Fecal incontinence

It is important to exclude malignancy – check for red flags/signs of bowel cancer – before commencing treatment.

Causes of Faecal incontinence

The cause of faecal incontinence is often multifactorial.

Faecal incontinence can be divided into passive and urge faecal incontinence.

Passive incontinence or soiling is often attributed to poor internal anal sphincter function. This may be as a result of inadvertent surgical injury, for example following haemorrhoidectomy but most commonly idiopathic degeneration with aging.

Urge faecal incontinence is when the individual has to rush to the toilet and is unable to get there in time resulting in a bowel accident. External anal sphincter weakness or defect is a common cause, often due to obstetric trauma.
In reality, both types of incontinence often co-exist.

Other causes of incontinence are:

Increased gut motility causing loose stools – infection, inflammatory bowel disease, or irritable bowel syndrome
Rectal prolapse, which stretches anal sphincter muscles and makes them dysfunctional
Neurological disease – spinal cord injury, cauda equina syndrome, multiple sclerosis, spina bifida, dementia
Lifestyle and environmental issues – poor toilet facilities, diet, dependence on carers for mobility and managing clothing or stress
Idiopathic or unknown cause
Pelvic floor dysfunction, which is often attributable to childbirth, and may not present until menopause.
Constipation with loading/impaction resulting in overflow diarrhoea

Who to refer, who not to refer, how to refer

Who to refer:

Rectal prolapse
Obvious anatomical abnormality of anus
Relevant and recent surgical or obstetric history
Refractory symptoms despite primary care management

How to refer:

Referral pathway – Refer to colorectal via Sci Gateway stating “Faecal Incontinence” as the problem. Please include results of all investigations and treatments already tried.

If referral is for symptom management or Surgical referral is not appropriate, e.g. if patient not fit for surgical intervention or not wishing this.

Majority of patients (>80%) will not require surgical intervention for their incontinence symptoms and conservative treatment could be commenced and continued in community.

Primary care management

Thorough assessment:

Exclude malignancy – check for red flags/signs of bowel cancer
Exclude other medical conditions – Thyroid dysfunction, Coeliac disease, IBD. Do relevant investigations for these if indicated.
Bowel habit and medication review.
Check previous surgical and obstetric history.
Examine patient. Visualise the anus and perform digital rectal examination. Exclude faecal impaction and overflow and assess anal tone and squeeze.

Treatment

Aim for one formed stool every 1- 3 days. Encourage patients to adopt a sitting or squatting position when opening bowels and avoid straining.

There are 3 elements to conservative management – all of which need to be considered:

Diet, Exercise and Medication

If constipation is the underlying cause:
Diet and exercise

Encourage high fibre diet: amount of soluble and insoluble fibre may need to be carefully balanced
Adequate fluid intake
Increased mobility/exercise

Medication
If these alone are not sufficient then treat with laxatives.

If stool is loose:

Diet and exercise

Exercise
Pelvic floor exercises can be accessed online. Here is one resource.

There are also useful apps, such as “Squeezy” that patients can download and use. It is important that pelvic floor exercises are done daily and need to be continued indefinitely.

Diet
Balanced nutrient intake. Fibre intake may need to be adjusted.
Limit caffeinated drinks (coffee, tea, coke, irnbru) to 2 per day.
Reduce other bowel stimulants – chocolate, spicy foods, alcohol etc.

Medication

Fibre supplementation
Optifibre: This is a powder which can be mixed with food or drink. It has no taste. This is usually taken as one scoop, once or twice a day. This will bulk up stools to gain regular bowel motions.

Fybogel: Similar to Optifibre but needs to be mixed up and tastes of orange.

Loperamide:
To slow the whole process, treat urgency, solidify liquid motion.
Can be used to stop loose stools and prevent accidents as required or regularly once or twice daily to have regular bowel motions. If a 2mg tablet is too strong, liquid loperamide can be more easily titrated to a small dose regularly using syrup form (5mls is 1mg). The dose could be increased up to 16mg/day.

Codeine:
Use if above is insufficient. 15mg bd (max 30mg qds). Slows motion down and helps solidify.
Reduce bowel stimulants such as caffeine, alcohol, chocolate and spicy food.

If evacuation of stool is an issue:
Suppositories or enemas to manage evacuation and/or ensure complete evacuation
Glycerol suppositories:
These are recommended for patients who feel they are not completely emptying their bowel. After their usual bowel motion advise patients to insert a suppository and wait a few minutes in the bathroom. Then empty bowels again. Some patients may use suppositories to help them start a bowel motion in order to manage the timing of evacuation more conveniently.

Mini-enema (microlax/ bisacodyl):
These can be used if glycerol suppositories have not worked.