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73
© 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_5
5
Clinical Assessment andDifferential
Diagnosis ofFecal Incontinence andIts
Severity
KathleenF.Hunter
andTamaraDickinson
Abstract
Assessment and diagnosis of fecal incontinence by the advanced practice nurse
involves critical thinking in the process of differential diagnosis of fecal inconti-
nence. Fecal incontinence is a stigmatized condition that requires the advanced
practice nurse to approach the patient from a perspective of cultural competence,
demonstrating respect and acknowledgment of the sensitive nature of the con-
cern. History taking starts with symptom assessment, as well as gathering a com-
prehensive health history. Use of a standardized symptom assessment instrument,
particularly one that includes quality of life, can be helpful. The physical exami-
nation includes abdominal examination, vaginal examination in women, assess-
ment of pelvic muscles in both women and men, and rectal examination. Arriving
at the differential diagnosis must take into account the data gathered in the his-
tory and physical exam, as well as consideration of the breadth of potential
causes, including red ag symptoms and signs. Laboratory investigations for
specic conditions that may contribute to fecal incontinence may include tests
for suspected hyper- and hypothyroidism, diabetes, celiac disease, colorectal
cancer screening, and infection. Diagnostic imaging to further evaluate fecal
incontinence may be ordered by the advanced practice nurse or be accessed
through referral.
Chapter author from the rst edition of this book:
Veronica Haggar, Clinical Nurse Specialist, Bladder and Bowel UK, Manchester, UK.
K. F. Hunter (*)
Professor Emeritus, University of Alberta, Edmonton, AB, Canada
e-mail: kathleen.hunter@ualberta.ca
T. Dickinson
UT Southwestern Medical Center, Dallas, TX, USA
e-mail: tamara.dickinson@utsouthwestern.edu
74
5.1 Introduction
The nursing process begins with assessment, from which the advanced practice
nurse initiates the critical thinking and differential diagnosis processes. Evidence-
based clinical decision making involves evidence-based research and theory, sub-
jective and objective assessment, patient preferences and values, and clinical
expertise [1]. Fecal incontinence management is often a collaborative process
between the advanced practice nurse and patient/caregiver in which patient- centered
expected outcomes are key to the development of a comprehensive plan.
Unique to nursing is the holistic health model in which the person is seen and
evaluated as a whole individual. For the advanced practice nurse to practice effec-
tively, cultural competence is crucial. This concept may be even more important
when sensitive topics such as fecal incontinence are discussed. The advanced
practice nurse needs to provide effective care as well as respectful care within the
framework of cultural competence [1, 2]. Cultural competence begins rst and
foremost with respect. In addition to cultural competence, the advanced practice
nurse needs to understand the sensitivity of this issue and approach the interview
and discussion with care. Research has shown that stigma associated with fecal
incontinence may create barriers to seeking care for both men and women [3]. The
taboo of this issue has been a catalyst for work that includes anti-stigma aware-
ness and education programs [4].
The 7th International Consultation on Incontinence identies that initial clinical
assessment of fecal incontinence should include: history, physical examination,
medication and diet (food and uid) review, and assessment of impact on quality of
life [5]. Box 5.1 provides an overview of the steps for assessment of fecal inconti-
nence, incorporating current practice recommendations [6]. As many people may be
reluctant to discuss this condition, active case nding is recommended and the
advanced practice nurse should inquire about any problems patients experience with
anal or fecal incontinence.
Box 5.1 Steps in Assessment of Fecal Incontinence
• Taking a thorough history allows the advanced practice nurse to under-
stand the concern from the patient’s perspective.
– The advanced practice nurse must demonstrate an open and respectful
manner to build rapport about a sensitive topic.
– The focused history should include: A methodical symptom assess-
ment, including identication of bowel elimination pattern (e.g., stool
consistency, frequency, episodes of fecal incontinence using a bowel
diary) and a fecal incontinence scale that includes quality of life impact.
(continued)
K. F. Hunter and T. Dickinson
75
5.2 Understanding theConcern: History Taking
andGaining thePatient Perspective
The interview is the process of obtaining important subjective data from the
patient. It is also the crucial point at which the advanced practice nurse can
develop rapport with the patient. Rapport allows the patient to be able to openly
share relevant information and to feel accepted [1]. Likewise, a good rapport
allows the advanced practice nurse to build a continuing therapeutic relationship
for future encounters for planning, treatment, and education. Important tech-
niques of communication for the interview involve the ability to listen, open-
ended and closed (or direct) questions as appropriate, facilitating the story,
empathy, and clarication [1]. The patient interview should end smoothly and
not abruptly. A summary of the focused concerns should be followed by allow-
ing the patient to express any concluding thoughts [1].
The focused interview of the patient with fecal incontinence should include
symptom assessment and health history. The health history includes a review of
systems to evaluate past and present health conditions and to identify current
pharmacological and non-pharmacological treatments. Particular attention
Box 5.1 (continued)
– A health history and review of systems, including comorbidities and
modiable risk factors, as well as current pharmacological and non-
pharmacological treatments.
– Functional assessment (activities of daily living, mobility, toileting abil-
ity, cognitive function).
– Dietary intake (food and uid intake, types of uid, as well as eating
patterns, weight changes, appetite changes, food intolerances, non-
prescription supplements) and any association with fecal incontinence.
• Physical examination should include:
– A general survey and observation of mobility.
– Abdominal examination.
– Female—pelvic/vaginal exam, inspection/assessment of perineal area
and pelvic oor assessment.
– Male—inspection/assessment of the perineal area and pelvic oor
assessment.
– Digital rectal exam.
• Other data to review:
– Results of recent laboratory and diagnostic tests
5 Clinical Assessment andDierential Diagnosis ofFecal Incontinence andIts Severity
76
should be paid to the gastrointestinal, reproductive, neurologic, and musculo-
skeletal systems. For women, obstetrical history should be included to identify
potential risk of obstetrical anal injury. A functional assessment should be con-
sidered to evaluate the ability to perform activities of daily living, mobility,
cognitive function, and independence [1]. Questions about diet and uid intake,
appetite changes, food intolerances or triggers of fecal incontinence, eating pat-
terns, weight changes, and non-prescription supplements will add information
about the patient’s nutritional status [1].
5.2.1 Focused History Taking withthePatient Presenting
withFecal Incontinence
As with any patient concern, history taking begins with a methodical symptom
assessment focused on the presenting concern. To ensure a thorough and systematic
approach, many advanced practice nurses use a mnemonic such as OLDCARTS
(Onset, Location, Duration, Character, Aggravating/associated factors, Relieving
factors, Temporal factors, Severity) [7], PQRST (Precipitating factors, Quality,
Radiation, Severity, Timing [onset duration frequency]) or CLIENT OUTCOMES
(Character, Location, Impact, Expectation, Neglect, Timing, Other, Understanding/
beliefs, Treatment, Complementary therapies, Options, Modulating factors,
Exposure, Spirituality) [8]. Whatever the approach, the goal is to gain an in-depth
understanding of the patient’s perspective and symptom experience.
The symptom assessment in fecal incontinence should include use of a stan-
dardized assessment tool for assessing anal and fecal incontinence severity and
effect on quality of life [1]. Symptoms included in the tools vary, but most cover
the nature of the incontinence (e.g., incontinence of feces and atus), as well as
awareness of the incontinence, frequency of loss, and consistency of stool. Some
instruments have questions on accompanying complaints, such as urgency and
abdominal pain, or incorporate a quality-of-life score with assessment of symp-
tom severity. Examples of tools include the International Consultation on
Incontinence Modular Questionnaire-Bowel Symptoms (ICIQ-B) [9], Revised
Faecal Incontinence Scale [10], the Jorge Wexner Continence Scale [11], Fecal
Incontinence Quality of Life (FIQOL) scale [12], and St Mark Incontinence scale
[13]. However, there is no tool currently available that assesses/scores the severity
of fecal incontinence only. A detailed review of instruments for rating the severity
of fecal incontinence is available in Chap. 16 of the 7th International Consultation
on Incontinence [14]. These tools are most often used for research, but can be
K. F. Hunter and T. Dickinson
77
Fig. 5.1 Example of a stool consistency classication system [16]. (Reproduced with permission
from the copyright holder, D.Z. Bliss)
useful in clinical practice as well. The advanced practice nurse using a standard-
ized instrument should be aware of what it measures in comparison to other tools
in order to interpret its ndings correctly and choose a tool suitable for their prac-
tice that is easy for their patients to complete.
Assessment must also include asking about the type of stool. There are sev-
eral visual tools available. The Bristol Stool Chart is a tool commonly used by
clinicians or researchers in identifying types of stool form/consistency by using
seven illustrations and descriptions of stool forms varying from hard to watery
consistency [15]. Another visual tool, specically for fecal incontinence devel-
oped for patients used by Bliss and colleagues [16] has illustrations and descrip-
tions of four stool consistency types (hard and formed, soft but formed, loose
and unformed, liquid) (see Fig.5.1).
It is also helpful to have the patient track their bowel movements 24h a day for
several days to determine the pattern of bowel movements and episodes of anal or
fecal incontinence. Table5.1 includes the International Continence Society recom-
mendations for questions that should be included as standard items on a bowel diary
when assessing fecal incontinence in adults [17]. These questions include stool con-
sistency, timing of passing, and type of stool or fecal leakage and associated symp-
toms such as incomplete evacuation and constipation. These symptoms are addressed
in Chaps. 8 (about managing fecal incontinence in nursing home residents) and 9
(about neurogenic fecal incontinence).
5 Clinical Assessment andDierential Diagnosis ofFecal Incontinence andIts Severity
78
Table 5.1 Recommended questions to include as standard on a bowel diary to assess fecal incon-
tinence in adults [17]
a
Add a column for each day of the week
b
If a graphic chart of stool consistency/form or amount is used as an option, answer choices will
need to be adjusted to match the graphic charts
This article was published in Continence 2023;6. Standard questions for a bowel diary to assess
fecal incontinence in adults: A consensus project of the International Continence Society: 100588
by Bliss DZ, Igualada-Martinez P, Engberg S, Herbert JH, Gurvich OV, Igbedioh C, Hunter, A.,
Voelkl, J., León, K.C., Schizas, A.M.P.Reprinted with permission of the International Continence
Society and Elsevier
K. F. Hunter and T. Dickinson
79
5.3 Physical Examination
5.3.1 General Survey/Mobility
As noted in the introduction, the physical examination begins with a general survey
observation of the patient’s mobility. People with impaired mobility may have dif-
culty accessing a toilet or getting on a toilet on time, compromising continence.
5.3.2 Abdominal Examination
With the patient lying supine, inspect the contour and symmetry of the abdomen,
noting if it is at, scaphoid, rounded, or protuberant [1]. Distention can be marked
in obstruction of the colon. Observe for scars, striae (stretch marks), and pulsations
(in the thin person, normal pulsation of the aorta may be observed). Use the dia-
phragm of the stethoscope to auscultate in the four quadrants for the normally high-
pitched bowel sounds. The absence of bowel sounds (a silent abdomen) is established
only after listening for 5min. A silent abdomen may indicate intestinal obstruction,
paralytic ileus, or peritonitis. Percuss the abdomen in all four quadrants. Normally,
tympany should predominate due to gas in the gastrointestinal tract, with dullness
over the liver and spleen. Perform light and deep palpation to assess for any areas of
tenderness or for masses. Dilated loops of bowel may be palpable in fecal impac-
tion, ileus, or megacolon.
5.3.3 Female Pelvic/Vaginal Exam andAssessment
ofthePelvic Floor
Female pelvic examination should be undertaken with attention to assessment of
any pelvic organ prolapse and pelvic oor strength and tone, particularly if symp-
toms suggestive of prolapse were reported during the history. For example, the
patient may have reported a bulge near the anus (anorectal prolapse). Higher stage
vaginal pelvic organ prolapse (e.g., past the level of the hymen) can induce bladder
symptoms as well as symptoms of anorectal dysfunction including constipation,
incomplete bowel evacuation, the need to strain, splint or digitally support or apply
manual pressure to defecate, a sensation of anorectal blockage, fecal urgency or
soiling after defecation [18]. Higher stage posterior vaginal wall prolapse can
involve a rectal protrusion into the vagina (rectocele).
Descent of the anterior, posterior vaginal walls or uterus (vaginal vault after hys-
terectomy) may be detected during inspection and palpation. With the patient in the
dorsal lithotomy position, gently separate the labia and inspect the vaginal orice
for any bulge of tissue. Ask the patient to perform a Valsalva maneuver so the extent
of the prolapse is evident. Insert the speculum to visualize the vaginal canal. To
adequately assess the prolapse and identify if it involves the anterior or posterior
walls (or both), use a Sims’ speculum or the lower blade of a Graves speculum. The
5 Clinical Assessment andDierential Diagnosis ofFecal Incontinence andIts Severity
80
single blade is reinserted, lifting the anterior wall, and then reinserted to hold back
the posterior wall [19]. The examiner inserts a gloved nger and again has the
patient Valsalva to assess for apical (uterine or vault) prolapse.
The Pelvic Organ Prolapse Quantication System (POPQ) staging method is
recommended for measuring, describing, and staging pelvic organ prolapse (POP)
[18]. It uses anatomically specic points and their relationship to each other. Six
points are measured, in centimeters, within the vagina in relationship to the hymen.
• Two points on the anterior vaginal wall
• The cervix or vaginal cuff scar (post-hysterectomy)
• Posterior fornix (not applicable post-hysterectomy)
• Two points on the posterior vaginal wall
Three other anatomical landmarks are also the measured, total vaginal length,
genital hiatus, and perineal body. The nine numbers are then presented in a grid. The
numbers have positive or negative values depending on whether they are above or
below the hymen. Negative numbers are within the vagina (or above the hymen) and
positive numbers or external (or below the hymen). The greater the degree of posi-
tive numbers the greater the genital prolapse external to the vagina. This number of
measurements allows the individual variation of prolapse to be quantied and docu-
mented with accuracy. However, it may require additional education and skill-
building to use reliably.
For a less complex system, it is also possible to clinically stage the POP, looking
at the most distal portion of the prolapse (anterior, posterior, or apical) in relation to
the hymenal ring
• Stage 0: No prolapse is demonstrated.
• Stage I: The most distal portion of the prolapse is more than 1cm above the level
of the hymen.
• Stage II: The most distal portion of the prolapse is situated between 1cm above
the hymen and 1cm below the hymen.
• Stage III: The most distal portion of the prolapse is more than 1cm beyond the
plane of the hymen but everted at least 2cm less than the total vaginal length.
• Stage IV: Complete eversion or eversion at least within 2cm of the total length
of the lower genital tract is demonstrated.
The strength of the pelvic oor can be estimated using vaginal palpation. With
one of two gloved nger or two in the patient’s vagina, ask the patient contract the
pelvic oor by squeezing the rectum as if they were trying to stop themselves from
passing atus. You may need to coach the patient not to contract the abdominal or
buttocks muscles. Contraction and lift of the pelvic oor is often graded on the
modied Oxford scale developed by Laycock [20]. The contraction is scored from
0–5, with 0 being no contraction, 1 a icker, 2 a weak squeeze without lift, 3 a fair
squeeze with some lift, 4 a good squeeze with lift, and 5 a strong squeeze with lift.
This scale is subjective and requires training and experience to use. Specialist nurses
K. F. Hunter and T. Dickinson
81
and physiotherapists may also employ other instruments to measure contraction
more accurately and reliably. During contraction, the examiner should also palpate
the puborectalis muscle (part of the levator ani muscle that forms a sling around the
rectum and maintains the anorectal angle) for any defects that suggest previous
injury [18].
5.3.4 Male Assessment ofPelvic Floor
In the male, the pelvic oor strength can be assessed during rectal examination by
palpating for contraction of the puborectalis muscle above the internal anal sphincter.
5.3.5 Rectal Examination
Assist the patient to take the left position with legs exed and right leg higher than
left (male or female), the lithotomy position (female) or standing position bent for-
ward with arms resting on an exam table with toes pointed in (male) [1]. The rectal
examination begins with inspection of the perianal area and anus. Note any scarring,
lesions, hemorrhoids, and rectal skin tags. Identify any erythema, rash, or excoria-
tion of the perianal tissue or external presence of stool/smearing in undergarments.
Normally, the anal opening is symmetrically round and closely tightly. Observe for
any sphincter asymmetry as well as reduced or absence of tissue in the perineal
body, a bromuscular mass between the urogenital triangle and the anal triangle in
both males and females. In the female, the perineal body is the tissue between the
posterior border of the vagina and the rectum, and can be damaged in childbirth.
Potential abnormal ndings are listed in Table 5.2. Describe the position of any
abnormalities using clock face terminology (e.g., 12 o’clock is anterior towards the
symphysis pubis, 6 o’clock towards the coccyx) [1].
With a gloved nger, apply gentle traction on the anal verge to further check for
any gapping. To perform the digital rectal exam, lubricate the index nger and gen-
tly insert into the anus towards the umbilicus. You should feel the sphincter tighten,
then relax. Assess the resting tone, important in maintaining continence, and for
stool in the rectum. Palpate the entire muscular ring of the sphincters by gently
rotating the nger. Press your thumb externally on the perineal body and palpate.
Have the patient voluntarily tighten the sphincter to assess tone in the external anal
sphincter [21]. Insert your nger further to assess the rectum, rotating gently, check-
ing for any hard stool or masses. Palpate the anterior rectal wall, assessing for a
bulge suggestive of rectocele. The prostate in the male and the cervix in the female
are palpable in this position. The advanced practice nurse can use the digital rectal
examination scoring system (DRESS) to describe both resting and squeeze pressure
[22]. The score ranges from 0–5 (0—no discernible pressure, to 3—normal, to 5—
extremely tight). Ask the individual to bear down and check if the anal sphincter
relaxes before withdrawing the nger [21]. As you withdraw your nger, take note
of any blood, stool, or mucus. Any stool on the glove should be soft and brown.
5 Clinical Assessment andDierential Diagnosis ofFecal Incontinence andIts Severity
82
Table 5.2 Potential abnormal ndings on inspection of anus and digital rectal exam (DRE)
Appearance of an
anus
Etiology
Further examination
Anus gapping or
open a rest
(patulous)
May be related to poor pelvic oor tone,
rectal prolapse, or neurological damage
Have the patient perform a
Valsalva maneuver to see if
the rectal mucosal walls
prolapse
If a neurological component is
suspected (e.g., poor tone),
check sensation in the saddle
area
Rectal prolapse Rectal mucosa or full thickness of rectal
walls protrude past the anal sphincters
Contributors may include weakened
sphincter tone, poor pelvic oor tone
(with or without concomitant pelvic
organ prolapse in the female), or
diastasis of the levator ani
May be reduced spontaneously
or manually
A rectal prolapse that cannot
be reduced should be
referred for surgical
treatment quickly [14]
Thickened
sphincter
May be associated with chronic
constipation and straining
Have the patient sit on a
commode and attempt to void,
check the perineum for rectal
prolapse [5]
Keyhole
deformity
Indicative of a sphincter defect Ensure the entire sphincter is
palpated during exam to
identify the location of any
disruption in the continuity of
the sphincter or rectopube/
diastasis
Anal ssures Painful splitting or tearing in the mucosa
of the anus. Chronic anal ssures may
lead to chronic granulation tissue and a
sentinel skin tag in the anal canal.
Ulceration may be present. Suspected
anal or rectal cancer should be
investigated [24]
Paradoxical
puborectalis
contraction (also
called
dyssynergia)
Persistent contraction of the sphincter/
pelvic oor due to non-relaxation during
Valsalva. Associated with retained stool
and overow incontinence
5.3.6 Neurological Exam
The cauda equina means the horse’s tail, and so named as it includes the nerves with
dorsal and ventral lumbar, sacral, and coccygeal roots that fan out. Sympathetic
innervation of the rectum arises from T11-L1 via hypogastric plexus and cause
relaxation of the rectum and anal canal and contraction of the internal anal sphinc-
ter. The internal anal sphincter maintains a constant tone that increases as the pres-
sure in the rectum increases. Parasympathetic innervation arises from the second,
third and fourth sacral roots, with parasympathetic stimulation leading to relaxation
K. F. Hunter and T. Dickinson