Bowel Incontinence

• What it is
• Classification and causes
• Treatment and management
• Progression and recovery.
• Sources of evidence
• Ability to deal with incontinence

What it is

The term incontinence refers to the involuntary passage of faeces with loss of control over the place of defaecation by the individual. Invariably, it is the sign of an underlying medical condition and the effects of a number of predisposing problems. It is estimated that between 1 – 10% of adults living in the community have faecal incontinence, and that up to 1% have long-term incontinence affecting the quality of life. Many people with faecal incontinence however fail to seek medical attention because of a reluctance to discuss the condition, fear of social stigma or a belief that it is not amenable to treatment.

Classification and causes

There is no universally agreed consensus on how faecal incontinence should be classified. This reflects the fact that the exact pathological changes are not fully understood and that in many cases there are a number of contributory causes.

The causes (anatomical and physiological) can be considered under three main headings:

• Disorders of the anus and rectum - sphincter laxity or damage, severe haemorrhoids, rectal prolapse, tumour & constipation.
• Faecal urgency – any cause of diarrhoea, or constipation with spurious diarrhoea (diarrhoea occurring as a result of constipation, when liquid faeces leak around a hard mass of faeces lodged in the rectum).
• Disorders of neurological control of the ano-rectal muscles and anal sphincter – for example, spinal cord injury, spina bifida, dementia nerve damage in childbirth.

High-risk groups for faecal incontinence include:

• Frail older people
• People with loose stools or diarrhoea
• People with neurological diseases such as spina bifida, stroke, multiple sclerosis, spinal cord injury, Parkinson’s disease etc
• People with cognitive impairment e.g. dementia, severe brain injury
• People with learning disabilities
• People with urinary incontinence
• People with vaginal and/or rectal prolapse
• People who have had bowel, anal or pelvic surgery
• People who have had pelvic radiotherapy (+/- surgery) for malignant disease
• Women following prolonged or complicated childbirth

Treatment and Management

The aims of treatment in faecal incontinence are to remove or improve both the underlying cause(s) and the contributory factors.

Treatment of diarrhoea

Underlying diarrhoea is treated with anti diarrhoeal medications such as loperamide and codeine phosphate. In inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease drugs are prescribed to modify the underlying disease process, thus relieving diarrhoea. Faecal impaction causing spurious diarrhoea is treated with enemas.

Improvement of bowel habit

Diarrhoea, constipation and faecal impaction can be improved by attention to dietary factors e.g. increased roughage, and adequate fluid intake. People are helped by going to the toilet on a routine basis, allowing adequate time for defaecation and having easy access to the toilet.

Incontinence aids

There are a wide variety of incontinence pads and waterproof pants that can be used by people with faecal incontinence. These may need to be used in conjunction with barrier creams and special cleaning products to protect the skin from rashes and infection.

Bowel retraining and incontinence programmes

Education and training of people and their carers in managing faecal incontinence is undertaken by specialist teams, which include incontinence nurses, physiotherapists, occupational therapists and dieticians.

Specialist investigation and surgery

Remediable causes such as rectal prolapse and severe haemorrhoids are treated with routine surgery. Specialist investigation including barium proctograms, electrophysiological techniques, ultrasound and MRI scans are used to assess and treat impaired ano-rectal function. Surgery may also be used to repair the anal sphincter or insert an artificial sphincter. Other techniques involve use of devices to stimulate the pelvic nerves that control defaecation.

Progression and recovery.

Since the causes of faecal incontinence are frequently multi factorial it is helpful to divide cases into two groups:

• who are most likely to have long-term faecal incontinence and need assistance from others:
  • Frail older people
  • People with faecal urgency, diarrhoea in conjunction with limited mobility
  • People with spurious diarrhoea
  • People with long term neurological conditions e.g. multiple sclerosis,
  • People with cognitive impairment e.g. dementia,
  • People with learning disabilities
• who can expect recovery from faecal incontinence, improvement with treatment and an increased ability to manage their incontinence independently:
  • Younger age groups in general
  • People with normal cognitive function
  • Women following child birth, although delayed problems may occur
  • People with inflammatory bowel diseases causing diarrhoea e.g. ulcerative colitis, Crohn’s disease
  • Following bowel, anal and pelvic surgery
  • Following spinal cord injury.

Sources of evidence

Within the community, people with faecal incontinence, especially the elderly are likely to receive advice and treatment from community (district) nurses and specialist incontinence nurses. People recently discharged from hospital, or who have been assessed for placement in residential homes, including those with dementia, are likely to have a formal care plan detailing incontinence problems. The individual or their family is usually provided with their own copy of this plan. In some cases a copy may be available in the general practitioner records.

Information on incontinence and how it is managed may also be available from occupational therapists, physiotherapists, social workers and staff in residential homes. Customers, their relatives and other carers are often able to describe the help provided on a daily basis.

Reports from specialist incontinence teams may be obtained from the nurses and other therapists based in the clinic. People with medical conditions causing faecal incontinence may also attend neurology, gastroenterology, geriatric, colorectal surgical, neurosurgical or rehabilitation clinics. Information for people with learning disabilities may be obtained from community teams.

Ability to deal with incontinence

Adults with normal cognitive function

They should be able to manage pads and aids on their own unless they have problems with manual dexterity or visual impairment. In addition they should be able to take medication, manage diet and establish appropriate routines without help from others. This would include people with some types of spinal injuries, people recovering from a relapse of multiple sclerosis and from bowel and/or pelvic surgery. Some people with long-term neurological disorders affecting bowel function may need regular enemas to prevent faecal impaction with resultant spurious diarrhoea as part of their care administered by others.

Recurrent diarrhoea, faecal urgency and the need to go to the toilet quickly may occur in people with exacerbations of ulcerative colitis, Crohn’s disease and irritable bowel disease. These should respond to appropriate treatment of the condition within days or weeks, and not cause persistent or long-term incontinence. These symptoms do not cause any difficulty in walking and should not be considered to cause restricted mobility.

Adults with learning disabilities

This group may need considerable input from carers to deal with faecal incontinence. This will include ensuring pads are worn, help with changing, cleaning, skin care and personal hygiene. They will need to be encouraged to go to the toilet regularly, to be taken to the toilet, to eat a suitable diet, to drink adequate fluids and to take medication to control bowel function.

Elderly or frail people

Help is likely to needed by older people with poor manual dexterity, visual impairment, restricted mobility and dementia. They need assistance in putting on incontinence aids and changing them when soiled. They need help with personal cleaning and applying barrier creams to protect the skin from rashes or pressure sores. If they have limited mobility they need help to and from the toilet, and help on and off the toilet or commode. They may also need encouragement and reminding to go to the toilet at regular intervals. Consumption of a suitable diet, adequate fluid intake, and supervision of medication and administration of enemas are required to establish a regular bowel habit and avoid faecal impaction.

Amended April 2008