start at a very low dose and increase until the desired stool consistency has been achieved.
     - Doses should be taken as and when required by the individual and adjusted in response to symptoms and lifestyle.
     - For long-term use, doses from 0.5—16mg daily can be used as required. For doses under 2mg, loperamide syrup should be considered.
  • Patients who are unable to tolerate loperamide should be offered codeine phosphate or co-phenotrope.
  • Loperamide should not be offered to patients with hard or infrequent stools, acute diarrhoea without a diagnosed cause or an acute flare-up of ulcerative colitis.


Specific groups
Special management will be needed for patients:

  • with faecal loading or constipation.
  • with limited mobility.
  • who are hospitalised and who develop faecal loading and associated incontinence.
  • with neurological or spinal disease/injury.
  • with learning disabilities.
  • who are severely or terminally ill.
  • who have acquired brain injury.
     

Specialist referral
Patients who continue to have episodes of faecal incontinence after initial management should be considered for specialised management. This may include pelvic floor muscle training, bowel retraining, specialist dietary assessment and management, biofeedback, electrical stimulation or rectal irrigation.

The full guideline is available at http://guidance.nice.org.uk/CG49.

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