Diagnosis

• Focussed baseline assessment required: identify contributory factors
  • Hx and Exam including Ano-rectal examination
  • Cognitive assessment where necessary
• Management of condition specific interventions:
  • Faecal loading
  • Treatable: Infective; IBD etc
  • Lower Gastro Cancer
  • Rectal prolapse
  • Anal sphincter injury (3rd and 4th degree obstetric injury)
  • Cauda equine / disc prolapse

Investigation

• n/a

Management

Conservative

• Diet manage stool consistency, modify 1 item a time, nutritionally balanced, consider malnutrition
• Dehydration / hard stools: manage 1.5 Litres per day
• Bowel habit training: post meal, private accessible toilet, avoid straining, sitting or squatting
• Emotional and psychological support
• Offer continence products: sufficient body worn disposable pads, anal plug, skin care, odour control

Medication

• Consider drugs that may cause incontinence, excessive laxative use or dietary factors first
• Offer anti-diarrhoeal (Loperamide) once these causes excluded, initial low dose, increased as req’d
• Do not give Loperamide if: Acute diarrhoea without known cause, UC, hard stools
• If faecally loaded: rule out obstruction then offer rectal laxative, or oral if unsuccessful

Specialist Intervention – especially neurological spinal disease / injured patients

• Pelvic floor muscle retraining: monitored by digital assessment
• Bowel retraining
• Rectal irrigation
• Electrical stimulation
• If remain symptomatic consider: ano-rectal physiology studies and imaging
• If remain symptomatic: emotional and psychological support, 6 mth review
• If cognitively impaired consider behavioural and functional analysis to determine if behavioural

Surgical

• Surgical repair for those with full length external sphincter defect greater than 90 degrees
• Factors reducing effectiveness: pudendal nerve injury, internal sphincter injury, external atrophy
• If surgery not an option consider sacral nerve stimulation
• If nerve stimulation unsuccessful consider neo-sphincter: graciloplasty or artificial anal sphincter

NICE Source: CG49 Faecal incontinence in adults: management. Summary compiled by Dr D P Sheppard MBBS.