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Faecal incontinence (Primary and Secondary Care) (Guidelines)

Warning

People who report or are reported to have faecal incontinence (FI) should be offered care to be managed by healthcare professionals who have the relevant skills, training and experience and who work within an integrated continence service.
Because faecal incontinence is a socially stigmatising condition, healthcare professionals should actively yet sensitively enquire about symptoms in high-risk groups

High risk groups 

  • frail older people
  • people with loose stools or diarrhoea from any cause 
  • women following childbirth (especially following third and fourth degree obstetric injury)
  • people with neurological or spinal disease/injury (for example, spina bifida, stroke, multiple sclerosis, spinal cord injury) 
  • people with severe cognitive impairment 
  • people with urinary incontinence 
  • people with pelvic organ prolapse and/or rectal prolapse 
  • people who have had colonic resection or anal surgery 
  • people who have undergone pelvic radiotherapy 
  • people with perianal soreness, itching or pain 
  • people with learning disabilities 

When assessing faecal incontinence healthcare professionals should:

  • be aware that FI is a symptom, often with multiple contributory factors for an individual
  • avoid making simplistic assumptions that causation is related to a single primary diagnosis ('diagnostic overshadowing').

Focused baseline assessment should comprise:

  • relevant medical history
  • a general examination
  • an anorectal examination
  • a cognitive assessment, if appropriate.

People with the following conditions should have these addressed with condition-specific interventions and/or referrals before healthcare professionals progress to initial management of faecal incontinence:

  1. a faecal loading +/- overflow diarrhoea (consider causes)
  2. potentially treatable causes of diarrhoea (for example, infective, inflammatory bowel disease and irritable bowel syndrome)
  3. warning signs for lower gastrointestinal cancer (needs qFIT +/- urgent referral to colorectal surgical unit -see separate guidance box 2)
  4. third-degree haemorrhoids without bleeding or other signs of (c) (may need routine referral to colorectal surgical unit)
  5. rectal prolapse (needs urgent referral to colorectal surgical unit)
  6. acute anal sphincter injury including obstetric and other trauma (managed by on-call obstetric or general surgery team)
  7. acute disc prolapse/cauda equina syndrome (emergency medical referral)
Bleeding 

repeated rectal bleeding without an obvious anal cause 

any blood mixed with the stool 

Bowel habit  persistent change in bowel habit towards loose stool for more than 4 weeksa
Mass *

unexplained abdominal mass 

palpable anorectal mass 

Pain  abdominal pain associated with weight loss b
Iron deficiency anaemia  unexplained iron deficiency 

PLUS 

FIT value d > 10mg Hb/g 

*FIT not required if there is abdominal or rectal mass 

  1. consider alternative causes e.g. infective diarrhoea, changes of medication or hypothyroidism
  2. also consider an UGI cancer
  3.  defined as a low Hb by local lab criteria AND a ferritin<30
  4.  referrals without a FIT are likely to be downgraded to urgent or routine pathways (unless rectal or abdominal mass is present)

Initial management of faecal incontinence in primary care

Recommend a diet and fluid intake that promotes an ideal stool consistency and predictable bowel emptying. Healthcare professionals should:

  1. take into account existing therapeutic diets
  2.  ensure that overall nutrient intake is balanced
  3. advise patients to avoid caffeine, and to modify one food at a time if attempting to identify other potentially contributory factors to their symptoms
  4. encourage people with hard stools and/or clinical dehydration to aim for at least 1.5 litres intake of fluid per day (unless contraindicated).
  5. consider the opportunity to screen people with faecal incontinence for malnutrition, or risk of malnutrition

With respect to bowel habit and technique, people with FI should be encouraged to

  1. adopt a squatting position if emptying is incomplete
  2. do regular pelvic floor exercises, if necessary using squeezyapp.com

Medications:

  1. Consider alternatives to medications that might be contributing to FI. A surprisingly common example is metformin (suspect if onset of FI follows starting metformin or an increase in dose).
  2. Antidiarrhoeal medication should be offered to people with FI associated with loose stools once other causes have been excluded. It should not be offered to those with hard or infrequent stools, acute diarrhoea without a diagnosed cause, or an acute exacerbation of colitis. The antidiarrhoeal drug of first choice should be loperamide capsules, meltlets or syrup (unlicensed). Begin at a low dose and escalate slowly as required. Anecdotally, some patients seem to benefit from combining loperamide, fybogel and yoghurt in a paste. An alternative to loperamide is codeine.

Other coping mechanisms include pads, toilet passkeys, etc

Referral for specialist management

Patients who are still limited by their FI should be encouraged this is not uncommon and there are a variety of possible treatments available to them in NHS Highland, depending on the cause(s) and on what modalities they can best cope with. Options may include:-

  • Specialist physiotherapy
  • Rectal irrigation
  • Anal plugs
  • Biofeedback (ie muscle retraining guided by real-time manometry/pressure recordings or EMG)
  • Sphincter surgery
  • Rectal prolapse surgery
  • Surgery for obstructed defaecation (and post-defaecation staining)
  • Implantable Sacral Nerve Stimulator devices
  • Stoma formation (rarely necessary)

Therefore specialist assessment is required before selecting best treatment option(s). Unless there is concern about unexplored risk of polyps, cancer or colitis, assessment by the specialist team after referral is mostly done purely on history and examination. However some patients may also require anorectal manometry and endo-anal ultrasound. For just a few, the team may recommend a defaecating MR or fluoroscopic proctogram.

Referral pathway

The non-urgent specialist service for FI is accessed through our specialist physiotherapists, as follows;

Faecal incontinence referral pathway

Local pelvic floor MDT Team

The local Pelvic Floor MDT comprises:-

  • Colorectal Surgeons : Kenneth Walker, Angharad Jones
  • Colorectal Nurse Specialists: Cathie King, Fiona Barling
  • Urologist: Karina Laing
  • Urology Nurse Specialists: Kathleen MacKenzie, Lonya Krzyzanowski, Claire McCutcheon
  • Gynaecologists: Tracey Sturgeon, Philip Boabang
  • Specialist Physiotherapists: Kirsteen Ferguson, Diane Stark, Lynn Tait, Alison Clarke
  • GI physiologist (anorectal physiology & ultrasound, biofeedback): Harriet Bolton
  • Radiologist

Last reviewed: 01/08/2022

Next review date: 31/08/2025

Version: 1

Approved By: TAM Subgroup of ADTC

Reviewer name(s): Kenneth Walker, General Surgeon .

Document Id: TAM520

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