Faecal Incontinence

Introduction

Faecal incontinence is defined as the involuntary loss of solid or liquid faeces. Based on the mechanism, it is divided into the following:

  • Urge incontinence is characterized by the desire to defecate, but incontinence occurs despite efforts to retain stool.
  • Passive incontinence is characterized by the lack of awareness of the need to defecate before the incontinent episode.

The prevalence is higher in adults that are ≥65 years old and care-seeking (adults in home care and long-term care settings).



General Approach

All staff working with people with faecal incontinence should be aware of the physical and emotional impact this condition can have on their patients and their carers.

  • Consider patients' needs and preferences when planning treatment and ensure they have the opportunity to make informed decisions in this partnership.

Initial management of faecal incontinence consists of supportive care, medical therapy and pelvic floor physical therapy.



Supportive care

Avoiding foods or activities known to worsen symptoms.

  • Incompletely digested sugars (e.g. fructose, lactose, sorbitol)
  • Caffeine
  • Milk
  • Prunes, figs or other food that have laxative properties

Improve perianal skin hygiene.

  • The anoderm should be kept clean and dry, without excessive wiping or use of astringent cleaners.
  • Alternatively, a premoistened pad or tissue can be used for wiping.

Application of a barrier cream (e.g. zinc oxide) to the perianal skin.

Incontinence pads can be used to protect both skin and clothing from faecal soiling.

Access to emotional and psychological support.

NOTE: Prompted voiding and regular physical activity may increase continent bowel movements but does not appear to reduce frequency of faecal incontinence in nursing home residents, likely due to high incidence of underlying anorectal pathology.



Medical therapy

Medical therapy should be aimed at reducing stool frequency and improving stool consistency.

  • For constipation-associated faecal incontinence, consider lactulose or other laxatives.
  • For diarrhoea-associated faecal incontinence, consider fibre supplements as bulking agents, loperamide, diphenoxylate/atropine, cholestyramine and clonidine.
  • For patients with decreased internal anal sphincter resting pressure (particularly those with ileal pouch procedures), medications associated with some improvement in bowel control include topical phenylephrine and oral sodium valproate.



Subsequent Management

If initial management fails, additional evaluation with anorectal manometry and endorectal ultrasound/magnetic resonance imaging should be performed to detect functional and structural abnormalities causing faecal incontinence.

  • Consider biofeedback therapy in patients with faecal incontinence if anorectal manometry demonstrates weakness of the external anal sphincter or decreased ability to perceive rectal distension because of nerve injury.
  • Consider surgery and procedures
    • Anal sphincteroplasty
    • Injectable anal bulking agents (e.g. dextranomer stabilized in hyaluronic acid)
    • Stoma creation, including colostomy or ileostomy (not commonly used)
    • Implanted bowel control devices
    • Sacral nerve stimulation

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