The first article in this two-part series looking at faecal incontinence (FI) outlined its effect on people’s quality of life, highlighted its prevalence, explained the different definitions available and summarised the anatomy and physiology of the lower intestinal tract (Yates, 2023). Here, part two concentrates on the multiple causes/risks of FI, the knowledge and skills required to complete a basic assessment and initiate conservative therapies, including the role of medication and pelvic floor rehabilitation, and also discusses management options for FI. 

Figure 1. Causes of faecal incontinence (adapted from ICS, 2015; Royal College of Nursing [RCN], 2019; Yates, 2021). 

CAUSES OF FAECAL INCONTINENCE  


There are many underlying causes for faecal incontinence (FI) and for some individuals these are multifactorial. They can be categorised into non-traumatic, traumatic and other influencing factors (International Continence Society [ICS], 2015; Young, 2022; Figure 1).  
 

Non-traumatic causes  


Non-traumatic causes are the most prevalent and are due to anal sphincter or evacuatory dysfunction, namely: 
  • Congenital malformations: conditions such as spina bifida or anorectal abnormalities  
  • Neurological disorders: individuals with neurological disorders may have abnormal anorectal reflexes, reduced or absent sensation, muscle control or both (Scott et al, 2021), e.g. multiple sclerosis (MS), cerebrovascular accident (CVA), dementia, spinal cord injury, diabetes (due to diabetic neuropathy) 
  • Chronic constipation: constant straining can gradually stretch the pelvic floor and rectal muscles so that they get weaker and can no longer control the passage of stool or wind. Chronic constipation may cause a dry, hard mass of stool to form in the rectum and become too large to pass. This is known as faecal impaction. This allows liquid watery stool from farther up the digestive tract to flow around the impacted stool and leak out, i.e. ‘overflow diarrhoea’  
  • Anal conditions: i.e. haemorrhoids, which are swollen veins in the rectum. These swollen veins can keep the anus from closing completely, letting stool leak out. Rectal prolapse when the rectum drops down into the anus can also cause faecal incontinence. The stretching of the rectal sphincter by prolapse damages the nerves that control the rectal sphincter. The longer this lasts, the less likely the nerves and muscles will recover. In women, FI can occur if the rectum protrudes through the vagina, a condition known as rectocele. 

Traumatic causes  


These can result from:  
  • Obstetric trauma during childbirth: the muscles of the anal canal can be stretched or torn during vaginal childbirth, which can lead to anal sphincter or pudendal nerve damage or both (Duelund-Jakobesen et al, 2016). This is often associated with large babies, prolonged labour, episiotomy (cut to assist birth), or instrumental assistance during delivery, e.g. forceps  
  • Loss of storage capacity in the rectum: usually the rectum stretches to accommodate stool. If the rectum is scarred or stiff it cannot stretch as much as it needs to, and excess stool can leak out. Things such as surgery (for bowel cancer, removal of piles, radiation treatment, or inflammatory bowel disease, e.g. Crohn’s disease, irritable bowel syndrome [IBS] or ulcerative colitis) can stiffen and scar the rectum (ICS, 2015; Royal College of Nursing [RCN], 2019). 
Other factors which may also impair faecal control and cause FI include anxiety, medications, diet/ diet intolerance, obesity, alcohol, caffeine consumption, accessibility for people with disabilities to toileting facilities, and impaired mobility or cognitive function.  

RISK FACTORS  


While there are a number of causes for FI, there are also several factors which may increase the risk of developing FI, including:  
  • Gender: being female, as FI can be a complication of child birth. Also studies show that there may be symptomatic improvement from oral oestrogen replacement. However, a study of topical oestrogen compared to placebo showed no difference. One study found a 30% increased risk of incontinence in patients currently taking oral oestrogens. At present, the role of the hormone receptors and relationship of menopause to the onset of incontinence is uncertain (Salvatore et al, 2017)  
  • Nutritional issues: eating disorders, allergies, obesity, alcohol or drug dependency  
  • Age: although FI can occur at any age, it is more common in adults over 65, especially frail older individuals  
  • Individuals who live in communal settings, e.g. nursing/ residential homes  
  • Patients who are critically ill or at the end of life  
  • History of abuse: physical or sexual  
  • Severe cognitive impairment  
  • Learning disabilities (RCN, 2019).  

ASSESSMENT  


Assessment of FI should be done with sensitivity, as individuals feel ashamed to talk about the issue, and many delay seeking help or never even discuss the problem with a healthcare professional (Assmann et al, 2022). Clinicians should introduce the subject if FI is suspected and ask relevant questions rather than wait for the patient to mention the problem. This should be done in a sensitive manner, considering speech and cultural differences (Assmann et al, 2022).  

The assessment itself should identify factors contributing to FI. Bowel habit should be thoroughly assessed to ensure that FI is the main problem and not constipation with overflow (Assmann et al, 2022). The individual should provide a detailed medical and surgical history and also obstetric history in women. The presence of other diseases that could cause FI should be ruled out, e.g. inflammatory bowel disease, coeliac disease, diabetes and prolapse (Assmann et al, 2022), as should red flag symptoms for bowel cancer.  

RED FLAGS 

  • Red flag symptoms for bowel cancer: 
  • Unexplained weight loss 
  • Bleeding from the back passage or blood in faeces 
  • Extreme tiredness for no obvious reason 
  • Recent and persistent change in bowel habit 
  • Abdominal lump or pain. 

Table 1. Wexner continence score. 

Figure 2. Bowel chart.  

Figure 3. Bristol stool chart.  
Consideration should also be given to any medication currently being taken, both prescribed or over the counter, as well as diet and fluids, cognition and mobility. How the problem affects social, psychological and quality of life (QoL) also needs to be assessed. This can be done by using a bowel symptom questionnaire, e.g. the International Consultation on Incontinence Questionnaire — Bowel Symptoms (ICIQ-B) (https://iciq.net/iciq-b), St Mark’s incontinence score or Wexner continence score (Table 1) (Duelund-Jakobsen et al, 2016).  

To ascertain a detailed history of the presenting problem, duration of symptoms, symptom pattern, type of leakage, frequency of leakage and stool consistency a stool diary should be completed (Figure 2) and the Bristol stool chart used (Figure 3).  

A physical examination should be completed starting with general appearance, including signs of mental distress (Assmann et al, 2022), and a general abdominal assessment checking for any distention. Digital rectal examination (DRE) should only be undertaken by a healthcare professional competent to do so. Observation of the perianal and perineal area (RCN, 2019) should be done before any interventions are implemented. Observation of the area can indicate the health of surrounding skin (or any excoriation of the skin or pressure or moisture damage areas), presence of haemorrhoids, anal fissure, anal lesions, anal skin tags, bleeding, external faecal matter/soiling and may indicate the presence of any prolapse (RCN, 2019). Any abnormalities should be documented if appropriate and/or reported to medical colleagues.  
Once visual examination has been completed, an internal DRE may be indicated. This can be used to: 
  • Establish the presence of faecal matter in the rectum, amount and consistency  
  • Assess anal tone and ability to initiate a voluntary contraction and what degree and to teach pelvic floor if required  
  • Assess anal pathology  
  • Assess anal and rectal sensation  
  • Gauge the need for the effects of rectal medication in certain circumstances  
  • Prior to the administration of suppositories/enema to establish whether there is faeces in the rectum (amount and consistency). This will help identify medication required and enable it to be the most effective.  
  • Prior to using transanal irrigation (TAI) to assist in establishing the correct TAI device required, tone of pelvic floor, and presence of stool in rectum  
  • Prior to placement of anal plug  
  • Establish the need for manual removal of faeces and evaluating bowel emptiness  
  • To assess the outcome of rectal or colonic washout (RCN, 2019). 
DRE should be undertaken in a position that facilitates reliable diagnosis and comfort for both the individual and healthcare professional (Assmann et al, 2022). Other investigations that may assist diagnosis are plain x-ray to rule out impaction, stool cultures, or faecal immunochemical tests (FIT) (Young, 2022), imaging of anal sphincter muscles by ultrasound or magnetic resonance imaging (MRI) scan, or inspection of the interior anal canal (anoscopy, sigmoidoscopy, colonoscopy) (ICS, 2015). 

CONSERVATIVE THERAPIES  


Conservative therapies should be first-line treatment for individuals with FI and can be divided into a number of treatments. Individuals may only require one or a combination of different interventions to note any improvement. These can be subdivided into dietary and lifestyle adjustments, skin care and hygiene, medications and pelvic floor rehabilitation (Figure 4).  
 

Dietary/fluid adjustments  


Dietary modification is an important part of the treatment plan and individuals should be advised to avoid foods that contribute to loose stools, e.g. lactose, sorbitol (found in artificial sweeteners), fructose, caffeine and alcohol (ICS, 2015; Shaw and Wagg, 2016). They should also be educated about eating patterns and soluble, insoluble fibre and fibre supplements. A low FODMAP diet may help in reducing the number of FI symptoms and episodes, but evidence is limited (Assmann et al, 2022). Expert opinion suggests that adequate fluid intake is important in preventing hard stools and constipation, but again this is lacking in research.  

Figure 4. Conservative treatments for FI. 
Foods that may exacerbate bowel dysfunction can include (National Institute of Diabetes and Digestive and Kidney Diseases, 2023):  
  • Spicy foods — they can irritate the bowel increasing motility, e.g. curries  
  • Soluble fibre — can increase bloating  
  • Supplementary feeds — can induce diarrhoea (consider added fibre options) 
  • Certain fruits, e.g. apples, peaches, pears, figs, prunes  
  • Certain vegetables, e.g. legumes  
  • Nuts  
  • Hot/chilli peppers  
  • Fatty and greasy foods  
  • Foods that may contain dairy produce, e.g. cheese, ice cream, chocolate.  
Recommended fluid intake is between 1.5–2L each day for the general adult population, depending on level of activity and prevailing weather conditions (National Institute of Diabetes and Digestive and Kidney Diseases, 2023).  

However, some fluids can make FI worse, including:  
  • Milk — possible intolerance (avoid foods such as cheese, ice cream)  
  • Coffee and caffeine — may increase motility of the bowel  
  • Diet drinks — may contain sorbitol, mannitol, xylitol, and maltitol, which could act as a laxative  
  • Alcohol — excessive quantity can increase bowel motility  
  • Fizzy carbonated drinks — may increase abdominal bloating. 
The use of probiotics has been a more recent innovation. These products influence the gut microbiota. However, a study by Faber et al (2021) concluded that more research was required in this area with a larger sample size.  

Figure 5. Correct sitting position for defecation (RCN, 2019). 

Lifestyle adjustments  


Bowel habit is important in preventing FI and individuals should work to establish a regular pattern (ICS, 2015). This can be assisted by using the natural reflexes, e.g. gastric colic reflex (identified in part one of this series; Yates, 2023). A more recent innovation is the use of probiotics which influence gut flora, however this needs further research. Education should take place with regards to correct sitting technique on the toilet with feet well supported and knees higher than hips (Figure 5). 

Individuals should also be advised on coping strategies, such as locating toilets, carrying cleansing kits and spare clothes. However, Assmann et al (2022) state that there are no studies or evidence to support lifestyle changes, such as weight loss or smoking cessation, on FI.  
 

Skin care and hygiene  


The care of the skin and surrounding tissues is vital to prevent incontinence-associated dermatitis (IAD). Individuals with FI are more likely to develop IAD compared with those who have urinary incontinence (UI) (Gray and Giuliano, 2018). This is because faeces contain biolytic (lipid-digesting) and proteolytic (protein-digesting) enzymes that are damaging to the skin. Liquid faeces contain higher levels of digestive enzymes than formed stools, so patients with diarrhoea and faecal overflow/incontinence are at increased risk of IAD (Beeckman et al, 2015; Yates, 2020). 

Research shows that using recommended skin care preparations, such as washes and moisturisers, compared to the use of soap and water are beneficial in preventing and treating IAD. However, Assmann et al (2022) found that there was no significant difference between differing skin care products.  

Medications  


The most frequently used medications in FI are anti-diarrhoea medications and bulking agents (Assmann et al, 2022). These do not treat the underlying cause, but merely alter the stool consistency to reduce the risk of FI (Young, 2022). One randomised control trial (RCT) conducted by Markland et al (2015) examined the effects of fibre (psyllium) compared to loperamide. While it was identified that overall FI episodes and QoL improved in both treatment groups, there were no significant differences between the two groups. Also, adverse effects were reported to be similar in both groups, with constipation being the most common side-effect of loperamide and diarrhoea for the fibre. Both of these medications can be used as first-line treatments for FI and should be personalised and titrated according to the person’s presentation, assessment and response at review (Assmann et al, 2022). 
 

Pelvic floor rehabilitation  


As the muscles of the pelvic floor control the opening of the rectum and maintain sphincter pressure and colorectal angle, if they are weak, faecal leakage can occur (Yates, 2019a). Pelvic floor exercises have been widely researched with regards to UI, but less so for FI (Young, 2022). Once a full continence assessment and pelvic floor examination have been carried out, patients need education and a pelvic floor rehabilitation programme tailored to their capabilities and needs (Yates, 2019a).  

Studies show that pelvic floor exercises with biofeedback result in less FI episodes per week and a reduction in severity, rather than just pelvic floor exercises alone (Assmann et al, 2022). However, no significant difference in QoL results between the two treatments has been found. Assmann et al (2022) concluded that for pelvic floor exercises to be effective, individuals should be assessed and instructed by a professional competent in pelvic floor assessment and rehabilitation. The evidence for pelvic floor rehabilitation in FI again, like many interventions, needs more research to prove efficacy.  

MANAGEMENT OPTIONS  


Management options are not usually first line but may be used at any point to support the individual.  
 

Pads  


Containment pad products are not a treatment option but may be available to individuals via the NHS or purchased independently. They assist in containing FI, which may provide dignity to individuals and improve QoL. Healthcare professionals need to be aware that wherever they work in the NHS, there will be specific guidance relating to assessment and provision of these pad products and usually a criteria will apply with regards to pad products available and the number that can be issued.  
 

Transanal irrigation (TAI)  


If conservative measures fail, transanal irrigation (TAI) is the next non-surgical intervention which aims to assist improvement of bowel control (Emmanuel et al, 2013) (Figure 6).  

There are now numerous different types of devices available on prescription for TAI. They include high volume devices that can clear the transverse/descending colon and rectum to low volume devices that clear rectum only. Examples of these devices are identified in Figures 7, 8 and 9.  

Figure 6. Hierarchy of bowel interventions (Emmanuel et al, 2013). 

Figure 7. Equipment selection for TAI (Henderson et al, 2018). 
Studies show that TAI is clinically effective in patients with FI (Mekhael et al, 2021). While most individuals will be independent using a device, some will require support from either family, carers or district nurses. Healthcare professionals should be competent assessing patients for the suitability of TAI and proficient in its use, and be aware that there are contraindications, such as active inflammatory bowel disease, acute diverticulitis, colorectal cancer, within 12 months after a radical prostatectomy or three months of rectal/colorectal (Emmanuel et al, 2013; Henderson et al, 2018; Yates, 2019b), and that some patient may report complications in the beginning. Thus, it is important to educate and support individuals in the early stages of introducing the device, otherwise there can be a high percentage of discontinuation (Juul and Christensen, 2017).  

Regular follow-ups and ongoing support are also needed to address any evolving issues that may arise during the use of TAI.  
 

Anal devices  


Anal devices or anal inserts are designed to be inserted into the anus and prevent FI by forming a plug. There are now a number of different types available on prescription. Studies show that use of the correct insert for the individual can decrease the severity of FI, and some can maintain continence (Leo et al, 2019). However, some individuals find they cannot tolerate the device or discontinue use because they find it uncomfortable and sore. There are few adverse effects associated with these devices (Assmann, 2022). 

Figure 8. Example of a low volume cone device. 

Figure 9. Example of a high volume device. 

CONCLUSION  


Faecal incontinence is an extremely distressing condition. However, a number of treatments exist for its management. Healthcare professionals should be skilled in the assessment and management of FI and have the necessary skills to improve QoL for individuals or appropriately refer to a specialist. The greatest issue for healthcare professionals is that there is no recognised consensus of treatment options and studies are often controversial or contradictory, which is no help to clinical staff in the field. Far more in the way of clinical research and trials needs to be undertaken in this field to improve outcomes for individuals with FI, and to provide robust guidance to healthcare professionals who care for them. 

Key point  

  • ● There are many underlying causes for faecal incontinence (FI) and for some individuals these are multifactorial 
  • ● Assessment of FI should be done with sensitivity, as individuals feel ashamed to talk about the issue, and many delay seeking help or never even discuss the problem with a healthcare professional 
  • ● Conservative therapies should be first-line treatment for individuals with FI and can be divided into a number of treatments 
  • ● The stigma of FI needs to be replaced with well-researched treatment options delivered with compassion, empathy and respect 
  • ● More in the way of clinical research and trials needs to be undertaken in this field to improve outcomes for individuals with FI.  
Ann Yates is Director of Continence Services, Cardiff and Vale UHB ann.yates@wales.nhs.uk 

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