Faecal Incontinence: An overview
Frank Booth, RGN
Background
Most people will agree that there will be little within healthcare that is more offensive or devastating than faecal or bowel incontinence. It must be remembered that this is a sign or symptom rather than a disease in itself. Faecal Incontinence can effect between 1% and 10% of adults, depending on the frequency and definition of faecal incontinence used. It is likely that 0.5–1.0% of adults experience regular faecal incontinence that affects their quality of life [1]. Occasionally, faecal/bowel incontinence (constipation or particularly, diarrhoea) can be the basis of a life threatening condition and thus should not be considered as routine or simple, rather dealt with quickly, sympathetically, and using the very best clinical guidance.
As there is no consensus on methods of classifying the symptoms and causes of faecal incontinence; it is generally classified according to symptoms, character of the leakage, patient group, or presumed primary underlying cause [1]. Therefore, a comprehensive initial assessment will determine which factors are reversible. If addressing these fails to restore continence, specialised options and investigations will be required.
What is normal?
Frequency
In a healthy adult, a bowel action occurs between once every three days and three times per day. However, this variation makes defining ‘regular’ and ‘normal’ difficult, so one should work on the basis of what is regular and routine for that individual.
What should stools look like?
The stools should be a light brown in colour, and of a consistency that facilitates easy passing. Overall, stools are good indicator for our general good/poor health and well being. The Bristol Stool Chart [2] (Figure 1) has been used to qualify what normal looks like; Type 3 or 4 can be considered ideal. There is also a children’s version, which is very descriptive! [3] (Figure 2)
Many factors such as diet, mobility, bowel motility, medication and ill-health affect the consistency, appearance and smell of the stool.
Causes
Bowel incontinence is not a condition in itself; it is a symptom of an underlying problem or medical condition. It can also be caused by long-term conditions such as [4]:
- diabetes
- multiple sclerosis
- dementia
- Crohn’s Disease or colitis
- haemorrhoids
Many cases are identified as diarrhoea or constipation or weakening of anal sphincter
As we age and particularly as we enter our more senior years, our bowel habits change. This is normal. As a baby we have no actual control of our motions and we pass both urine and faeces when our body decides to do so; continence is therefore a learned process. As we grow up we learn that it is neither nice nor proper within our society to be constantly wet or soiled. As our physical and mental abilities develop so do our abilities to recognise feelings and sensations and react accordingly, for example, going to the toilet.
As in many cases when we are injured, have an illness or are simply blessed with old age, we can start to lose a certain understanding of such learned processes. However, many older people, and people with significant or even life changing illnesses are not incontinent, but some are.
Psychological factors
The loss of families and friends can lead to loneliness, which can sometimes makes us tired of living. Depression can mean that we no longer may want to keep up standards; our homes can become dirty, our clothes soiled. When and/or if faecal incontinence follows, the attitude may be ‘why bother, no one else does?’
Physical factors
Bowel incontinence is an inability to control bowel movements, resulting in the involuntary passage of stools [4]. This could be due to:
- neurological conditions
- spinal column changes
- gut disorders
- specific illness affecting/attacking the small intestine and/or large intestine
- unknown reasons
Management
Bowel incontinence can be extremely upsetting and hard to cope with, but effective treatments are available and a cure is often possible; help can be found from the General Practitioner, specialist continence services, or groups such as the Bladder and Bowel Foundation 5. Trust Policies should be in place to support staff in what to do and how to manage faecal incontinence.
In many cases with the right treatment, a person can maintain normal bowel function throughout their life. The National Institute for Health and Care Excellence 1 offers us excellent guidance on managing bowel related matters. Treatment will often depend on the cause and severity of the condition, but possible options may include:
- lifestyle and dietary changes to relieve constipation or diarrhoea (good food and plenty of fluids; however, excessive alcohol consumption can in itself cause bowel problems
- exercise programmes to strengthen the muscles that control the passage of stools
- medication to control symptoms of diarrhoea and constipation
- surgery, of which there are a number of different options including the use of stomas but this is rarely needed for most people
Conclusion
It is important to remember that:
- bowel incontinence is not something to be ashamed of – it can be simply a medical/non-medical problem that is no different from diabetes or asthma or symptomatic of something else that has no ‘illness’ linked to it
- it can be treated or managed
- bowel incontinence is not normal or a normal part of ageing
- it will probably not go away on its own – most people will need some support or intervention