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83
of the internal anal sphincter. The external anal sphincter and levator ani muscles are
innervated by the pudendal nerve (S2, 3, 4) and is a voluntary muscle [23].
If neurological involvement is suspected, the advanced practice nurse must
assess the dermatomes in the saddle area. Sensation can be tested using sharp/dull
differentiation and light touch in the areas of S2–S4. Stroking the area around the
anus should normally elicit the anal reex (anal wink). Acute onset of perianal (sad-
dle) anesthesia with urinary retention and fecal incontinence may represent cauda
equina syndrome. This syndrome is brought on by compression of the cauda equina
in the lower lumbar spinal canal from trauma, tumor, infection/inammation, or
herniated disc [25]. This condition requires immediate intervention to prevent long-
term damage.
5.4 Diagnostic Reasoning andDifferential Diagnosis
ofFecal Incontinence
Diagnostic (clinical) reasoning involves the synthesis, interpretation, and prioritiza-
tion of the patient data from the history, physical exam, and any existing laboratory
and diagnostic imaging results available. As with any condition, the advanced prac-
tice nurse must be careful not to close off diagnostic possibilities too soon, and
consider an array of possibilities that may explain the patient’s fecal incontinence,
including red ag symptoms that may indicate serious disease and acute conditions
requiring immediate attention.
5.4.1 Common Conditions andRed Flags
Fecal incontinence can arise from a variety of etiological factors, including diet and
food intolerances, chronic diarrhea or impaction, functional and cognitive issues,
inammatory or infectious disease, congenital conditions, central or peripheral neu-
rological conditions, colorectal cancer, obstetric trauma, or post-surgical interven-
tion. Many of these conditions are discussed in detail in subsequent chapters of this
book. As fecal incontinence can be associated with a number of conditions from
different body systems, it may be useful to use a mnemonic to assist in the identi-
cation of potential conditions, followed by analysis and prioritization of the most
likely conditions, and ruling out those that are less likely. One tool is the mnemonic
VINDICATED [26] (see Table5.3).
Red ag symptoms need to be considered when constructing a differential diag-
nosis, as they should be investigated quickly and appropriate referrals made. Red
ags symptoms that may present with fecal incontinence can include abdominal
pain, rectal bleeding, unexplained anemia, blood mixed in stool, weight loss, change
in stool caliber (e.g., a ribbon like stool suggestive of rectal obstruction from a
mass) or any other recent, sudden change in bowel habits (diarrhea or constipation).
Colorectal cancer symptoms may include a change in bowel habit lasting more than
a few days, non-relief of the need to move the bowels after having a bowel
5 Clinical Assessment andDierential Diagnosis ofFecal Incontinence andIts Severity
84
Table 5.3 Application of the VINDICATED mnemonic to fecal incontinence diagnostic reasoning
Possible conditions
V=vascular Protruding internal hemorrhoids
Rectal ischemia
I=infectious/
inammatory
Diarrhea from gut infection (e.g., Clostridium difcile (C. difcile))
Perianal infections
Proctitis
N=neoplasm Anal carcinoma
Rectal carcinoma
D=degenerative Diseases of the central nervous system (e.g., cerebrovascular accident,
dementia, multiple sclerosis)
Pelvic organ prolapses
Rectocele
I=iatrogenic/injury Diarrhea from gut infection (e.g., C. difcile)
Obstetric injury (forceps, episiotomy, perineal tears) leading to
sphincter disruption or pudendal nerve injury
Spinal cord injury
Post-colon/rectal resection or anorectal surgery
Anorectal trauma
C=congenital Congenital abnormalities such as rectal sphincter malformation
Spinal bida
Hirschsprung’s disease
A=autoimmune Inammatory bowel disease
T=toxic Constipation, fecal impaction, or diarrhea as medication side effects
Food intolerance or allergy (lactose intolerance, Celiac disease)
E=endocrine Diabetes, hypothyroidism
D=depression Constipation associated with low activity/poor diet
movement, bright red rectal bleeding, dark brown or black stool, abdominal cramp-
ing or pain, weakness/fatigue, and unexplained weight loss [27]. An individual with
these symptoms should be referred for a colonoscopy as part of the investigation.
Patients with suspected inammatory bowel disease or malabsorption syndrome
would benet from referral to a gastroenterologist, although the advanced practice
nurse may initiate investigations as part of the referral. Findings on the physical
examination that require surgical referral include a suspected recto-vaginal stula or
pelvic organ prolapse beyond the introitus. Etiologies/causes of fecal incontinence
can be multifactorial or unknown (i.e., idiopathic).
5.5 Diagnostic Investigation
5.5.1 Laboratory
There are a number of laboratory test that may be undertaken to exclude or monitor
other pathologies that contribute to fecal incontinence. These include laboratory
tests for hypo or hyperthyroidism, diabetes, colorectal cancer screening, celiac
disease.
K. F. Hunter and T. Dickinson
85
Hypo or hyperthyroidism affects the body’s metabolic rate (raising or lowering),
consequently increasing or decreasing the number of bowel movements. An
increased metabolism (hyperthyroidism) will increase the number and rate of bowel
movements, which will decrease colonic transit time and create a softer stool and
possibly fecal urgency with fecal incontinence. Hypothyroidism will do the oppo-
site, increasing the possibility of constipation and impaction. Thyroid function tests
usually include Thyroid Stimulating Hormone (TSH), produced by the pituitary
gland to stimulate the thyroid gland to produce thyroxine, and thyroxine (T4). An
elevated TSH and a low T4 is indicative of hypothyroidism, and a low TSH and
elevated T4 is indicative of hyperthyroidism.
Suboptimally controlled diabetes can result in peripheral nerve damage affecting
the nervous control and sensation of the bowel, resulting in changes in gastrointes-
tinal motility and diabetes related enteric neuropathy. Bowel symptoms can arise as
changes to colonic motility and lead to constipation or diarrhea, while anorectal
dysfunction can adversely affect sphincter control [28]. Diabetes has also been
associated with an increased risk of some cancers, including colorectal cancer [29].
A random blood glucose can be ordered, although more commonly, Hemoglobin
A1c (HbA1c) is used to monitor diabetes as it measures glycated hemoglobin and
reects average blood glucose levels over a three-month period.
The Faecal Immunochemical Test is appropriate if there is any sign of gastroin-
testinal bleeding. It is a screening test for Colorectal Cancer that is specic for the
globin portion of human hemoglobin. It does not require any dietary or medication
restrictions and consequently has better patient compliance. False positives due to
mucosal inammation or medication are also reduced.
Patients with chronic diarrhea and signs of malabsorption suggestive of celiac
disease should have an IgA anti-tissue transglutaminase antibody and total IgA
(TTG IgA) blood test while on a gluten-containing diet [30]. IgA anti-tissue trans-
glutaminase antibody is an antibody produced in response to the eating of gluten,
common in those with celiac disease, where diarrhea is a common symptom. A
second blood sample may also be sent for endomysial antibody (EMA) testing in
children with suspected celiac disease. Those who are positive should be referred to
a gastroenterologist for further evaluation, including biopsy. Other relevant tests
include stool studies to identify fecal parasites or microbial infection, such as
Clostridium difcile. Stool osmolality is sometimes used in the evaluation of chronic
watery diarrhea.
5.5.2 Diagnostic Imaging
There is a wide variety of diagnostic imaging tools available to assist in the assess-
ment of fecal incontinence. Although the advanced practice nurse may not be
involved in interpretation of the test, she/he should have an understanding of the
purpose and indications of investigative testing for appropriate ordering and refer-
ral, as well as explaining investigations to patients.
5 Clinical Assessment andDierential Diagnosis ofFecal Incontinence andIts Severity
86
Proctoscopy (using a rigid scope) and sigmoidoscopy (with a exible scope) are
used to identify polyps, malignancy, and proctitis. This test is usually conducted by
a gastroenterologist, colorectal surgeon, or other health care professional with spe-
cialized training.
Anorectal manometry measures the pressures in the anal canal and distal rectum
including resting and maximal (squeeze) anal pressures, rectal compliance, and rec-
tal sensitivity to distension [31]. It can be key to understanding the underlying
pathophysiology in fecal incontinence [32] and chronic constipation unresponsive
to medical treatment [31]. Rectal compliance and sensitivity are measured by rectal
balloon ination, and probes can measure thermal and electrical sensitivity in the
anal canal. Anal resting pressure is the combined pressure of the internal sphincter,
external sphincter, and the anal cushions. There is, however, a lack of dened values
for a normal range. Patients with fecal incontinence tend to have a lower anal resting
tone than continent patients, though other factors contribute such as stool consis-
tency and rectal compliance. The maximal pressure (squeeze pressure) is the
increase in anal canal pressure with the contraction of the external anal sphincter,
usually measured from resting pressure to maximal squeeze. Reduced maximal
pressures are typically due to injury of the external anal sphincter, neurological
conditions, poor patient compliance or voluntary control. Rectal compliance and
sensitivity are measured using rectal balloon ination in the distal rectum with feed-
back from the patient regarding the rst sensation, rst urge to defecate, and the
maximum tolerable volume. Hypersensitivity is a contributor to urgency fecal
incontinence, while hyposensitivity results in passive or overow fecal incontinence
[32]. Recent advances in technology have allowed the development of ambulatory
monitoring [31] and high-resolution manometry using a catheter with over 200 min-
iature pressure sensors provides more detail of sphincter function [5].
Anorectal ultrasound and endoanal MRI measure sphincter muscle thickness and
detect muscle defects from trauma or surgical injury. Endoanal ultrasound (EAUS)
is the gold standard investigation for the structural assessment of the anal canal [32].
This test assesses the external sphincter and puborectalis muscle, and can assist in
differentiating incontinent patients with intact anal sphincters from those with
defects, scarring and atrophy due to vaginal delivery or anal surgery. It is also
extremely useful prior to surgical repair and in the evaluation of treatments.
Ultrasound can also be performed trans perineal or transvaginal, and when added to
endoanal ultrasound, provides additional information on the condition of the pelvic
oor muscles and levator hiatus. Endoanal Magnetic Resonance Imaging (MRI) has
been shown to be useful prior to sphincter repair and provides some prognostic
information; however, this is more costly than ultrasound.
Defecography (defecating proctogram or evacuation proctography) involves the
evacuation of a simulated stool (barium) and allows for both static and dynamic
measurements of the pelvic oor, puborectalis function, and anorectal angle [31].
Defecography has limited usefulness as a diagnostic test in the assessment of fecal
incontinence, but can be helpful in chronic constipation to examine for dyssynergia
characterized by a paradoxical decrease in the anorectal angle during defecation. It
is also used to identify rectal intussusception and rectocele [5].
K. F. Hunter and T. Dickinson
87
Neurophysiological testing has a long history with assessment of incontinence,
but is used less frequently as the accuracy of imaging techniques has increased. It
now tends to be used in complex cases that may be secondary to neurological dis-
ease and spinal injury. Electromyography assesses external sphincter and puborec-
talis muscle activity, although it is largely replaced now with more accurate sphincter
imaging techniques [5]. Pudendal Nerve Conduction Studies measure the nerve
conduction velocity in the pudendal nerve, but there is little evidence that pudendal
neuropathy correlates with incontinence [5].
5.6 Conclusion
Assessment and diagnosis of fecal incontinence by the advanced practice nurse
involves skills of history taking, using an approach that is considerate of the sensi-
tive nature of the problem, and specialized physical examination techniques.
Differential diagnosis must include thinking broadly of a wide variety of potential
contributors and causes, and the advanced practice nurse must use the data from the
history and physical examination to identify the most likely cause of the fecal incon-
tinence and initiate any relevant investigations and referrals.
Box 5.2 presents an example case study describing the clinical assessment of
fecal incontinence.
Box 5.2 Case Study
Mrs. P is a 55-year-old female who came to the primary care clinic with con-
cern over increasing bowel “accidents.”
History of present illness: Mrs. P describes herself as generally healthy.
Infrequent episodes of fecal incontinence (less than monthly) started to occur
at age 30, after the birth of her third child. These occurred when the stool was
loose. In the last 5 years, the episodes have started to become more frequent,
accompanied by fecal urgency. This is problematic if she is not near an acces-
sible toilet. The episodes of a large fecal loss of soft, formed stool are now
occurring at least weekly. She also nds smearing of a small amount of stool
in her panties daily. This makes her feel “dirty” all the time, and she worries
about odor, particularly when she is at work. Avoiding spicy foods, which
makes her stool loose, helped for a while. She did not report abdominal pain
or rectal discomfort, but she does describe intermittent pressure in the
perineum and rectum.
ICIQ-B total score=51. Summary: 1–2 bowel movements daily, none at
night, always needs to rush to toilet, no medications to stop the bowels (over
the counter medications made her too constipated), staining daily (wears pan-
tiliner), unable to control atus, some control of stool loss if near toilet, leak-
age (smearing) unpredictable, worries about having fecal loss during
intercourse. Quality of life score= 46, circled “10” (very bothersome) for
(continued)
5 Clinical Assessment andDierential Diagnosis ofFecal Incontinence andIts Severity
88
Box 5.2 (continued)
questions 19–23, except staying at home, which she cannot do as she works
out of the home.
Medical history: Hypertension, occasional tension headaches
Current medications: Candesartan 16mg PO daily, acetaminophen prn.
Surgical History: None
Obstetrical History: G3P3. All deliveries vaginal. The third stage of labor
was short (less than 5h), the baby was over 9 pounds, states she had tears that
required suturing
Review of systems: No additional symptoms/concerns identied
Physical exam: Weight 142 lbs, Height 5′4″
• Abdomen: at, normal bowel sound x4 quadrants, soft on palpation, no
masses, no tenderness/pain on palpation.
• Perineum/perianal tissue: Faint scarring in perineal body, posterior vaginal
orice to anterior rectum.
• Vaginal: Tissue pale pink, moist. Stage II posterior compartment prolapse.
Pelvic oor contraction graded 2 (weak).
• Digital rectal exam: Sphincter tightens on insertion of exam nger, resting
tone and voluntary squeeze are weak. Interruption of the sphincter ring at
11 o’clock on palpation, no masses. Soft bowel stool on the gloved nger.
• The NP then undertook a differential diagnosis based on history and physi-
cal exam, with the most likely diagnosis of fecal incontinence due to old
obstetrical injury to the perineal body and rectum, stage posterior compart-
ment pelvic organ prolapses, and weakness of the pelvic oor.
Investigations and plan: Anorectal ultrasound to assess defect of the anal
sphincter muscle. Results to be reviewed with Mrs. P at next visit in 3weeks,
further referral for possible surgical repair to be discussed based on results.
In the meantime, Mrs. P was asked to keep a bowel diary for 7 consecutive
days, noting the time/date of episodes of fecal leakage, stool consistency/
form, amount of stool leakage, leakage of atus, sense of urgency to reach
the toilet and if she had any sensation of incomplete bowel emptying or
blockage. She was also asked to keep a food diary to identify any foods that
cause loose stools. She was taught pelvic oor muscle exercises and pro-
vided with a pamphlet to refer to, along with a recommendation to consult a
pelvic oor physical therapist associated with the clinic for more intense
pelvic oor therapy.
An appointment was made for follow up in 3weeks. The NP reassured
Mrs. P that the symptoms, and their effect on her quality of life, were of con-
cern to the NP and clinic staff, and they would support her addressing her
concerns.
K. F. Hunter and T. Dickinson
89
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© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Z. Bliss (ed.), Management of Fecal Incontinence for the Advanced Practice
Nurse, https://doi.org/10.1007/978-3-031-94526-7_6
6
Management ofFecal Incontinence
inCommunity-Living Adults
SharonEustice
andDonnaZ.Bliss
Abstract
This chapter focuses mainly on independent, community-dwelling adults who have
fecal incontinence. This chapter includes a review of factors associated with fecal
incontinence, considerations for assessment in this population, and strategies for con-
servative management. Conservative management includes support of self-manage-
ment of lifestyle changes, including diet modications; use of medications; behavioral
interventions such as pelvic oor exercises, biofeedback therapy, and electrical stim-
ulation; and extracorporeal magnetic innervation. The chapter also addresses the con-
tainment of fecal incontinence with devices and absorbent products.
6.1 Introduction
Fecal incontinence is a prevalent and often misunderstood problem [1] that is
socially stigmatizing [2] and embarrassing to those suffering with it [3, 4]. Although
not a life-threatening disorder, fecal incontinence negatively impacts quality of life
S. Eustice
Bladder and Bowel Specialist Service Cornwall Partnership NHS Foundation Trust,
Bodmin, Cornwall, UK
e-mail: sharoneustice@nhs.net
D. Z. Bliss (*)
University of Minnesota School of Nursing, Minneapolis, MN, USA
e-mail: bliss@umn.edu
Chapter authors from the rst edition of this book:
Allison Bardsely, Assistant Professor Coventry University Coventry, UK: Allison Bardesly,
Assistant Professor Coventry University Coventry, UK: Winnie K. W. Yeung: Frankie Bates, retired
from position in 1st ed: Urology Wellness Clinic, St. Joseph’s Hospital, Saint John, NB, Canada.
92
and can be debilitating. It also has signicant adverse medical, social, and economic
consequences. There is a diversity of individuals in the community who suffer from
fecal incontinence, from young postpartum women to older adults and both sexes.
Conservative management should always be the rst-line treatment, targeting symp-
tomatic relief, an approach recommended by an international group of experts [5,
6]. Unfortunately, due to the taboo nature of this topic, many individuals will suffer
in silence and not seek medical intervention [2, 7, 8]. Many patients who do not seek
care from clinicians rely on trial and error [4, 9] approaches that may not be effec-
tive. Both patient and caregiver often do not recognize fecal incontinence as a treat-
able condition that can be improved [10, 11].
6.2 Management Overview
Initial management of fecal incontinence should focus on correcting any reversible
factors causing fecal incontinence and minimizing the physical and psychosocial
impact (e.g., pain, skin damage, embarrassment) [12]. Conservative management
relies on the participation and self-management by the patient and/ or caregiver-
supported management. Management strategies may be needed for a long period
and can be complex for some people; therefore, support of self-management from
healthcare professionals and healthcare systems is vital for success [13]. Self-
management support involves patient (and perhaps also caregiver) education and
assisting patients to increase their skills, self-efcacy, and condence to manage
their health problems. It includes the development of a plan of care with a clinician
that addresses the patient’s goals, and engagement of the patient in therapies, moni-
toring, and record keeping of progress and problems. It involves clinician follow-up
and modication of the plan as needed [13]. Individualized and patient-focused
management, protection of patient privacy, and maintenance of patient dignity are
key nursing responsibilities. The management plan also needs to be sensitive to the
cultural taboos and stigma associated with fecal incontinence [2, 14]. Healthcare
professionals must acknowledge and initiate discussions around assessment of
symptoms, and impact on the individual, as stigma may prevent an individual from
seeking care and communicating about their fecal incontinence [1, 5, 15, 16].
Fecal/anal incontinence symptom severity scales and quality of life scales
provide an estimated measure of the severity of fecal incontinence, frequency of
leakage, urgency, use of pads, and impact on quality of life [5] (see Chap. 5).
Although these scales are commonly used for research, utilizing them in clinical
practice can provide an evaluation of the effectiveness of a treatment/ manage-
ment program. The Wexner [17] and St. Mark’s [18] anal incontinence scores
are two scoring systems that have been utilized in practice [5]. Three subtypes
of fecal incontinence are passive, urge, and functional incontinence (see Chap.
1) [5]. Assessing fecal incontinence severity, the degree of bother to the patient,
and any subtype present is important to understanding treatment approaches and
patients’ goals for management [5, 19].
S. Eustice and D. Z. Bliss