Nursing Tips on Fecal Incontinence

Article contributed by:

Ms Ong Choo Eng, Senior Nurse Clinician, Specialty Nursing
Singapore General Hospital
for New Dimension - biannual newsletter of the Society for Continence, Singapore

 

Fecal incontinence refers to the involuntary loss of gas or liquid stool or solid stool.

 
Fecal incontinence can undermine self-confidence, create anxiety, and lead to social isolation.  People who suffer with fecal incontinence should learn as much as possible about their condition and discuss their symptoms honestly with their clinician.  Fecal incontinence is a treatable condition; treatment can lessen symptoms in most cases and can often completely cure incontinence.
 

 

On this page: ► Fecal Incontinence Causes ► Fecal Incontinence Diagnosis	► Fecal Incontinence Treatment ► Reducing Fecal Incontinence

 

Fecal Incontinence Causes

Damage to the anal sphincters — Damage most commonly occurs during vaginal childbirth and anal surgery.

 
Neurologic causes — Neurologic disorders such as diabetes, multiple sclerosis, and spinal cord injury can decrease sensation and control over the lower digestive tract.  Nerve damage during vaginal childbirth can also decrease anal sphincter function.

 
Decreased distensibility of the rectum — Conditions such as inflammatory bowel disease (eg, Crohn disease and ulcerative colitis) and radiation-induced inflammation of the rectum (radiation proctitis) can impair the rectum's ability to expand and store fecal matter.

 
Fecal impaction — When hardened feces accumulates in the rectum, this can cause the anal sphincters to relax and allow liquid stool to escape around the blockage.  Fecal impaction is a common cause of incontinence in older adults.  Factors that make impaction more likely include certain mental health conditions, immobility, and loss of rectal sensation.

 
Diarrhea — Diarrhea of various causes, including irritable bowel syndrome, active inflammatory bowel disease, or acute gastroenteritis, can lead to loss of liquid stool.  In some cases, if the diarrhea is treated, the person will be able to control their incontinence.

 
Unknown causes — In some cases, the cause of fecal incontinence cannot be identified; this is called idiopathic incontinence.  Idiopathic incontinence most commonly occurs in middle-aged and older women.
 

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Fecal Incontinence Diagnosis

The underlying cause of fecal incontinence can often be established with a combination of a medical history, a physical examination, and diagnostic tests.

 
Diagnostic tests — Diagnostic tests are particularly useful in pinpointing the cause and ensuring the correct treatment.  One or more tests may be recommended, based upon the suspected cause(s) of incontinence.

 
Direct examination — Colonoscopy or sigmoidoscopy will be recommended.  These tests can help identify inflammation, tumors, and other disorders that can cause fecal incontinence.

 
Anorectal manometry — Anorectal manometry measures the internal pressure in different areas of the lower digestive tract under different conditions.  This test can identify several of the different causes of incontinence and may be especially useful in revealing poor tone of the anal sphincters.  Manometry can also be used to determine if rectal sensation and rectal reflexes are impaired.

 
Ultrasound or MRI — An ultrasound or magnetic resonance imaging (MRI) examination of the rectum can reveal abnormalities of the anal sphincters, the rectal wall, and the pelvic muscles that help maintain continence.  These tests are reliable for identifying structural abnormalities of both the internal and external anal sphincters.

 
Stool tests — Look for infection.

 

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Fecal Incontinence Treatment

Three types of treatment are commonly used for fecal incontinence: medical therapy, biofeedback, and surgery.  The specific treatment(s) recommended will depend upon the underlying cause of fecal incontinence.

 
Medical therapy — Medical therapy includes medication and certain measures that can reduce the frequency of incontinence and firm the stools, which can reduce or eliminate episodes of fecal leakage.

 
Bulking substances — Substances that promote bulkier stools may help control diarrhea by thickening the stools.  Fybogel (a form of fiber) is one type of bulking substance that is commonly used.  Increasing dietary fiber may also help to bulk stools.

 
Medications that reduce stool frequency — The frequency of stools can be reduced by drugs such as Loperamide (Imodium) and Diphenoxylate (Lomotil).  Loperamide can also increase the tone (tightness) of the anal sphincter muscle.

 
Anticholinergic medications — When taken before meals, anticholinergic medications (such as the prescription drug hyoscyamine) can decrease the incontinence that occurs after meals in some people.  The medications work by reducing contractions in the colon.  However, this drug is not available in Singapore for this indication.

 
Treatment of impaction — A clinician can perform manual evacuation to remove hard impacted stool inside the rectum to facilitate subsequent bowel movement.  The person will be given one or more medications to keep the bowels moving on a regular basis.

 
Defecation programs — when incontinence is related to a disability or mental health condition, a clinician will often recommend a scheduled toileting program.  This usually involves sitting on the toilet at a regular time every day, after a meal.  Incontinence is less likely to occur if the person empties their bowels regularly.

 
Biofeedback — Biofeedback is a safe and noninvasive way of retraining muscles.  During biofeedback training, sensors are used to help the person to identify and contract the anal sphincter muscles, which help maintain continence.  This is usually done in a healthcare provider or physical therapist's office.

 
Sacral nerve stimulation — Electrical stimulation can eliminate leakage in 40 to 75 percent of people whose anal sphincter muscles are intact.  The mode of action is not completely understood but believed to be restoration of the autonomic nerves to the anus and rectum.  An electrode is implanted into the nerve root at the sacrum and connected to a pacemaker, similar to a cardiac pacemaker.

 
Anal electrical stimulation — Electrical stimulation involves using a mild electrical current to stimulate the anal sphincter muscles to contract, which can strengthen the muscles over time.  The electrical current is applied using a small probe, which the patient inserts inside the rectum for a few minutes every day for 8 to 12 weeks.

 
Injectable bulking agent — The gel is injected into the anal sphincter just below the lining that may help build tissue in the anal canal, thereby narrowing the opening of the anus and allowing the patient to better control their anal sphincter.

 
Surgery — Several different surgical procedures can help alleviate fecal incontinence.  Surgical repair can reduce or resolve incontinence, particularly for women who develop a tear in the external anal sphincter during childbirth and in people with injury of the sphincter due to surgery or other causes.  Surgery cures fecal incontinence in 80 percent of women with childbirth-related sphincter tears.

 
Colostomy — Colostomy is a surgical procedure in which the colon is surgically attached to the abdominal wall.  Stool is collected in a bag that fits snugly against the skin.  This eliminates leakage of stool from the rectum.  Variations on the procedure may allow the person to control bowel emptying.
 

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Reducing Fecal Incontinence

There are some tips that patients can take to help minimize leakage of stool.

 

►	Avoid foods and drinks that may cause loose or more frequent stools, which can worsen fecal incontinence.  These can include dairy products (for people who are lactose intolerant), spicy foods, fatty or greasy foods, caffeinated beverages, diet foods or drinks, sugar-free gum or candy, and alcohol.
►	Eat smaller more frequent meals.  In some people, eating a large meal triggers the urge to have a bowel movement, and sometimes cause diarrhea.  Eating smaller and more frequent meals can reduce the frequency of bowel movements.
►	Increase fiber in the diet.  Fiber increases stool bulk and often improves the consistency of stool.  The recommend daily intake of fiber is 25 to 30 grams.  The amount of fiber should be increased gradually over a few weeks to reduce the possibility of bloating and gas.
►	Drink a large glass of warm water every morning to move the bowel.  Take more starchy food when having diarrhea to make the stool more form.  Avoid Caffeine drink and spicy food as that may irritate the inner layer of the large intestine and cause diarrhea.
►	Keep a food diary of your daily intake and monitor what kind of food gives you what kind of outcome.
►	Colonic washout of the whole large intestine daily or alternate day to clear the stools inside using warm tap water for those who have difficulty in moving their bowel daily.  Please note that this procedure should be performed under strict monitoring and is not recommended to be performed by unlicensed or non-healthcare staff.
►	Pelvic floor exercise is done under supervision from the Healthcare profession.  This exercise is to strengthen the Pelvic Floor muscle if the incontinence is due to weakening of the muscle.
►	Anal Plug is like a tampon inserted into the rectum and it will absorbed watery stool for 4-6 hrs to prevent watery leakage.
►	Sanitary Pad is also one of the options a person can use to control minor leakage.
►	Barrier creams are recommended for those people who have frequent diarrhea or diaper wearer.  The Barrier creams serve as protection for the skin from constant irritation from the stool contents.

 

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Article contributed by:
Ms Ong Choo Eng, Senior Nurse Clinician, Specialty Nursing
Singapore General Hospital
for New Dimension - biannual newsletter of the Society for Continence, Singapore

Dated: December 2015

 

 

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