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103
Table 6.2 Example diet and uid intake diary
Meal 1 Meal 2 Meal 3 Snacks
Nonalcoholic
drinks, number of
cups/glasses, ml,
or ounces
Alcoholic
drinks, number
of glasses, and
ml or ounces
Other
comments (e.g.,
food from a
restaurant, etc.)
Type of food and how prepared
(e.g., baked, fried, etc.)
Day Date Time
Monday
Tuesday
6 Management ofFecal Incontinence inCommunity-Living Adults
104
Exercise has a similar effect [55]. To establish a “normal” bowel pattern, recommend the
patient eat at regular times, avoid aggravating foods, attempt a bowel movement after
eating, and exercise regularly. Once established, changes can be made if necessary to
their usual eating habits, especially promoting a high-ber diet and encouraging high
water intake. Educating the patient regarding rectal fullness, listening to body signals
indicating the need to defecate (so as not to “miss the moment”), and adopting satisfac-
tory toileting routines can promote more normal bowel habits.
Often, individuals are apprehensive about having a bowel movement in a public
place due to fear of odors, noise, atulence, etc. Odor eliminators/reducers that
neutralize the smells associated with defecation can encourage individuals to use
public toilets. These products are available in either odorless or scented sprays or
drops that can be placed in the toilet bowl before a bowel movement.
With increasing volume in the rectum, an urge to defecate occurs. If this initial
signal of rectal fullness is ignored, it can lead the patient to miss their bowel move-
ment completely that day. The urge may disappear over time. Liquid stool can be
very hard to control as it will rapidly transit through the intestine into the rectum.
The rectal sphincter mechanism cannot always withhold liquid stool for the time it
takes to get to the toilet. Therefore, adjusting the consistency of the stool away from
the liquid form is paramount. A study by Collins etal. [56] showed that 81% of
patients completing a program of therapy by a specialist physiotherapy or nurse
improved symptoms (per the St. Mark’s anal incontinence score). The program con-
sisted of a median of three visits with these specialists. The fundamental role of the
nurse (or physiotherapist) in assessing and treating fecal incontinence is not to be
underestimated [57].
6.8.1 Management Recommendations forRegular Bowel Habits
• Teach the patient the recommended position on the toilet as needed.
• Advise the patient to eat meals, sleep, and rise at regular times.
• Advise the patient to defecate about 30min after meals, to take advantage of the
gastrocolic reex, and before bed.
• Advise the patient to avoid foods that aggravate fecal incontinence and drink
recommended amounts of uid, considering any health conditions.
• Teach the patient to complete a bowel diary/chart for 1–2weeks and evaluate
their report at a follow-up visit to inform the treatment plan.
6.9 Taking Control: Rectal Evacuation
Patients with fecal incontinence often feel that they have no control over their bowel
function, and this transfers to feeling as if they have no control in their lives [4, 5]
(see Chap. 1). They will often describe how they are unable to leave their homes
until “their bowels are empty” for fear of having an accident. They may describe
devastating outings during which they had an episode of fecal incontinence while
running their errands [4]. Therefore, the psychological impact of the lived
S. Eustice and D. Z. Bliss
105
experience should be considered by the advanced practice nurse and ensure that
consultations seek to understand the impact on the patient [58].
Advising and educating patients about how to evacuate their rectum completely,
before any outings and in the comfort of their own home environment, may help to
give them a better sense of control. Suggesting interventions to empty their bowel,
such as the use of a glycerine or bisacodyl suppository per rectum upon arising and
following their rst meal/drink of the day, will help them to evacuate most of their
rectal contents. This should prevent accidents and enable them to exercise, social-
ize, work, and manage their daily chores with less worry. If a glycerine suppository
is ineffective for rectal evacuation, the patient may need to use a small enema. This
can be conducted independently or by the caregiver. These enemas come in dispos-
able units and should not cause the patient a lot of discomfort. Trans-anal irrigation
is another option to use to evacuate the bowel.
6.9.1 Trans-Anal Irrigation
Trans-anal irrigation (TAI) has been used by patients with neurogenic bowel prob-
lems for many years to manage both fecal incontinence and constipation (see Chap.
9). Additionally, other patients, especially those with passive fecal incontinence or
incomplete evacuation, may nd performing TAI using mini-irrigation devices
helpful [56, 59]. Three examples of these irrigation devices are the Qufora® (MBH
International A/S, Allerod, Denmark) and Peristeen® (Coloplast A/S, Humblebak,
Denmark devices and Aquaush Compact info@clinisupplies.co.uk (see Chap. 9).
The use of TAI by community-living adults with fecal incontinence is increasing
as it can provide individuals with some control over bowel and rectal emptying.
Trans-anal irrigation Trans-anal irrigation is described in detail in Chap. 9. Briey,
it is used to empty the contents of the large bowel in a place and at a time convenient
to the individual. While seated on the toilet, the individual slowly instills water
through a small external catheter into the rectum through the anus. When the cath-
eter is removed, the water and fecal matter are emptied from the bowel into the
toilet. Most individuals will irrigate on alternate days; however, the volume of water
required and frequency of use vary between individuals. The procedure is designed
to be self-administered, but carers/ healthcare professionals can also be utilized to
assist. Careful selection of suitable individuals is important to maximize effective-
ness, prevent complications, and maximize quality of life [60, 61]. Some reasons
patients discontinue TAI are procedural problems (e.g., catheter falls out), pain,
taking too much time, and lack of satisfaction with the result [62].
6.9.2 Management Recommendations forBowel Evacuation
• Assess the potential capability of performing and the benet of bowel and rectal
evacuation.
• Teach patient and/or caregiver appropriate procedures (for using a suppository,
mini-irrigation system, etc.).
• Ensure use of patient-friendly information and implement timely follow-up/review.
6 Management ofFecal Incontinence inCommunity-Living Adults
106
6.10 Practical Coping Strategies
Coping with fecal incontinence is enhanced for some patients by a sense of con-
trol and preparedness for preventing accidental leakage or managing it if it occurs
[4]. A common coping strategy is knowledge of the location of the closest toilet
when in public places [4, 34]. This knowledge can prevent leakage, especially
when there is urgency. There are mobile applications (for example, searching toi-
let nder in the application store) that can assist inlocating toilets and in mapping
routes while traveling short or long distances. In restaurants, a request can be
made for seating at tables nearer the toilet/restroom without divulging the reason
for the table selection [34]. Awareness of typical times of leakage, often by keep-
ing a bowel diary, can be helpful for scheduling appointments outside the home
around these times. Women report that carrying a small kit in their purse or hand-
bag containing moist wipes for cleansing, an absorbent pad, underwear, and a
plastic bag for soiled items increases their feelings of security [4]. Women and
men feel that they can provide advice and support to others with fecal inconti-
nence after gaining experience and developing condence in self-managing their
own condition over the years [5, 63, 64].
6.10.1 Management Recommendations toPromote
Practical Coping
• Inquire about the patient’s current level of coping and strategies used.
• Share practical strategies for coping with fecal incontinence used by other
patients to increase a sense of control.
• Suggest participation in a support group if available.
6.11 Medications
6.11.1 Medication Review
Several medications can exacerbate fecal incontinence [65], and so a medication
review should form part of the clinical assessment (see Chap. 5). A medication
review should consider any prescribed medication as well as over-the-counter medi-
cations, herbal remedies, and recreational drugs, as these may have unintended side
effects which can aggravate or cause fecal incontinence. Nitrates and calcium chan-
nel blockers can decrease sphincter tone, whereas metformin and some antacids
(e.g., those containing magnesium) can lead to loose stools. Excess vitamin and
mineral supplementation can loosen stools. Long-term laxative use can lead to
incontinence in some patients. Box 6.3 lists some of the medications that can exac-
erbate fecal incontinence.
S. Eustice and D. Z. Bliss
107
6.11.2 Medication Treatment
Many individuals will use a combined approach for managing fecal incontinence,
for example, diet and uid modication, medications, and behavioral therapy. The
use of medication focuses on three main aspects: the reduction of diarrhea, increas-
ing resting anal canal pressure, and treatment and/or prevention of constipation
[66]. Medications used to treat diarrhea act to improve stool consistency by slowing
intestinal transit or optimizing uid reabsorption, thereby increasing the viscosity
and overall volume of the stool. About 8–10 L of uid enters the small intestine
daily. The majority of this is reabsorbed in the small intestine and the colon.
Types of medications used to treat fecal incontinence are synthetic opioid deriva-
tives, loperamide, codeine phosphate, co-phenotrope, and cholestyramine. Opioids
produce an agonist effect on m or d opioid receptors on the enteric nerves, epithelial
cells, and muscle. The effects of opioids include decreased intestinal motility (m
receptors) and decreased intestinal secretion (d receptors), and increased absorption
(m and d receptors) [67]. Loperamide, codeine phosphate, and co-phenotrope act
primarily by peripheral m opioid receptors and have minimal central nervous sys-
tem (CNS) effects. Loperamide hydrochloride can be used in doses from 0.5 to
16mg per day in divided amounts. A typical starting dose is 2mg four times per day
(after meals and before bed). Loperamide is an opiate derivative that acts by increas-
ing the transit time through the small intestine and proximal colon, which promotes
water reabsorption and improves stool consistency [44, 66]. Loperamide also
impairs the recto-anal inhibitory reex and increases anal resting pressure and
reduces secretion in the bowel [68, 69]. Loperamide has a good safety record with
a low side effect prole. The main disadvantage of loperamide is that it can cause
constipation and abdominal pain, and as such, should be started at low doses and
titrated as required.
Box 6.3 Types of Medications That Can Worsen Fecal Incontinence
• Medications that alter sphincter tone: nitrates, calcium channel antago-
nists, β-blockers, sildenal, and selective serotonin reuptake inhibitors
• Broad-spectrum antibiotics (multiple mechanisms): cephalosporins, peni-
cillins, and macrolides
• Topical anal medications: glyceryl trinitrate ointment, diltiazem gel,
bethanechol cream, and botulinum A toxin
• Medications causing loose stools: laxatives, metformin, orlistat, selective
serotonin reuptake inhibitors, antacids containing magnesium, and digoxin
• Constipating medications: loperamide, opioids, tricyclic antidepressants,
antacids containing aluminum, and codeine
• Tranquillizers or hypnotics (reduce alertness): benzodiazepines, tricyclic
antidepressants, selective serotonin reuptake inhibitors, and antipsychotics
6 Management ofFecal Incontinence inCommunity-Living Adults
108
Patients who are unable to tolerate loperamide hydrochloride can be offered
codeine phosphate or co-phenotrope [29]. Codeine phosphate acts in a similar way
to loperamide, although it has a greater side effect prole in long-term use. Codeine
phosphate can cause side effects such as constipation and drowsiness, which limit
its use. Combining the use of both loperamide and codeine phosphate may be use-
ful. Co-phenotrope (a proprietary mixture of diphenoxylate and atropine) acts on
the smooth muscle of the intestinal tract, inhibiting gut motility and excessive gut
propulsion. However, as it can cross the blood-brain barrier, it can cause euphoria
and dependence in long-term use [33].
Cholestyramine is a medication used for bile acid malabsorption. This often-
overlooked condition can lead to chronic diarrhea, increasing the risk of fecal incon-
tinence [70]. When food is consumed, bile acids are produced in the liver, kept in
reserve in the gallbladder, and then discharged into the small intestine. The ileum is
where nearly all the bile acids are reabsorbed and eventually passed back to the
liver. Bile acid malabsorption is the phrase used to describe the disruption of this
cycle. Cholestyramine helps to prevent diarrhea by binding the bile salts in an effec-
tive manner [71].
Overall, evidence for these medications is limited. However, Loperamide hydro-
chloride has been studied the most, and results suggest clinical effectiveness for the
right patient [5, 72]. Individuals with evacuation difculty or post-defecation fecal
incontinence may benet from using suppositories, mini-enemas, or trans-anal irri-
gation to empty the rectum of fecal contents or provide a regular bowel evacuation.
6.11.3 Medications forImpaction/Constipation-Related
Fecal Incontinence
Suspected impaction or constipation as a cause of fecal incontinence should be
identied and treated before initiating treatment specic to fecal incontinence.
Accumulation of feces in the rectum can cause rectal distension and secretion and
partial opening of the internal anal sphincter. Medications that can be constipating
are loperamide, opioids, codeine, tricyclic antidepressants, and antacids containing
aluminum. Constipation is treated with diet, uid, and lifestyle modications such
as increasing physical activity, as previously discussed. However, for those indi-
viduals for whom this is ineffective or inappropriate, stool softening and stimulant
laxatives should be the rst choice. A regime should start with regularly adminis-
tered osmotic agents (e.g., polyethylene glycol), with the addition of a stimulant
laxative such as senna on an as-required basis [73]. Polyethylene glycols (macrogol
laxatives) are increasingly being used for chronic constipation [74], and there is
clear evidence that these are superior to lactulose and ispaghula husk [75, 76].
Table6.3 lists oral laxatives for fecal impaction or constipation. Although oral med-
ication is always preferable, a combination of oral laxatives and rectal interventions
(enemas or suppositories) may be required initially [77]. Rectal stimulants include
bisacodyl and glycerine suppositories. Rectal stimulants can be used alone or in
S. Eustice and D. Z. Bliss
109
Table 6.3 Oral laxatives for fecal impaction or constipation
Type of
laxative
Name Action
Considerations
Stimulant Senna®,
bisacodyl®,
co-danthramer®,
co-danthrasate®,
dioctyl®, docusol®
Stimulate an increase
in colonic motility
(peristalsis) and
mucus secretion
Stimulant laxatives are rapid
acting, usually taking effect in
8–12h
They are best taken in the evening
or at bedtime. Stimulant laxatives
are effective when used with
bowel management programs,
where predictable rectal contents
are required prior to performing
digital stimulation or digital
removal of feces. Prolonged use
can be justied for some patients,
but monitoring of potassium and
electrolytes may be required
Osmotic Lactulose ® and
magnesium salts
Osmotic laxatives act
by drawing uid from
the body into the
bowel by osmosis.
This increases the
water content of the
feces, making it softer
and easier to pass
It can take 2–3days to see an
effect
Larger doses can lead to
dehydration
Isosmotic Macrogol oral
powder compound
(3350)
(polyethylene
glycol, PEG)
Cosmocol®,
Laxido®, Movicol®
Macrogol laxatives
increase stool water
content and directly
trigger colonic
propulsive activity
and defecation. This
has a four-in-one
mode of action: bulks,
softens, stimulates,
and lubricates
Macrogols are licensed for fecal
impaction and can be used for
chronic constipation
combination with digital stimulation and digital removal of feces. Consideration
should also be given to overdosing of laxatives, which may lead to fecal inconti-
nence, due to incorrect use [78].
6.12 Behavioral Therapies
6.12.1 Pelvic Floor Muscle Training
Pelvic oor muscle training is recommended as part of the initial therapy for man-
aging fecal incontinence [5]. Pelvic oor muscle training is low risk and, with
emerging evidence, is now recommended for fecal incontinence [5, 79]. The pelvic
oor muscle consists of approximately 70% slow-twitch (type 1) and 30%
6 Management ofFecal Incontinence inCommunity-Living Adults
110
fast-twitch (type 2) muscle bers [80]. Pelvic oor muscle weakness is recognized
as one of the problems encountered in patients with incontinence, and reeducation
should address the perceived decit.
The aim of pelvic oor muscle training is to teach the patient to isolate and cor-
rectly contract the pelvic oor muscles to increase strength, endurance, and coordi-
nation of sphincter function. The individual is instructed to contract and relax the
muscles for progressively longer periods of time, approximately three times per day
in different positions (sitting, lying, and standing). Repeated contractions (working
toward 10 per time) are thought to improve continence through increased support
for the pelvic organs [81]. The individual is encouraged to perfume the exercises
during routine daily activities such as upon awakening in bed and waiting in a line
at a grocery store to increase adherence.
Instruction can be simple verbal education, although many individuals will tend
to use incorrect muscles (such as gluteal and abdominal muscles) to extenuate their
pelvic oor contraction. A nger digit placed vaginally or rectally by the practitio-
ner as well as a hand placed externally on the perineum will often help to instruct
the patient to isolate the pelvic oor muscles. This technique will also enable the
practitioner to feel the strength and endurance of the patients’ pelvic oor muscle
contraction as well as assess rectal tone and the presence of any prolapses.
Thoracoabdominal pelvic muscle training has also been advocated, as it has been
theorized that training all core muscles to work in tandem may be more effective
than a narrow focus on the pelvic oor muscles alone [82].
6.12.2 Biofeedback Therapy
Biofeedback therapy is an effective way of increasing proprioception of the location
of the pelvic oor muscles, thereby improving treatment outcomes for fecal incon-
tinence. Biofeedback therapy is a term that can be used to describe many different
types of training regimens for different muscle groups, including the pelvic oor. It
is dened as the process of gaining greater awareness of many physiological func-
tions, primarily using instruments that provide information on the activity of those
functions, with the goal of being able to manipulate them by the patient themselves
[83]. Biofeedback can be used to gain awareness of the pelvic oor muscle group by
using striated muscles that are under voluntary control. Since many patients have
difculty in identifying, controlling, and coordinating the function of the pelvic
oor muscle group, patients may perform them ineffectively if the practitioners give
only verbal instructions for pelvic oor muscle exercises.
Biofeedback can help to increase strength and endurance of the pelvic oor and/
or anal sphincter. The biofeedback apparatus gives information about how strongly
the muscles are being contracted, whereby the patient can use that information to
learn how to do the pelvic oor exercises more effectively. It is also thought that
biofeedback motivates the patient to improve by giving information on performance
and progress. The theory behind strength and endurance training of the sphincter
S. Eustice and D. Z. Bliss
111
muscles or the detrusor muscle is that the patient will be able to hold in the stool or
urine for a longer period, enabling them to make it to the toilet with fewer accidents.
Biofeedback can range in varying degrees from simplistic to more complex ther-
apies. Simple techniques range from telephone discussions to face-to-face visits
with verbal education only [84]. More complex therapies include medical-grade
equipment, ranging from a simple pelvic oor home exerciser (like that used by Dr.
Arnold Kegel over 50years ago) to more complex models. These modules give the
patient a visual representation of how well they are contracting their pelvic oor,
showing both strength and endurance. Pressure probes can be used either vaginally
or rectally or for less invasive treatments; EMG electrodes can be applied. Surface
electrodes are also placed on the gluteal or abdominal accessories to ensure the
patient does not use their accessory muscle to help extenuate their pelvic oor con-
traction. Box 6.4 describes an example biofeedback protocol.
Biofeedback therapy can also be utilized for dyssynergic-type evacuation of
stool and enhance relaxation of the external anal sphincter [85]. This should be
combined with learned techniques of correct positioning on the toilet and relaxation
to defecate as discussed earlier in the chapter.
Biofeedback therapy should always be used as an adjunct to other conservative
therapies (including diet and uid modications, techniques to improve evacuation,
bowel training programs, management of stool consistency, and review and modi-
cation of medications if necessary). These will benet approximately 25% of
patients and should be the rst line of treatment [86]. Home exercise programs of
specic regimes of repetitions and development of an individualized pelvic oor
muscle training program are essential for biofeedback to be effective. Biofeedback
regimens vary from 6 to 12 weekly or biweekly treatments, and no standardization
is seen in the literature. Heymen etal. [87] reported that patients treated with bio-
feedback and pelvic oor muscle training were signicantly more likely than
patients treated with pelvic oor muscle training alone to report adequate relief
(76% vs. 41%).
Most of the data in the literature relate to biofeedback to treat urinary inconti-
nence, and certainly, more studies need to be conducted for the treatment of fecal
incontinence. The 7th International Consultation on Incontinence (ICI) considers
the role of biofeedback to treat fecal incontinence, and although more RCTs are
advised, it is a worthwhile adjunct in combination with other therapies [5].
For fecal incontinence, biofeedback therapy can also be used to improve rectal
sensitivity and/or compliance. This type of treatment has also been termed volumet-
ric rehabilitation or discrimination training and is typically done with rectal bal-
loons [88]. The balloon is inated with air or water to determine the rst sensation
of rectal lling. It is then gradually inated with decreased amounts of air or water
to teach the patient to sense stool in the rectal vault at progressively lower volumes.
Normally, as the rectum lls up, the rectal walls expand. Stretch receptors in the
rectal walls stimulate the desire to defecate. If the person does not defecate on feel-
ing this urge, the stools may return to the colon, where more water is absorbed. The
rectal balloon allows for the patient to have more time to perform a voluntary anal
6 Management ofFecal Incontinence inCommunity-Living Adults
112
sphincter contraction before the volume of stool in the rectal vault overwhelms the
patient’s ability to hold it inside.
Rectal balloons can also be used on patients with fecal urgency and rectal hyper-
sensitivity; in those cases, the balloons are simply inated to progressively larger
volumes, which the patient is then coached to tolerate without feeling the need to
expel the rectal contents.
Box 6.4 Example Biofeedback Protocol
A protocol used in a clinic in Canada tailors the treatment regimen to the cli-
ent’s progress. Six weekly treatments are given initially; if the patient requires
further time management, this can be evaluated and offered. Treatment is con-
ducted using pressure probes either vaginally or rectally and surface elec-
trodes either on the abdominal muscles or the gluteal muscles (dependent
upon which accessories the patient is using when the initial assessment is
performed). The patient receives visual cues to start and stop their pelvic oor
contraction, and they can visualize their strength and endurance with a graphic
representation of their contraction. The patient is also able to visualize if they
are using their accessory muscles and, over time, try to use them less.
The treatment paradigm is structured specically for the patient. If they
have a weak contraction of 1–3μV and poor endurance of 2s, then the patient
needs to be encouraged to isolate their pelvic oor muscle and hold for a lon-
ger period. Goal lines can be added to the biofeedback treatment graph to help
the patient. Initially, the patient is taught slow-twitch exercises to increase
strength and endurance in the slow-twitch muscle bers of the pelvic oor.
The treatment duration is 15min. Once the patient has shown that they can
isolate well, without the use of any accessory muscles, and their strength and
endurance are improving, they are then taught fast-twitch exercises. They are
taught to do 10 quick repetitions of their pelvic oor muscle (described as
“icks”) in 10s. This will help them to be able to recruit their pelvic oor
muscle more readily when they use their pelvic oor muscle appropriately to
suppress a bowel movement or to defer their urge to defecate until reaching
the toilet.
Over the 6-week period, depending on how the patient progresses, the goal
lines can be increased to help the patient hold their contraction longer or
increase their strength.
The advanced practice nurse needs to ensure that the patient is compliant
with their daily home program in between weekly sessions. The patient should
be started on an individualized pelvic oor muscle training program. This
would typically be three sets of ten exercises, three times a day [33, 89]. If the
patient is found to tire easily, this routine can be reduced. The patient is
instructed to hold for 5s and rest for 5s, and gradually increase the time to
10s. Written instructions have been found to be valuable to patients in remem-
bering their routines.
(continued)
S. Eustice and D. Z. Bliss