Faecal incontinence (FI) affects around 1 per cent of the general population; rising to 25-35 per cent of institutionalised patients.
It can occur as an acute episode, often related to gastroenterological infection or acute illness but presents a greater challenge when the condition is chronic. It impacts on patients' quality of life and on relatives, carers and healthcare workers.
Some groups are at higher risk, particularly frail elderly people, those with cognitive impairment, neurological disease, spinal injury/cauda equina damage, previous colorectal surgery or radiotherapy, pelvic organ prolapse or urinary incontinence. The commonest cause in the UK is constipation and overflow.
FI is a symptom, not a disease, and the key to management is identification and management of the underlying cause. Often this cause is multifactorial involving physical illness, psychological and social factors.
The aim of the history in FI is to determine the nature and severity of the symptoms and to find likely causes in the current and previous medical history.
The patient should be asked about the nature of their bowel habit and any recent changes. In particular, ask about the consistency of the stool, frequency of defecation and incontinence, ability to delay defecation, and whether they are aware when leakage is occurring.
Ask about contributory factors, such as constipation or diarrhoea, acute severe or terminal illness, cognitive impairment, neurological disease, diabetes, prolapse and previous trauma or surgery (including obstetric trauma in women).
In patients with mobility problems, also enquire about ease of access to toilet facilities and their need for assistance.
Medications can cause or worsen FI. Check the patient is not on any constipating drugs, such as opioids and tricyclics, or drugs that cause diarrhoea, including metformin, magnesium antacids, SSRIs and beta-blockers. If there is any cognitive decline, look for drugs that reduce alertness and be aware that cognitive enhancers can cause diarrhoea. Recent antibiotic use could indicate Clostridium difficile. A dietary history may show that the patient's diet is likely to cause constipation or diarrhoea. Tube feeds and some supplementary feeds also tend to cause diarrhoea.
Finally, enquire about red flag symptoms, such as rectal bleeding, weight loss or loss of appetite that could point to lower GI cancer or inflammatory bowel disease.
2. Examination and investigation
A general examination should be carried out based on any suspicions raised from the history. A check on the patient's mobility and ability to adjust clothing can reveal non-disease factors that may affect the incontinence.
In addition, if psychological elements are suspected, a cognitive and behavioural assessment may be helpful.
An abdominal examination should be carried out to look for any masses and to check for high faecal loading. This should be combined with an inspection of the anus for prolapse, and perianal abnormalities. A digital rectal examination is mandatory to determine anal tone, presence of faecal loading and to ensure there is no palpable pelvic mass.
Investigations are not normally required prior to initial management but may be required to look for underlying conditions suspected after the history and examination.
Most patients require a combination of treatments and modifications to tackle their FI, taking into account their circumstances and preferences.
The first step is to manage any potentially reversible conditions such as faecal loading, infective diarrhoea, irritable bowel syndrome, or inflammatory bowel disease.
In addition, consideration of changes to the patient's medications may be required if any of these are suspected to contribute. Some conditions, such as suspected cancer, rectal prolapse, sphincter injury and suspected cauda equina syndrome may need referral for specialist treatment at this stage.
Dietary modification should be considered to prevent constipation or diarrhoea. A food diary followed by a step by step modification of the diet is the best approach. In addition, adequate fluid intake is required to prevent constipation
Advice should be given on bowel habit. Alterations include toileting after meals and adoption of a sitting/squatting position when defaecating to avoid straining.
If access to adequate toilet facilities is a problem, referral for home assessment may help.
Medication may include bulking agents or stool softeners to prevent recurrence of faecal impaction. If diarrhoea is present, the first choice medication is loperamide starting at a low dose then titrating upwards. Patients should be allowed to adjust the dose in response to the stool consistency. Codeine or co-phenotrope are alternatives.
In patients who fail to respond to treatment, referral to a continence or colorectal clinic is indicated for advice, continence products or occasionally for surgery.
- Dr Spinks is a GP in Strood, Kent
NICE guidance on faecal incontinence: the management of faecal incontinence in adults. CG 49, London, NICE, 2008.