Assessment of Fecal Incontinence

The patient assessment is crucial to finding out as much as possible about the patient’s incontinence.  

Direct questions to screen for presence of fecal incontinence Medical history:       Risk factors: gastrointestinal tract, cognitive & nervous system problems       Surgeries, obstetric history       Medications, including supplements       Dietary history: fiber, sweeteners, food triggers Physical examination:       Rectal exam       Neurological examination  Additional testing (e.g., stool studies, colonoscopy)

In a recent review, only about 10-30% of patients with fecal incontinence discussed it with their doctor. And of those who did, 88% said they initiated the conversation.

A fecal incontinence history should include the onset, frequency, volume, presence of blood, and type (gas, liquid, solid).

The Fecal Incontinence Severity Index (FISI) survey was designed to ask these questions and it a good way for the clinician to learn about their patient’s incontinence.

 

Surgical and obstetrical histories should be included in the risk evaluation. Also a medication history (including nutrient and herbal supplements), and diet information can provide clues about potential causes for fecal incontinence like lactose or gluten.

The physical examination should focus on a rectal exam as well as a related neurological examination.

 

There are three basic types of physical exams: the external inspection, the digital exam and a basic instrumentation exam.

The external exam is just that, where the clinician looks for the presence of stool, skin irritation, past surgical scars and other pathologies.

The digital exam can provide a clearer picture of the patient’s anal ‘resting and squeezing pressures’, as well as other things that can affect sphincter integrity.

And some additional basic instrumented testing may be warranted to determine any underlying issues.

 

Fecal Incontinence: Self-Care Treatment Options

Now let’s take a look at some of the treatment options, starting with self-care.

Dietary changes Supportive measures

We’ve talked about some of the things in your diet which can cause fecal incontinence—things like eating high-fiber foods, drinking plenty of fluids and getting regular exercise to help with constipation, and avoiding alcohol, caffeine and nicotine, along with possibly lactose or gluten, to help with diarrhea.

There are also several “supportive” measures which can be implemented in an effort to protect the adjacent skin from damage. These include protective zinc-oxide-based ointments and other similar products, gentle soaps and wipes, and pads. When used together they have been proven to be quite effective.[4]

 

Which brings us to bowel training.

Bowel training              Exercises to strengthen pelvic floor muscles              Biofeedback              Smoking cessation              Fecal containment              Surgical options

When the pressure of the stool in the rectum is greater than the pressure exerted against it by the pelvic floor, a bowel movement is triggered. So this means that the pelvic floor must be able to contract to allow bowel continence to be maintained. But this also means that those same muscles must able to relax in order to allow for defecation. If the pelvic floor muscles are unable to relax enough then some of the following therapeutic treatments should be tried:

Bowel training may help to trigger a bowel movement. Patients should be instructed to assume a sitting position on the toilet or bedside commode, then contracting abdominal muscles while bearing down to release the stool. Daily performance of this process, especially 20-40 minutes after a meal to stimulate bowel activity, is meant to establish a regular pattern of bowel movements. 

 

As for Kegel exercises, they can strengthen the rectal muscles and help in the control of bowel movements for people who are having trouble with their rectal sphincter. Kegels are most effective when used in conjunction with a regular exercise program.

 

Fecal containment

Perhaps the most useful products for fecal incontinence are those used for fecal containment. Pads and briefs are helpful, and varying options are available depending on the extent of the leakage. The come in a variety of shapes and sizes, and a continence nurse can be very helpful in finding the right product.

 

Surgical options

If bowel continence is not being achieved through dietary changes, bowel training and other non-surgical options, then surgery is considered.

Surgical options consist of sphincter repair or replacement, as well as a couple of other procedures. Sphincter replacement can be done with an artificial inflatable cuff, which is implanted around the anal canal.

There is also a surgery where the gluteus maximus muscles are wrapped around the anal sphincter to restore function, and sacral nerve stimulation is another procedure where electrodes are implanted to help the sphincter muscles to contract and relax.