Clinical

Diagnosis

Faecal Incontinence

Background

  • Urgency and faecal incontinence affects up to 10% of adults, but in only about 0.5–1.0% is the condition sufficiently disabling to affect their quality of life.
  • It is more common in the elderly, severely ill and frail, in the very young, and in those with spinal and neurological disorder, severe cognitive impairment or learning disabilities. Outside those groups, it is more common in women, where it is usually associated with obstetric injury to the pelvic floor. It is also a frequent complication of pelvic organ prolapse, colonic resection or anal surgery, pelvic radiotherapy and ingestion of some medications.
  • Faecal incontinence is more extreme and troublesome if the patient has diarrhoea or loose stools.
  • Minor leakage is associated with perianal soreness and itching.
  • Physiologically, faecal incontinence is the result of a complex interplay of defects in the anorectal continence mechanism, bowel irritability and behavioural or psychological factors, some of which may be relatively simple to reverse. Therefore, a detailed assessment and a structured approach to management is required.

Patient View

  • Faecal incontinence can be a major disability, disrupting a person’s social life, impairing sexual intimacy, making it difficult to go out to work, and severely impair quality of life.
  • For understandable reasons, faecal incontinence has remained a largely hidden problem, with many patients feeling too embarrassed or ashamed to admit their symptoms to healthcare professionals, or even to family and friends.
  • Access to clean toilets is a key factor and must be addressed by the provision of internet based apps such as loo seeker, can’t wait cards (as provided by The IBS Network) and RADAR key to allow access to ‘disabled’ toilets (National Key Scheme).
  • Patients need to be informed about continence products, pads, anal plugs, skin care and access to emotional and psychological support services.
  • Special consideration should be given to the needs of hospitalised and frail people and those with limited mobility, spinal disorders, neurological and cognitive impairment. Access to appropriate equipment and clothing is essential.

Current Practice

  • Mild degrees of urgency and occasional faecal incontinence are often at home by behavioural adjustment and bowel regulators, esp loperamide.
  • Patients with more severe difficulties are often referred to gastroenterologists and general surgeons in the local DGH, who may not have access to specialist procedures and advice.

Recommended Practice and Opportunities for Integrated Working

  • Where faecal incontinence occurs as a complication of another disease, for example diarrhoea caused by gastroenteritis, inflammatory bowel disease or irritable bowel syndrome, or faecal impaction with overflow incontinence, the primary condition should be treated first. Only if faecal incontinence remains a significant problem after bowel regulation, should referral to a specialist unit for incontinence be contemplated.
  • An integrated continence service with specially trained professionals should be established in a network of supraregional centres. This would incorporate physiological testing, access to specialist radiological and ultrasound techniques (endo-anal ultrasound), dietary and psychological assessments, neurological examination and specific management procedures such as biofeedback, pelvic floor muscle training, electrical stimulation, rectal irrigation and specialist surgery.
  • Local clinical teams should work with local or national organisations/charities to raise awareness of the caused, prevalence and symptoms of faecal incontinence and the resources and equipment needed to manage it, to facilitate mutual support, decrease the stigma and encourage people with faecal incontinence to seek appropriate help.

Opportunities for Savings

  • A network of specialist continence units would establish effective treatment procedures and plans and reduce the occurrence of planned and unplanned admissions.
  • Follow up could be conducted in primary care by practice nurses with prompt access to the specialist unit.

Quality Indicators (Outcome Metrics)

  • Ready access to specialist continence units.
  • Local continence nurses
  • Patient satisfaction (that their illness is taken seriously and treated promptly).
  • Delay before diagnosis.
  • Days off work.

Social Policy and Public Understanding

  • Provision and improved access to public toilets.
  • Acceptability of can’t wait cards
  • Well publicised provision of specialist units for faecal incontinence.
  • Faecal inconsistence is very common, seldom discussed and not well managed. We think there is a case for national development of a patient reported outcome measure that can be applied locally. This would need to be accompanied by a campaign to overcome stigma and encourage discussion.

References