Chapter 6: Elimination
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Source: NICE ([170]). Reproduced with permission of NICE.
Faecal incontinence
Definition
Faecal incontinence is a clinical symptom usually associated with diarrhoea. As mentioned above, diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual) (Barrie [13]).
Related theory
Faecal incontinence is a sign or a symptom, not a diagnosis. Therefore, it is important to diagnose the cause or causes for each individual. For many people, faecal incontinence is the result of a complex interplay of contributing factors, many of which can co‐exist (NICE [170]). Healthcare professionals must be mindful that faecal incontinence is a socially stigmatizing condition and therefore professionals must sensitively enquire about symptoms in patients reporting (or who are reported to have) faecal incontinence, particularly within high‐risk groups (Box 6.3).
Box 6.3
Faecal incontinence: high‐risk groups
- Frail older people
- People with loose stools or diarrhoea from any cause
- Women following childbirth (especially following third‐ or fourth‐degree obstetric injury)
- People with neurological or spinal disease or injury (e.g. spina bifida, stroke, multiple sclerosis, spinal cord injury)
- People with severe cognitive impairment
- People with urinary incontinence
- People with pelvic organ prolapse and/or rectal prolapse
- People who have had colonic resection or anal surgery
- People who have undergone pelvic radiotherapy
- People with perianal soreness, itching or pain
- People with learning disabilities
Factors that cause or contribute to the development of faecal incontinence are (Hayden and Weiss [98]):
- obstetric trauma
- anal surgery or pelvic radiation
- neurological diseases
- congenital conditions
- accidental or iatrogenic trauma
- colorectal disease
- diarrhoea, laxative abuse or faecal impaction.
Healthcare professionals should explain to patients that a combination of initial management interventions is likely to be needed. These will be based on the patient assessment and should consider the patient's personal preferences. This will form the basis of the patient's care plan. Initial management strategies may include a medication review; stool sampling and infection treatment; assessment of diet, bowel habit and toilet access; and discussions that focus on skin care advice, continence products, and the offer of emotional and psychological support. Specialist management may be required for those patients who still experience faecal incontinence after initial management options have been exhausted (NICE [170]).
Faecal collection devices (Figure 6.22) consist of a tube that is inserted into the rectum and held in situ by a water‐filled balloon (similar to that of the Foley catheter). Fluid stools then drain into a drainage bag. It is imperative that such devices are fitted by appropriately trained, competent healthcare professionals and that both local policies and the manufacturer's instructions are followed to ensure this equipment is used in an appropriate and safe manner (Ritzema [211]) (see Procedure guideline 6.18: Insertion of a faecal management system). When used correctly, they can be very beneficial.
Rationale
Indications
Faecal management systems are indicated for patients who are passing liquid or semi‐liquid stools, usually in association with one or more of the following criteria:
- patient unable to mobilize to toilet or commode (i.e. bed‐bound)
- patient has surgical considerations (i.e. to protect surgical sites or skin grafts)
- patient has skin excoriation associated with or exacerbated by faecal incontinence, or is at risk of developing this (Kowal‐Vern et al. [113])
- patient would benefit from help to reduce the spread of infectious diarrhoea by diverting it away from the patient's skin and keeping it contained in the closed system (Kowal‐Vern et al. [113]).
Contraindications
Contraindications to the use of faecal management systems include the following:
- solid or formed stool
- suspected or confirmed rectal mucosa impairment
- recent large bowel surgery
- rectal surgery within the past year
- sensitivity or allergy to any of the materials used in the device
- rectal or anal injury
- bowel obstruction
- faecal impaction
- anal tumour
- severe haemorrhoids
- spinal cord injury
- antithrombotic treatment
- thrombocytopenia (ConvaTec [53]).
Figure 6.22 Flexi‐Seal Faecal Management System. Source: Reproduced with permission of ConvaTec Ltd.
Procedure guideline 6.18
Insertion of a faecal management system
Table 6.9 Prevention and resolution (Procedure guideline 6.18)
| Problem | Cause |
Prevention | Action |
|---|---|---|---|
| Lack of stool flow | External obstruction, e.g. pressure from equipment or body part or kink in tubing | Ensure the tubing is positioned without kinks or obstruction. | Conduct a complete check of the catheter's patency and ensure it is free of any external obstruction and is positioned lower than the patient. Reposition the patient. Strip the drainage tube by using thumb and forefinger to manually move the contents along the length of the tube. |
| Blockage | Flush the drainage tube according to the manufacturer's instructions. | ||
| Stools too solid to pass through tubing | Ensure the stool is liquid or semi‐liquid. | If the stools are too solid, discontinue use of the device. | |
| Leakage |
Patient position
Blockage
Deflation of balloon | Ensure correct positioning of the patient and tubing. | Reposition the patient. |
| Rectal bleeding | Pressure necrosis or ulceration of rectal or anal mucosa | Use the correct technique for insertion and filling the balloon. Undertake regular monitoring. | Notify a senior clinician. |
