British Journal of Nursing - Faecal incontinence: a healthcare taboo

Faecal incontinence (FI) is one of the most taboo conditions in healthcare. It is a topic that is unlikely to be raised by individuals and may be avoided by health professionals. For those who experience FI, it is a devastating condition that can result in depression, social isolation, financial burden and skin breakdown. It is also associated with secondary morbidities and disabilities and has negative effects on a person's quality of life (International Continence Society (ICS), 2015).

People with FI describe spending considerable time and attention planning for accidents, avoiding situations where accidents might occur and the extreme anxiety that these unpredictable events generate (ICS, 2015). The ICS (2015) also identified that FI has serious consequences for sufferers by affecting their self-esteem and body image and creating feelings of shame and embarrassment, which can then impact on all aspects of their life. This is supported by Duelund-Jakobsen et al (2016), who added that FI reduces a person's ability to work and impacts their sexuality as they worry about odours and accidents during intimacy.

What is faecal incontinence?

FI is the term used to describe the inability to control the bowels (ICS, 2015). Benezech et al (2016) defined FI as the involuntary loss of flatus (wind) and/or solid or liquid stool through the anal canal, and the inability to postpone an evacuation until socially convenient. Attached to this definition is a time duration of having the problem for at least 1 month and an age component of at least 4 years, with previously achieved control (Benezech et al, 2016). However, the Royal College of Nursing (RCN) (2019) has further refined these definitions to include:

Anal incontinence: the involuntary loss of flatus, liquid or solid stool, which is a social or hygienic problem

Passive soiling (liquid or solid), which occurs when an individual is unaware of liquid or solid stool leaking from the anus; this may be after a bowel movement, or at any time.

Other definitions also include:

Urge FI, whereby contents of the bowel are discharged despite active attempts to retain contents

Faecal seepage (leakage of stool with normal continence and evacuation) (Benezech et al, 2016).

The severity of the condition can range from the involuntary passage of flatus to complete involuntary evacuation of all stool.

Prevalence

Faecal incontinence is surprisingly common and can affect men, women and children. It is estimated that approximately 0.5–1% of adults regularly experience FI. However, it is closely associated with age, with more than 15% of over-85-year-olds living at home having FI. This increases to 10–60% of those living in residential or nursing homes (RCN, 2019). However, due to societal taboos and its social impact, FI is under-reported and so measurement of actual prevalence and incidence are subjective and rely on patient reports. People are embarrassed to bring up the issue with their health professional and often suffer in silence for years before discussing their symptoms. However, Benezech et al (2016) identified that professionals often forget or avoid asking about FI. This could be due to a lack of understanding or knowledge of the condition, or because they are unaware of how to access therapeutic guidance on treatments.

Contributing factors

Normally, the bowel and rings of muscle around the back passage (anal sphincters) work together to ensure that bowel contents are not passed until the person is ready. There are two main muscles that make up the sphincter, whose role is to keep the anus closed. These muscles are the internal anal sphincter (inner muscle), which keeps the anus closed at rest, and the external anal sphincter (outer muscle), which provides extra protection when the urge to open the bowel is felt and during exertion, coughing or sneezing. These muscles, nerves and bowel sensations all contribute to keeping the sphincter muscles tightly closed unless required. This balance enables people to stay continent. Faecal incontinence occurs when this balance is not working correctly. The RCN (2019) and ICS (2015) identified that FI is mainly associated with the following:

Childbirth. This can be a significant factor because the muscles of the anal sphincters can be stretched or even torn during vaginal birth. There can also be nerve damage due to stretching of the nerve or a combination of direct muscle damage and nerve trauma. This usually occurs when the birth is difficult or when instruments have been used to assist delivery

Anal sphincter damage. This may be caused by surgery such as that for the treatment of cancer of the bowel or pelvic organs or, inadvertently, during operations to remove haemorrhoids (piles)

Congenital malformations. Conditions such as spina bifida or anorectal malformations that affect the nerves may cause a person to experience FI

Chronic constipation. Constant straining during defecation can gradually stretch the pelvic floor and rectal muscles so that they no longer control the passage of stool or gas. Further, when patients suffer impaction of stool, liquid material above the stool blockage leaks around and escapes through the anus. Such impaction may eventually cause leakage from the bowel called ‘overflow diarrhoea’. Blockage can be caused by tumours, as well as stool

Anal conditions such as haemorrhoids, rectal prolapse or anal fissures may be associated with leakage

Neurological disorders. Individuals with neurological conditions may have difficulty with sensation or with muscular control, or both. Spinal cord injury, cauda equina syndrome, multiple sclerosis, brain injury, spina bifida and cerebrovascular accidents are among the many conditions that are associated with FI

Diabetes. Nerve damage from diabetes, termed diabetic neuropathy, is a common cause of anal sphincter dysfunction

Chronic diarrhoea. Increased gut motility causes loose stools

Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) may lead to FI

Lifestyle and environmental issues: poor toilet facilities, diet, dependence on a carer for mobility and difficulty with managing clothing can all be associated with FI.

Assessment

A complete bowel assessment of an individual experiencing FI should be undertaken by a competent health professional (McClurg et al, 2013). Any red-flag symptoms that indicate a potential underlying pathology should be investigated so these can be ruled out. Red-flag symptoms include rectal bleeding, a change of bowel habits for 6 weeks, unintentional weight loss, pain before, during or after defecation, faecal leakage and faecal urgency (National Institute for Health and Care Excellence (NICE), 2007, RCN, 2019).

The assessment should also include taking a medical history, including obstetric history, medication, onset, duration, timing and nature of FI (ie flatus, solid/liquid stool), any associated triggers, eg particular foods, and fluid and diet intake. An individual's mobility and dexterity should be assessed, as well as their proximity to a toilet and whether carers are required and are available when needed (Emmanuel et al, 2019).

An examination (vaginal/rectal/abdominal/neurological) by a competent professional may be required. A rectal examination should include inspection for external haemorrhoids, presence of faecal matter, scars, skin excoriation and prolapse. An internal examination should only be undertaken by a health professional trained in assessment of bowels and pelvic floor dysfunction.

To assess the impact on quality of life, there are numerous validated questionnaires available such as the St Mark's incontinence score or the ICIQ-B bowel questionnaire (https://iciq.net/iciq-b). Most of these tools are freely accessible to health professionals (UK Continence Society, 2015; NHS England, 2018). NICE (2007) guidance includes tables of questions to consider. Further, more specialist investigations may be required, such as anorectal manometry and endoscopic ultrasound to diagnose the underlying cause.

Treatments

Faecal incontinence is a symptom and it is important to diagnose the specific problem prior to treating (RCN, 2019; NICE, 2007). First-line treatments should always be conservative and will depend on an individual's symptoms. These may include supportive measures such as improving wellbeing and nutritional status, advice on hygiene maintenance, avoidance of foods which can trigger FI and the implementation of defecation programmes (Shah et al, 2020). Medications, such as loperamide, could be initiated, and pelvic floor rehabilitation and biofeedback are also valuable methods of treatment. If conservative treatments fail, then progression to surgery may be the only option.

Transanal irrigation

For certain individuals, transanal irrigation (TAI) may be a positive alternative to surgery (Emmanuel et al, 2019). In TAI, lukewarm water is introduced into the bowel using a cone or catheter, allowing expulsion of water, along with the contents of the proximal colon and rectum. It is thought that this softens faecal matter and/or may stimulate peristaltic contractions. Regular use of TAI can aid emptying of the bowel and help to re-establish control of bowel function by choosing the time and place of evacuation (Emmanuel et al, 2019).

NICE (2018) has stated that if bowel continence cannot be achieved by medication, changes to diet and physiotherapy, long-term management strategies such as TAI should be considered. NICE has produced medical technologies guidance on using the Peristeen TAI system (NICE, 2018).

Peristeen is usually self-administered while sitting on a toilet, commode or shower chair. It comprises a rectal catheter with inflatable balloon, a manual control unit with pump, leg straps and a bag to hold water. The system uses a constant-flow pump that does not rely on gravity so that the user does not need to hang the bag up for the water to flow.

Some of the advantages of using such a TAI system include that it:

Improves symptoms and reduces the severity of chronic constipation

Reduces the severity and frequency of FI

Improves quality of life for people with bowel dysfunction

Reduces the rate of stoma surgery.

Conclusion

Faecal incontinence is a multifaceted condition. There are a variety of causes that may contribute to this condition and numerous treatments available that are effective. However, the main issue is that individuals who live with this condition are reluctant to come forward due to the stigma associated with FI, even though their quality of life is severely affected. Professionals are also reluctant to question individuals about FI and bowels in general and, when it is identified, are unsure of treatments. This condition requires a higher profile and needs to be discussed more openly by both professionals and individual patients. It should not be a taboo subject and people should not suffer in silence.