Faecal incontinence

Definition

Inability to prevent the discharge of faeces.

Nursing diagnosis

A state in which an individual experiences a change in normal bowel habits characterized by involuntary passage of stool

Causes

Causes may be divided into three broad categories,

1. Resulting from an underlying disorder of the colon rectum or anus.

2. Neurogenic causes

3. Resulting from faecal impaction

Any factors effecting sensation or inhibition, (physical or psychosocial inhibition)

1. Resulting from an underlying disorder of the colon rectum or anus.

Diarrhoea

* Ulcerative colitis

* Crohn`s

* Irritable bowel syndrome

* Villous papilloma (benign epithelial neoplasm)

* Carcinoma, (may also cause constipation)

* Infection

* Radiation

* Drug-induced

Muscle ring deficiency

Pelvic floor muscles support the anal sphincter, weakness will lead to stress incontinence,

* Congenital abnormality

* Obstetric trauma

* Other trauma eg. RTA, abuse

* Long term straining on defecation

The last three may also cause sphincter denervation due to stretching the nerve supply of the pelvic floor.

2. Neurogenic causes

Central causes

The medulla and higher cortical centres have a role in the defaecation reflex. Therefore any disorder of these may cause incontinence.

* Diminished sensation or awareness

* Cognitive deterioration

* Confusional states

* CVA

Nerve tract causes

Also the tracts between brain and bowel must be intact. Paraplegic patients may lose sensation and voluntary control.

* Spinal cord injury

* Cauda equina lesions, (from L1 down)

* Transverse myelitis

* S2 S3 nerve root damage

Total loss of S2 S3 innovation will produce a totally lax sphincter with uncontrollable incontinence

Neurological disease

* Multiple sclerosis

Skeletal muscular disorder

Impaired mobility, for whatever reason

* rheumatoid arthritis

3. Resulting from faecal impaction

By-passing

Severe constipation with impaction of faeces is probably the most common cause of faecal incontinence. Faecal desiccation occurs with the production of hard rounded "rocks" in the bowel.

This material promotes mucus production and bacterial activity resulting in foul-smelling brown fluid accumulation.

Continued over-distention of the two sphincters causes loss of tone and consequent control.

So called "spurious diarrhoea" then leaks out.

Leakage tends to be continuous without awareness.

Not always detectable by digital examination, (if higher up)

Causes of constipation

Simple constipation

No underlying pathology

* Low residue diet

* Dehydration

* Environment, (type and availability of toilet)

* Incomplete emptying or delayed defaecation

Factors include, poverty, education, dentition, lack of exercise,

Motility disorders

Increased transit time, (normal 3-7 days)

Idiopathic slow transit time can lead to megacolon

Older people have slower transit times (up to 8 - 15 days)

Often the lower colon is never completely emptied causing terminal distension

* Irritable bowel syndrome

* Idiopathic megacolon

* Increasing age, ("terminal reservoir syndrome")

Remember reduced frequency of defaecation can be normal with increasing age and does not usually require "medical" treatment

Psychiatric disorder

* Depression

* Confusion

* Anorexia nervosa

Remember in the elderly constipation may cause confusion, (ie differentiate between cause and effect)

Local pathology

* Anal fistula

* Prolapse

* Haemorrhoids

* Any painful condition may inhibit defaecation

* Diverticulitis

* Hirschsprung's disease, (aganglionic congenital megacolon)

Systemic pathology

* Endocrine disorders, (diabetes autonomic neuropathy and hypothyroid)

* Carcinoma

Iatrogenic

* Drug induced

* Immobility

* Nursing management, (eg use of bed pans)

* Laxative abuse

Drugs include, analgesics, (especially opiate), codeine, anticholinergics and anti-Parkinsonian.

Nursing observations

* Frequency

* Volume

* Change

* Unduly offensive smell

* Blood, (frank, fresh, altered, occult)

* Pus

* Pain

* Straining

* History of laxative use/abuse

* Urgency

* Diet

* Incontinence

* PR

* Peri-anal problems

* Preoccupation

* Anxiety

* Hypochondriasis

Treatment/management of faecal incontinence

As "overflow" diarrhoea is the most common cause of faecal incontinence the management/prevention of constipation/incontinence are essentially the same.

Assessment of the individual

Natural variation

Regular daily bowel action is desirable

3 times per day to 3 times per week

Therefore establish the normal for the individual

Consider changes to factors necessary to the maintance of the normal rhythm.

Factors include

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Record normal pattern, frequency?

Nature of the faeces, soft? well formed? associated pain or discomfort?

Does the faeces indicate constipation or diarrhoea, features which indicate constipation include,

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Factors which indicate diarrhoea include,

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How long has there been a problem?

When were the bowels last opened?

Are the bowels normally stimulated by a particular event, eg. gastrocolonic reflex?

Are laxatives taken, any other drugs which may effect GI function taken, eg.

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What is the normal fluid intake?

What is the nature of the diet? Factors to consider include,

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Rectal digital examination

Possible radiological examination

Presence of abnormal components, eg blood, mucous. Blood in the faeces may indicate,

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Faecal odour, check for changes, particularly offensive stools may indicate mal absorption.

Is there a need to defecate, how much notice do they have, does passing a motion leave the desire to pass more or a feeling of continued fullness.

What is the mental state of the individual.

Your key decision is,

a. to educate and treat yourself.

b. to refer for medical opinion

Factors discovered in your assessment which merit a medical opinion are,

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Specific Treatments

Management clearly depends on the cause,

Enemas, suppositories, access to toilet, manual evacuation, anti-diarrhoeal drugs, surgery.

Dietary

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Overflow

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Constipation

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Confusion/dementia

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Sphincter weakness, (muscle ring deficiency)

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Drug induced

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Neurological causes

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Paraplegia

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Painful defecation

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Acute diarrhoea

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Chronic diarrhoea

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Psychological management

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Social management, (including relationships)

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Management of specific conditions

Ulcerative colitis

Chron`s disease

Carcinoma

Infection

Radiation

Laxatives

Bulking agents

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Stool softeners

* liquid paraffin

* Castor oil

* lactulose

Irritant/chemical

* Senna

* Bisacodyl

Combined softener/irritant

* Dorbanex (carcinogenic)

Others

* Arocose oil

Per Rectum

* Glycerine, bisacodyl suppositories

* Phosphate, microenemas

Management of intractable faecal incontinence

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Encopresis in children

Treat according to cause

Congenital disorder

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Source of local pain

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Idiopathic megacolon

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Psychosocial (almost always the cause)

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