There are three steps in the assessment of faecal incontinence:
History-taking is an important component of assessing faecal incontinence, and should include assessing:1
Reproduced with permission from Waterham M, Kaufman J, Gibb S. Childhood constipation. Aust Fam Physician 2017;46(12):908–12.
- type of incontinence (eg solid, liquid or gas)
- Bristol Stool Chart (Figure 1) provides an objective grading system.
- Include a seven-day bowel chart to provide information about frequency, timing, episodes of incontinence and stool consistency (Grade of Recommendation: C).
- Loose bowel motions can be seen in faecal incontinence because of diarrhoea or ‘overflow incontinence’ secondary to constipation.
- frequency of bowel actions and usual bowel habit
- Urgency is closely associated with diarrhoeal illness, or any cause of loose bowel motions.
- Constant passive leakage is more characteristic of overflow incontinence because of faecal impaction or faecal incontinence because of impaired rectal emptying secondary to defaecatory dysfunction.
- timing of bowel actions
- Incontinence from severe dementia may result in postprandial bowel actions because of the gastrocolic reflex (stool consistency often normal).
- associated symptoms
- constipation, pain or straining, local symptoms (eg rectal bleeding)
- effect on lifestyle (eg avoiding going out) and hygiene (personal and domestic)
- dietary history and appetite, including intake of fruit and fibre
- comorbidities, past history and medications (including use of laxatives and enemas)
- cognitive status, mobility, visual acuity, manual dexterity, access to toilet and carer assistance.
After taking the patient’s history, an examination should be conducted, including:2,5
- digital rectal examination, to exclude faecal impaction or rectal mass, and assess anal sphincter tone (ie resting and squeeze pressure), rectal prolapse and pelvic muscle tone
- assessment of anal sphincter and pelvic muscle tone may be difficult or impossible in older people with cognitive impairment or in those who are unable to squeeze on demand. Reduced anal sphincter tone can occur with long-standing constipation – this is due to continued activation of the recto-anal inhibitory reflex, anal sphincter damage (eg post-childbirth) and lower spinal cord or cauda equina lesions (the latter would also usually be associated with reduced perineal sensation)
- assessment of skin integrity is important given faecal incontinence can lead to the development of dermatitis or pressure ulcers, especially in those with impaired mobility1
- primary neurological assessment, although not a common cause of faecal incontinence, primary neurological conditions such as spinal cord injury should be considered, and a lower-limb neurological examination should be conducted along with testing perineal sensation, and observing for the anal reflex (contraction of the external anal sphincter upon stroking perianal skin or ‘anal wink’).
Investigations are not necessary in all cases, but can be useful for more severe cases of faecal incontinence, especially if the cause is not clear. This could include:2
- a plain abdominal X-ray to exclude faecal loading, although interpretation of lesser degrees of faecal loading is subjective
- stool microscopy, culture and sensitivity, including testing for Clostridium difficile toxin for persistent or severe diarrhoea if there is no other clear cause for the faecal incontinence
- a colonoscopy to rule out sinister pathology; however, in the RACF context, a holistic view needs to be adopted to ensure benefits outweigh risks, and decisions are made in line with the patient’s values, preferences and long-term prognosis
- features that suggest underlying malignancy include change in bowel habit, appetite and weight loss, anaemia, rectal pain or bleeding and faecal incontinence.
- screening for malabsorption syndromes (eg lactose intolerance, gluten sensitivity, fat-malabsorption, carbohydrate malabsorption) in selected older people only, especially if there appears to be a relation to diet.
The management and treatment of faecal incontinence depends on the underlying cause. Multiple interventions may be required and, ideally, a multidisciplinary approach is advised where simple measures have been ineffective. However, there is currently limited high-quality evidence in this setting to guide management.
Faecal incontinence in RACFs is commonly due to constipation with colonic loading and overflow. Thus, efforts to prevent this should be part of the care plan for all residents. Behavioural and non-pharmacological measures include the following:1,2
- Try to stimulate the patient’s usual bowel pattern and establish a regular bowel pattern by encouraging (and assisting if necessary) the patient to open their bowels soon after a meal, at the same time each day. Stool transit can also be stimulated by appropriately trained professionals with abdominal massage in the direction of colonic transit.
- Encourage adequate dietary fibre (Level of Evidence: 1; Grade of Recommendation: B) and fluid intake (Level of Evidence: 2; plus consider dietitian referral).
- Promote optimisation of toilet access or provide a commode next to the bed.
- Advise regular exercise within the context of the patient’s comorbidities and physical abilities.
Regular prompted toileting and structured exercise programs administered separately have not been found to reduce faecal incontinence. However, the combination of both in one randomised controlled trial found a reduction in faecal incontinence, albeit with the need for increased staff-to-resident ratios in RACFs (1:5), challenging the feasibility of these interventions in everyday clinical practice.6
Simple patient and carer education on proper bowel habits includes the following points:7
- Respond promptly on urge to defaecate.
- Provide privacy to defaecate wherever feasibly possible.
- Adjust/modify position of toilet to facilitate rectal evacuation (eg back support, footstool to achieve squat position).
- Engage in regular exercise to promote bowel actions.
Bulking agents (eg psyllium found in oats, cereals, commercial preparations) may help reduce the incidence of faecal incontinence, although these should not be given to older people who are frail with poor oral intake as constipation can be worsened.Medications to treat constipation include:8
- stool softeners (eg docusate)
- osmotic laxatives
- stimulants (eg senna, bisacodyl) may work better than other agents for those with poor oral intake or fluid restrictions
- suppositories (ie glycerine, bisacodyl or microenema [eg docusate 5 mL]), generally for more severe constipation where the patient is unresponsive to other laxatives. This should be used according to response, but usually these are only required second or third daily.
All laxatives need to be regularly reviewed as overuse can lead to diarrhoea and faecal incontinence.
Transanal irrigation may be suitable for those with intact cognition and high motivation levels to comply with treatment. It can reduce the severity of constipation and incontinence, improve quality of life and promote independence.9 It requires nurse continence specialists to provide patient and carer support via training and education.
For severe constipation with impaction, consider the following:
- If a rectal examination shows the patient is rectally impacted, suppositories or a microenema should be administered, with a result expected within 30–60 minutes.
- If the rectal examination does not confirm rectal impaction, but the patient has not opened their bowels for some days +/– the abdominal X-ray showed faecal loading, oral macrogol can be given (up to eight sachets over a six-hour period for not longer than three days).
- Occasionally, impaction may require manual evacuation with premedication for pain if the faecal impaction has not been responsive to the above measures, although this is not commonly needed.
For faecal incontinence related to persistent diarrhoea, not clearly due to an infectious cause (eg acute gastroenteritis, C. difficile), loperamide can be used in an attempt to reduce the frequency of faecal incontinence. However, infection and other causes should be excluded prior to regular use. Rare adverse cardiac events have been reported with loperamide (although usually with higher doses), and it may also lead to constipation, especially if taken regularly.8
The treatment of faecal incontinence associated with neurological conditions (eg cerebrovascular disease, Parkinson’s disease) follows the same principles outlined above. Patients with spinal cord disease often have faecal incontinence associated with constipation, which is therefore the primary management target. Management principles such as a regular toileting program and non-pharmacological measures are also applicable in this patient group. A common laxative regime used in patients with spinal cord disease includes docusate and senna (given separately) in the evening, followed by glycerine +/– bisacodyl suppositories after breakfast in the morning. Anal stimulation may also be required to facilitate relaxation of the anal sphincter. Management can often be difficult and should be guided by specialist advice wherever possible.
Pelvic floor muscle retraining has few adverse effects; however, there is little evidence for its effectiveness in frail, disabled older people. It is also rarely practical in the residential care setting because of patient factors (eg cognitive impairment) and lack of resources to instruct in the technique and to monitor progress.
Containment strategies are often the mainstay of treatment, and include pads and bed protection. Anal plugs can be effective for achieving control of faecal incontinence in certain cases; however, these are often poorly tolerated. Input from nurse continence specialists can be invaluable in determining the best containment methods.Governmental subsidies such as the Continence Aids Payment Scheme (CAPS) may be available for eligible parties, although most patients in RACFs are ineligible.10State and territory specific programs such as the State-wide Equipment Program (SWEP) in Victoria may provide further financial assistance.
Skin care is crucial in the management of incontinence, and includes:11
- regular checks to ensure the skin is clean and dry
- washing skin with soap-free cleanser or soap alternative
- regular pad changes
- application of barrier cream.
A small minority of patients with troublesome faecal incontinence that is unresponsive to conservative measures who are willing, and are medically fit, to undergo invasive testing and surgical intervention can be referred for specialised investigations to assess for surgical treatments. These can include surgical sphincter repair or considerations of other strategies such as peri-anal bulking agents, sacral neuromodulation or percutaneous tibial nerve stimulation.5
Many regional aged-care service providers offer a specialised continence service with access to a geriatrician, nurse continence specialist and continence physiotherapist. The National Continence Helpline (1800 330 066) can provide details of these clinics and services.