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A nursing assessment tool for adults with fecal incontinence
CONTINENCE CARE SECTION EDITOR: Mary H. Palmer, PhD, RNC, FAAN
A Nursing Assessment Tool for Adults With Fecal Incontinence Christine Norton, MA, RN, and Sonya Chelvanayagam, MSc, RN
Fecal incontinence affects slightly more than 1% of community-dwelling adults. This article describes an assessment format, with a research basis when available, that has been developed in a specialist nursing clinic in the United Kingdom. The focus is on how to obtain the most useful information from the patient to plan appropriate nursing interventions. A subsequent article will describe the biofeedback program developed as part of a package of care to meet individual needs of persons with fecal incontinence. (J WOCN 2000;27:279-91)
F
ecal incontinence is a common health care problem, affecting more than 1% of the adult population.1 It is a particularly embarrassing symptom that is socially unacceptable, yet many with the problem do not seek professional help.2 Fecal incontinence has a major negative impact on physical and psychological health and lifestyle, with severe social restrictions in many instances.3 Fecal incontinence has multiple possible causes, the most common being obstetric trauma.4 Other causes include congenital, traumatic, or iatrogenic sphincter damage; intestinal hypermotility resulting in diarrhea; neurologic disease; local anorectal pathology; and, in immobile individuals, fecal impaction with overflow soiling.5,6 Recent advances in investigation techniques, particularly anorectal manometry and endoanal ultrasound, enable accurate characterization of structural or functional causes of fecal incontinence in individual patients. Nevertheless, treatment options are limited for many who primarily rely on surgery or constipating drugs to alter stool consistency and diminish the risk of subsequent incontinence. Fecal continence is a complex function that involves multiple modulatory mechanisms that influence stool consistency, intestinal motility, rectal vault storage, and anal sphincter function. Therefore, when managing a patient with fecal incontinence, it is essential to define what combination of these factors contributes to soiling. Although previous authors
have stressed the importance of assessment7 and provided general guidelines for management,8,9 our search of the literature found no tool adequate for the assessment of fecal incontinence in a population of independent, communitydwelling adults. We decided that an essential first step when working with patients with fecal incontinence at our hospital specializing in colorectal dysfunction was to define important areas of assessment and pertinent demographic data. The checklist we developed to assess these variables is provided in Figure 1. The main focus is fecal incontinence, although many patients have additional bowel problems, and some questions were designed to explore these aspects of gastrointestinal function. This assessment instrument is not intended to measure formally such important psychosocial aspects of fecal incontinence as coping or quality of life; instead, it provides baseline information intended to direct the formulation of a plan of care. A combination of empiric (clinical) experience and literature review was used to design the instrument. We found this combination necessary because research evidence is not available at this stage to substantiate every aspect of the assessment. Completion of the instrument requires approximately 20 to 30 minutes. This article will review the domains covered in the initial assessment and provide a rationale for the clinical relevance of each item.
Christine Norton is Nurse Specialist (Continence), Physiology Unit, St Mark’s Hospital, North West London Hospitals NHS Trust. Sonya Chelvanayagam, MSc, RN, is Biofeedback Research Nurse, Physiology Unit, St Mark’s Hospital, North West London Hospitals NHS Trust. Sonya Chelvanayagam is funded by Action Research, a UK medical research charity. Reprint requests: Christine Norton, MA, RN, Physiology Unit, St Mark’s Hospital, North West London Hospitals NHS Trust, Watford Road, Harrow, Middlesex, HA1 3UJ, United Kingdom. Copyright © 2000 by the Wound, Ostomy and Continence Nurses Society. 1071-5754/2000/$12.00 + 0 21/1/109082 doi:10.1067/mjw.2000.109082
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BIOFEEDBACK HISTORY SHEET Therapist: Date of first appointment: Name: Date of birth:
Age:
Hospital No.: Address: Telephone home/work: Referred by: GP: Marital status: Single ❏ Married ❏ Lives with partner ❏ Divorced ❏ Widowed ❏ Occupation (former if retired): Ethnic group: White ❏ Asian ❏ Black ❏ Chinese ❏ First language:
Fluency in English:
Main complaint Duration of symptoms/trigger for onset: Usual bowel pattern: Any recent change? Usual stool consistency: 1. Lumps 2. Lumpy sausage 3. Cracked sausage 4. Soft smooth sausage 5. Soft blobs 6. Fluffy, mushy 7. Watery, no pieces Fecal incontinence: How often? Urgency?
How much ? Time can defer for:
Urge incontinence: Never ❏ Seldom ❏ Sometimes ❏ Frequently ❏ Difficulty wiping: Yes ❏ No ❏ Sometimes ❏ Postdefecation soiling: Yes ❏ No ❏ Sometimes ❏ Passive soiling: Yes ❏ No ❏ Sometimes ❏ Events causing incontinence: Amount of flatus: Control of flatus: Good ❏ Variable ❏ Poor ❏ Ability to distinguish stool/flatus? Yes ❏ No ❏ Abdominal pain relieved by defecation? Other pain? Rectal bleeding? Mucus? Nocturnal bowel problems? Evacuation difficulties? Straining? Incomplete evacuation? Need to digitate anally or vaginally or support the perineum?
Painful defecation?
Bloating? Sensation of prolapse? Pads/pants? Bowel medication? Continued on page 281 Figure 1. Bowel history sheet.
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Other current medication: Medical history (include psychological): History of depression/antidepressants? Physical or social difficulties with toilet access? Previous bowel treatments and results: Obstetric history: Difficult deliveries or heavy babies? Dietary influences: Smoker? Weight/height/body mass index: Fluids (caffeine): Skin problems? Bladder problems? Effect on lifestyle/relationships: Emotional/psychological effects: Physiology findings: Biofeedback assessment: Max squeeze Endurance Repetitions of fast twitch Sensitivity to distension Coordination Ability to isolate Plan: Follow up: Figure 1. Bowel history sheet (continued).
THE ASSESSMENT INTERVIEW When managing a patient with a socially and personally sensitive condition such as fecal incontinence, it is important to build a relationship of trust so that symptoms and problems can be openly and frankly discussed. This assessment also requires the patient and nurse to establish a vocabulary of words that are mutually understood and acceptable. Even though all of our patients have been referred specifically for therapy (usually biofeedback) for fecal incontinence, many express embarrassment and find it difficult to report symptoms. The experience seems to be similar to that described for urinary incontinence, another taboo subject that is not openly discussed, even with partners or family.10 The need for a common vocabulary is compounded because some
patients are unaware of medical terms such as “defecation” or even “stool” or “anus”; but they are reluctant to use what they perceive as slang terms when discussing fecal incontinence with a professional. The wording we use for each item is indicated by italics. When reading this article and considering applying this instrument to your practice, it should be remembered that we designed the questions for an English population, and colloquial expressions will require adaptation for use in other patient populations. The essential point is to find a vocabulary that is mutually understood by both nurse and patient.
Chief Symptom What bothers you about your bowels/what is the main problem with your bowels? This item was designed to help the nurse understand the patient’s perspective on
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Figure 2. Bowel action diary form.
the problem and identify which symptoms are most bothersome. We have found that the symptom identified by the patient as most bothersome may be quite different from the primary symptom documented by the referring physician. Circumstances surrounding the onset of the problem can give important clues as to causation. Sometimes a causative event can be clearly identified, such as onset of symptoms immediately after
traumatic childbirth or a hemorrhoidectomy. At other times the patient may not have made a link between potential contributing factors and the onset of fecal incontinence. In these cases, probing questions about a change in medication or onset of menopause may help to identify contributing factors. Many people cope with fecal incontinence for years without seeking professional help. 2 In these patients, we find it useful to explore
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Figure 3. 7-Point visual scale for stool consistency.
what triggered consultation. Have the symptoms worsened? Has the ability to cope with symptoms been compromised?
Bowel Elimination Patterns How often do you move/open your bowels? There is a common misconception among the general population that normal bowel habit is once per day. In fact, function varies between 1 to 3 times a day to once in 3 days.11 A minority of the total population, approximately 40% of men and 33%
of women, move their bowels once on a daily basis.12 Instead, most are irregular in the frequency of bowel movements, with women of childbearing age (25-49 years) being the most irregular. One third of young women move their bowels less than once per day and 1% do so less than once per week. A variable bowel habit is a classic feature of irritable bowel syndrome (IBS).13,14 Knowledge of this variability is important when assessing a patient’s bowel elim-
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Figure 4. Rectal filling results in reflex internal sphincter relaxation.
Figure 5. Continence is maintained by voluntary external sphincter contraction.
ination patterns because of common misconceptions about the frequency of bowel movements and constipation. The term constipation is interpreted differently by various persons.15 Infrequent bowel motions, provided the stool is easy to pass and not hardened, does not meet clinical criteria of constipation and it is not a cause for concern or justification for interven-
tion. Conversely, some very constipated people can produce a stool several times per day, but only at the expense of long periods of straining on the toilet. There is, in the general population, no age-related decrease in the actual frequency of defecation, although there seems to be an increase with age in self-report of constipation and an increase in laxative use.16
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The use of a laxative does not necessarily imply a diagnosis of constipation. A recent change in the frequency of bowel motions should be noted because it may indicate an underlying disease or malignancy. Any recent unexplained change in bowel habit in a patient older than 40 years old should be investigated by barium enema radiograph or colonoscopy. Although fecal incontinence is rarely the sole presenting symptom for intestinal cancer, up to 25% of patients with cancer note occasional bouts of fecal soiling.17 A diary of bowel actions for a week often provides useful baseline information (Figure 2). This diary is routinely sent to patients with their appointment letter, and very few fail to bring it, correctly completed, to the first consultation.
Stool Consistency What is your stool (bowel movement) like? Is it loose, soft but formed, hard or hard pellets? Does this vary? Careful assessment of stool consistency with particular attention to reported changes in consistency or color also provides important information in the evaluation of fecal incontinence. For example, patients with IBS or inflammatory bowel disease are particularly prone to variations in stool consistency. When the patient has difficulty in describing the stool, a visual prompt may be helpful (Figure 3).12 This type of scale is useful because patients have been found to be generally accurate when assessing their own stool consistency.18 When asked to respond to this 7-point visual scale for stool consistency, types 3 or 4 represent the most usual selections. Nevertheless, only 56% of women describe these types as normal, whereas 61% of men describe them as normal. Loose stool is significant because it increases the risk for both passive and urge fecal incontinence; a pelletlike stool consistency is important because it may indicate slow colonic transit and constipation.
Fecal Incontinence A particularly sensitive query is required when asking patients about fecal incontinence because many people are reluctant to admit stool soiling, and it may be difficult to identify terms expressing this sign that are mutually understood and acceptable. Even people consulting a gastroenterologist often refrain from volunteering the symptom of fecal incontinence. In one study, less than half of the patients admitting to incontinence on a
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questionnaire had told their doctor about it.2 In addition to reluctance in identifying the symptom of fecal incontinence, it can be difficult to assess the severity of soiling because many people severely restrict their lifestyle, thus limiting the risk of incontinence. As a result, fecal incontinence may occur infrequently, even though it represents a major concern. Many patients also find it difficult to estimate the amount of stool lost during an incontinent episode. We have found it particularly helpful to question patients about the 2 major types of fecal incontinence: urge or passive.
Urgency and Urge Incontinence When you need to open/move your bowels, do you need to rush to get to the toilet? How long can you hold on for? When the rectum fills, the internal anal sphincter relaxes reflexively to enable “sampling” of the rectal contents by the sensitive nerve endings within the dentate line in the upper anal canal (Figure 4). With normal bowel control, defecation can be deferred for long periods of time because the urge to defecate is opposed by voluntary contraction of the striated external anal sphincter muscle,19 which generates sufficient pressure to prevent immediate stool expulsion and to return the stool to the rectum (Figure 5). Retrograde peristalsis may even remove the stool away from the anal sphincter and back into the sigmoid colon in some cases.20 If bowel control is normal, the urge diminishes, and the patient is typically able to defer defecation for up to several hours. Indeed, it has been shown that voluntarily ignoring the call to defecate can reduce the frequency of defecation by 50% and slow colonic transit.21 In contrast, a reduced squeeze pressure and an inability to sustain a submaximal contraction of the external sphincter has been found to correlate with the symptom of urgency.22,23 Some patients with fecal incontinence generate high amplitude colonic pressure waves (up to 500 cm water pressure).20 Without an adequate sphincter response to oppose this high-pressure bolus contraction, resistance to the expulsion of stool is diminished and urge incontinence is likely. In addition, patients who have diarrhea, such as those with inflammatory bowel disease, are at a particularly high risk of severe urgency and urge incontinence from colonic peristalsis opposing sphincter function and to the loose consistency of the rectal contents.
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Do you ever fail to reach the toilet in time and have a bowel accident? Urge incontinence often reflects a weakness or defect in the external anal sphincter, 24,25 and obstetric trauma is the most common cause of sphincter damage. 26 Urgency may become a particular problem because of a fear of future accidents for the individual who already has had an episode of fecal incontinence. As a result, the patient may respond immediately to any urge to defecate in an attempt to prevent incontinent episodes. This rapid response may create a vicious cycle so that any bowel sensation is interpreted as likely to lead to incontinence. Because of this fear, a sensation of rectal urgency generates intense anxiety, or even panic, which exacerbates the sense of urgency. When a patient reports rectal urgency, it is important to establish how frequently urge incontinence actually occurs and whether restrictions in activities are from actual or feared soiling.
Passive Incontinence Do you have any leakage from your bottom of which you are unaware? Is this liquid or solid? Does this occur at any time or only after you have opened/moved your bowels? The smooth muscle of the internal anal sphincter is responsible for up to 80% of resting tone in the anal canal,5 and passive soiling is associated with internal anal sphincter damage detected by ultrasound.24,25 A weak or disrupted internal sphincter is incapable of completely closing the anal canal. If the stool is loose or soft, some may remain in the anal canal and ooze out after defecation. Incompetence of the internal anal sphincter is often the result of inadvertent surgical damage (particularly after hemorrhoidectomy or sphincterotomy) or idiopathic smooth muscle degeneration.27 Patients with internal anal sphincter incompetence have difficulty cleaning the anus after defecation and experience subsequent soiling, which may persist for several hours. Others have passive soiling at unpredictable times and in the absence of any awareness of stool soiling. In still others, soiling is provoked or exacerbated by physical exertion such as walking or running. Passive loss of solid stool or loss of copious amounts of mucus may result from rectal prolapse.
Flatus Can you control wind? Are you able to tell the difference between wind and the need to
empty your bowels? Although the concept of “wind” is a common expression for the passage of flatus among English patients, nurses from the United States may prefer to ask patients if they are able to control the passage of “gas” from the bowels. In addition, it is important to determine whether patients are able to distinguish between the passage of flatus and stool. This sensory deficit may occur after iatrogenic or traumatic damage to the sensory nerves involved in the “sampling” reflex previously described. Incontinence of flatus may appear a trivial symptom, but many people who are unable to control the passage of flatus experience embarrassment in work, social, or intimate situations.
Pain Do you have pain associated with opening/moving your bowels? Does it occur before moving your bowels and is relieved by opening your bowels, or is it a pain as you actually pass a stool? Abdominal pain in association with altered stool consistency, frequency, or bloating in the absence of organic pathology is diagnostic of IBS,14 which is common among patients with fecal incontinence. Pain with the urge to defecate may occur in these patients, rendering it difficult to defer defecation. They may describe a colicky or spasmodic “stabbing” pain. In contrast, the occurrence of anal pain with defecation is often caused by hemorrhoids or an anal fissure, which are also common among patients with fecal incontinence. Chronically constipated people also tend to report abdominal discomfort; it is usually characterized by a feeling of bloating. Constipation or constipation-predominant IBS is also associated with abdominal bloating; we have observed that some women report the need for two sets of clothes because of this bloating. They have a normal wardrobe, but they also own clothes that are 1 to 2 sizes larger for periods when their bowels have not moved for several days.
Blood and Mucus Do you pass any blood or mucus when your bowels move/open? The passage of blood or stool during defecation occurs with a number of conditions. For example, streaks of bright red blood may occur in patients with hemorrhoids or an anal fissure. The passage of fresh (bright red) or older (darker red) blood may also occur in patients with an underlying malignancy. The presence of blood and mucus in an individual with a
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history of straining may indicate the presence of a solitary rectal ulcer. Copious mucus with normal bowel function may indicate a villous adenoma; the passage of mucus in the presence of variable stool consistency and defecation often occurs with IBS. Passive incontinence of clear or fecal stained mucus also may indicate a rectal prolapse. Whenever a patient reports the passage of blood or mucus, further investigation is warranted. Colorectal cancer is the second most common cancer in the western world, and up to one fourth of patients will have fecal incontinence among their presenting symptoms.17 Therefore symptomatic management for fecal incontinence must be deferred until the reason for passing blood or mucus is determined.
Evacuation Difficulties Do you have difficulty opening your bowels? Do you need to strain? If so, for how long? Do you ever need to insert a finger into your bottom or vagina to help pass stool? Do you need to push on the area by your anus? Does it feel as if you have not completely emptied your bowels? We have found that these questions are helpful when determining whether the patient has difficulty evacuating stool from the rectum. Constipation, the most common cause of evacuation difficulty, will not be covered in detail in this article. Constipation commonly co-exists with fecal incontinence in frail or disabled people.28 We have found that people with chronic constipation often describe defecation as “unsatisfying.” On closer questioning, this dissatisfaction occurs because of difficulty evacuating stool from the bowels leading to a sensation that the bowel is never properly emptied. As a result, many patients with constipation repeatedly return to the toilet and some spend long periods of time (as much as hours) straining in an attempt to evacuate the bowels without adequate results. Persons with a weak pelvic floor may also perceive difficulty evacuating stool from the bowels because of downward movement of the pelvic floor and anus with straining. In addition to pelvic floor muscle weakness, some women have a rectocele develop after childbirth or because of excessive straining when attempting to defecate or urinate. A rectocele causes the anterior wall of the rectum to bulge into the vagina as the woman strains to defecate. Some women find that exerting gentle backward pressure by placing a finger
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in the vagina may promote evacuation of stool “trapped” in the rectocele.
Sensation of prolapse Some people with fecal incontinence report a dragging feeling, or a perception that the rectum protrudes from the anus, particularly during or after straining. These sensations are typically caused by rectal prolapse. In the majority, the prolapse reduces spontaneously after defecation, but occasionally the patient may find it necessary to replace the rectum manually after prolapse. Rectal prolapse is associated with fecal incontinence in approximately 60% of cases.29
Pads or Pants Do you need to wear a pad because of problems with leakage from your bowels? If so, what type of pad? Do you need to change your underwear during the day because of leakage? If yes, how often? Patients may wear pads because of urinary incontinence, and so it is important to identify if pads or underwear are changed because of fecal incontinence. In addition, patients who describe urgency may always wear a pad because of fear of incontinence rather than actual accidents.
Medication Many drugs can influence bowel function, predisposing the patient either constipation or loose stools (diarrhea). For example, analgesics and antidepressants are commonly associated with constipation, whereas nonsteroidal anti-inflammatory drugs and antibiotics often lead to loose stools or diarrhea.30 A detailed discussion of specific medications that affect stool consistency is beyond the scope of this article.
Medical History Questions about the patient’s medical history may give important clues regarding the cause of fecal incontinence. Major neurologic disease, abdominal surgery, diabetes, thyroid disease, psychological disturbances, and many other disorders may have an influence on bowel function. About 4% to 5% of patients with insulindependent diabetes have fecal incontinence caused by diarrhea associated with peripheral and autonomic neuropathies.31 Anal trauma, such as that associated with unwanted anal intercourse, may cause internal anal sphincter damage and subsequent fecal incontinence.32 Many women date the onset of bowel symptoms to gyne-
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cological surgery, especially hysterectomy.33,34
Access to Toileting Facilities For persons with physical disabilities, fecal incontinence may be more attributable to inadequate toilet access than impairments in bowel function.35 Others may have fecal incontinence because of inadequate access to the assistance of care providers. The practicalities of bowel management can be difficult for anyone with a physical impairment. Solutions often need to be imaginative and creative. They must be tailored to the individual’s abilities, lifestyle, physical environment, and the availability of help. Many patients do not feel safe on commode chairs, and transfer from a wheelchair may be difficult. One study found that 37% of 147 patients with a spinal injury did not feel safe and 42% felt that the brakes were ineffective; 35% had falls during transfers and 23% needed hospitalization for the resulting injuries.35,36
fiber diet will soften the stool and may make it more difficult to control. Food containing specific spices may upset intestinal function. Some patients are able to identify specific foods that trigger bowel problems, but others are not. Nicotine is thought to slow upper gut motility and increase total transit time,38 but it may also speed rectosigmoid transit. 39 These observations correlate with clinical reports that smoking a cigarette facilitates the initiation of defecation. It is not known whether obesity has an adverse effect on bowel control. Some people with anorexia become constipated; others abuse laxatives, possibly in an attempt to control weight. Some persons have pelvic floor problems, possibly from excessively strenuous exercise regimes or muscle wasting. Caffeine is known to stimulate smooth muscles within the gastrointestinal tract,40 and we have observed that it may exacerbate urgency in patients with fecal incontinence.
Skin Problems Obstetric History How many babies have you had? Were forceps used for any of these deliveries? Did you tear, or did you have stitches? How heavy were the babies? Was there any problem with bowel control after the deliveries? Women who have had difficult deliveries, particularly when assisted by forceps or deliveries involving a third-degree tear, are at risk for fecal incontinence.4,26 Women with severe anal trauma often report immediate onset of symptoms; others develop symptoms of fecal incontinence years later when an additional factor, such as a surgical procedure or disease, alters a previously predictable and stable bowel elimination pattern. Prolonged labor (particularly the second stage), and heavy babies can cause trauma and damage to the anal sphincter. Postnatal women are frequently asked about bladder function and taught the importance of pelvic floor exercises. Bowel function is much less frequently considered or mentioned. Women with pre-existing IBS are known to be more likely than others without IBS to have postpartum fecal urgency (64% vs 10%) and poor control of flatus (35% vs 13%), at least in the short term.37
Diet, Smoking, Weight, and Fluid Intake Many people find that what they eat influences their bowel function. A high-
Although certain patients with fecal incontinence have few problems with skin irritation, others have severe soreness and itching. Skin problems are common among those with passive soiling of stool or mucus. Diarrhea also may lead to perianal skin problems when digestive enzymes from the small bowel come into contact with the skin. Double incontinence (a combination of urinary and fecal leakage) tends to exacerbate perineal skin problems. In addition to these factors, postmenopausal women may have skin problems because of hormone deficiency.41 When skin problems prove resistant to simple skin care and barrier creams, it is worth seeking a dermatologic opinion because the patient may have a secondary infection or a treatable skin condition.
Urinary Continence Do you have problems with leakage from your bladder? Does urine leakage occur if you cough, sneeze, or laugh? Do you need to rush to the toilet to pass water? Urinary and fecal incontinence may coexist; the presence of double incontinence may be a sign of severe pelvic floor muscle dysfunction. Approximately 25% of women attending a urodynamic clinic for investigation of urinary incontinence will admit to fecal incontinence on a postal questionnaire, but only 15% do so on direct questioning, emphasizing the difficulty many women have in admitting this symptom.42 Al-
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though pelvic floor muscle problems may occur with double incontinence, at least one study found that fecal incontinence was more frequently associated with detrusor instability and urge incontinence compared with genuine stress incontinence. This relation may reflect the overlap of IBS with an unstable bladder.43
Psychosocial Factors If a patient reports symptoms of fecal incontinence, it is important to ascertain how this has affected his or her lifestyle. Some patients report feeling very restricted, and they are forced to plan journeys around toilet facilities. In severe cases, fecal incontinence may cause a person to remain in the home. Clearly such behaviors profoundly affect the individual, partner, and family. Patients with fecal incontinence often report avoiding sexual intimacy because of feeling dirty or fearing that an episode of incontinence will occur during sexual activity. Although it has been postulated that fecal incontinence has a major negative impact on psychosocial well-being, remarkably few formal studies have been done in this area.3 It is known that children born with congenital anorectal abnormalities and with persistent fecal incontinence have an increased risk of behavioral and social problems than their peers.44,45 One qualitative study has documented in detail the difficulties for children and their families of growing up with fecal incontinence,46 but there have been no similar studies in adults. In addition to isolation and embarrassment, depression is common with these patients and we specifically ask about it when assessing patients with fecal incontinence.
Examination A physical examination completes the assessment of fecal incontinence. A general assessment of the patient’s physical abilities is completed because it provides clues to conditions that may influence or impair treatment strategies. A focused examination and detailed history are able to predict the findings of anorectal physiologic studies in some cases.47 A low resting tone in the anal canal on digital examination is associated with passive leakage, and there is often gaping of a “funnel-shaped” anal introitus if gentle traction is applied away from the anal verge.24,25 Many patients with postdefecation soiling have trapping of soft stool in this funnel, which ordinary wip-
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ing with dry paper will not remove. Reduced strength and duration of voluntary contraction of the anus has been found to correlate with the symptom of urgency of defecation.22,24,25 Urge incontinence of stool is also associated with reduced puborectalis squeeze and a reduced anorectal angle; many also report urge and stress urinary incontinence.25 Estimation of resting and squeeze sphincter tone on physical examination has not been found to correlate well with any objective measure of sphincter function or with continence to rectally infused saline.48 Also, no validated scale for assessing the strength or endurance of anal squeeze is currently available. Adaptation of the Oxford grading scale, used for grading of vaginal pelvic floor contraction when treating patients with Kegel exercises for urinary incontinence, may prove useful.49 In men, digital examination has been found to be reliable when assessing multiple aspects of pelvic floor muscle function, with the single exception of endurance.50 This limitation is clinically relevant because of increasing evidence that fatigue of voluntary squeeze is important in the evaluation of pelvic floor muscle function. Fortunately, anorectal manometry can be used to evaluate fatigue.51 In addition to limitations regarding fatigue, digital rectal examination is also poor at estimating resting tone.52 The presence of stool in the rectum during digital rectal examination may suggest constipation or fecal impaction, particularly when noted in a frail or immobile person. However, digital rectal examination alone is an unreliable indicator of a large volume of stool in the colon, particularly if the stools have a soft and puttylike consistency rather than a hard consistency.28,53 When an impaction or large volume of colonic stool is suspected, a plain abdominal radiograph may be helpful. Ideally, every person with unexplained fecal incontinence should have a full medical examination to check for any rectal masses. Physical examination encompasses more than an assessment of anal sphincter and anal sphincter function. The perianal skin should be examined for rashes, the presence of soiling, congenital defects, hemorrhoids, or skin tags (the latter may make perianal cleaning very difficult and lead to minor soiling problems). Wiping the anus with wet cotton wool may show fecal staining not apparent to visual inspection. This maneuver is helpful because it may reveal fecal soiling that is sufficient to cause itching or
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pruritus ani. The perineum should be inspected for scarring from episiotomy or tears. Nevertheless, it must be remembered that perineal inspection does not correlate well with the presence of occult anal sphincter damage as seen on anal ultrasound, and an apparently intact perineum does not preclude underlying sphincter damage.54 Examination of the posterior wall of the vagina is necessary to identify a rectocele. When prolapse is suspected, examination of the anus and rectum must occur with the patient in the upright as well as supine positions. The patient can be asked to sit on a bedside commode or toilet and lean forward. The patient is then asked to strain vigorously. A prolapsing rectum will be visible or can be felt as a protruding bulge at or below the anal verge.55 Perineal descent of greater than 2 cm on straining is considered abnormal.55 The contours of the lower back also must be inspected because abnormalities may indicate previous undiagnosed spina bifida occulta.
CONCLUSIONS The nursing assessment outlined in this article provides a basis on which to plan individual care for adults with fecal incontinence. It includes a detailed review of continence-related bowel symptoms, general medical history, and documentation form for physical examination. This evaluation should be conducted by a nurse with a comprehensive understanding of colorectal symptoms and their clinical relevance in the management of fecal incontinence. This understanding allows the nurse to individualize care, rather than relying strictly on containment of stool with preventive skin care. Although we have found the tool to be both comprehensive and understandable to both patients and health care professionals, we acknowledge that it will require adaptation when used with patient groups in different countries or cultures. REFERENCES 1. Nelson R, Norton N, Cautley E, Furner S. Community-based prevalence of anal incontinence. JAMA 1995;274:559-61. 2. Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol 1996;91:33-6. 3. Rockwood TH, Church JM, Fleshman JW, et al. Fecal incontinence quality of life scale. Dis Colon Rectum 2000;43:9-17. 4.Sultan AH, Kamm MA, Hudson CN, Thomas JM,
Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905-11. 5. Kamm MA. Faecal incontinence. BMJ 1998; 316:528-32. 6. Norton C. Faecal incontinence in adults 1: prevalence and causes. Br J Nurs 1996;5:1366-74. 7. Jensen LL. Faecal incontinence: evaluation and treatment. J WOCN 1997;24:277-82. 8. Doughty D. A physiologic approach to bowel training. J WOCN 1996;23:46-56. 9. Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36:77-97. 10. Ashworth PD, Hagan MT. The meaning of incontinence: a qualitative study of non-geriatric urinary incontinence sufferers. J Adv Nurs 1993;18: 1415-23. 11. Connell AM, Hilton C, Irvine G, Lennard-Jones JE, Misiewicz JJ. Variation in bowel habit in two population samples. BMJ 1965;ii:1095-9. 12 Heaton KW, Radvan J, Cripps H, Mountford RA, Braddon FEM, Hughes AO. Defaecation frequency and timing, and stool form in the general population: a prospective study. Gut 1992;33:818-24. 13. Thompson WG, Dotevall G, Drossman DA, Heaton KW, Kruis W. Irritable bowel syndrome: guidelines for diagnosis. Gastroenterol Int 1989;2: 92-5. 14. Drossman DA, Richer JE, Talley NJ, Thompson WG, Corazziari E, Whitehead WE. The functional gastrointestinal disorders. Reston (VA): Degnon Associates; 1994. 15. Kamm MA, Lennard-Jones JE. Constipation. Petersfield, United Kingdom: Wrightson Biomedical; 1994. 16. Harari D, Gurwitz JH, Avom J, Bohn R, Minaker KL. Bowel habit in relation to age and gender. Arch Intern Med 1996;156:315-20. 17. Curless R, French J, Williams GV, James OFW. Comparison of gastrointestinal symptoms in colorectal cancer patients and community controls with respect to age. Gut 1994;35:1267-70. 18. Bliss DZ, Savik S, Jung H, Jensen LL, LeMoine M, Lowry AC. Comparison of subjective classification of stool consistency and stool water content. J WOCN 1999;26:137-41. 19. Whitehead WE, Orr WC, Engel BT, Schuster MM. External anal sphincter response to rectal distension: learned response or reflex. Psychophysiology 1981;19:57-62. 20. Herbst F, Kamm MA, Morris GP, Britton K, Woloszko J, Nicholls RJ. Gastrointestinal transit and prolonged ambulatory colonic motility in health and faecal incontinence. Gut 1997;41:381-9. 21. Klauser AG, Voderholzer WA, Heinrich CA, Schindlbeck NE, Mueller-Lissner SA. Behavioural modification of colonic function: can constipation be learned? Digest Dis Sci 1990;35:1271-5. 22. Delechenaut P, Leroi AM, Weber J, Touchais JY, Czemichow P, Denis P. Relationship between clinical symptoms of anal incontinence and the results of anorectal manometry. Dis Colon Rectum 1992;35:847-9. 23. Gee AS, Durdey P. Urge incontinence of faeces is a marker of severe external anal sphincter dysfunction. Br J Surg 1995;82:1179-82.
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24. Engel AF, Kamm MA, Bartram CI, Nicholls RJ. Relationship of symptoms in faecal incontinence to specific sphincter abnormalities. Int J Colorectal Dis 1995;10:152-5. 25. Hill J, Corson RJ, Brandon H, Redford J, Faragher EB, Kiff ES. History and examination in the assessment of patients with idiopathic faecal incontinence. Dis Colon Rectum 1994;37:473-7. 26. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric and sphincter tears: risk factors and outcome of primary repair. BMJ 1994;308:887-91. 27. Vaizey CJ, Kamm MA, Bartram CI. Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence. Lancet 1997;349:612-5. 28. Barrett JA. Faecal incontinence and related problems in the older adult. London: Edward Arnold; 1993. 29. Henry MM, Swash M. Coloproctology and the pelvic floor. 2nd ed. London: Butterworth Heinemann; 1992. 30. Non-steroidal anti-inflammatory drugs. In: British National Formulary. London: British Medical Association & Royal Pharmaceutical Society; 2000. 31. Wald A. Systemic diseases causing disorders of defaecation and continence. Semin Gastrointest Dis 1995;6:194-202. 32. Engel AF, Kamm MA, Bartram CI. Unwanted anal penetration as a physical cause of faecal incontinence. Eur J Gastroenterol Hepatol 1995; 7:65-7. 33. Taylor T, Smith AN, Fulton PM. Effect of hysterectomy on bowel function. BMJ 1989;299:3001. 34. van Dam JH, Gosselink MJ, Drogendijk AC, Hop WC, Schouten WR. Changes in bowel function after hysterectomy. Dis Colon Rectum 1997; 40:1342-7. 35. White H. Aids to continence for people with physical disabilities. In: Norton C, editor. Nursing for continence. 2nd ed. Beaconsfield, United Kingdom: Beaconsfield Publishers; 1996. p. 299316. 36. Nelson A, Malassigne P, Amerson T, Saltzstein R, Binard J. Descriptive study of bowel care practices and equipment in spinal cord injury. Sci Nurs 1993;10:65-7. 37. Donnelly VS, O’Herlihy C, Campbell DM, O’Connell PR. Postpartum fecal incontinence is more common in women with irritable bowel syndrome. Dis Colon Rectum. 1998;41:586-9. 38. Scott AM, Kellow JE, Eckersley GM, Nolan JM, Jones MP. Cigarette smoking and nicotine delay postpranial mouth-cecum transit time. Digest Dis Sci 1992;37:1544-7. 39. Rausch T, Beglinger C, Alam N, Meier R. Effect of transdermal application of nicotine on
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colonic transit in healthy nonsmoking volunteers. Neurogastroenterol Mot 1998;10:263-70. 40. Brown SR, Cann PA, Read NW. Effect of coffee on distal colon function. Gut 1990;31:450-3. 41. Donnelly V, O’Connell PR, O’Herlihy C. The influence of estrogen replacement on faecal incontinence in postmenopausal women. Br J Obstetrics Gynaecology 1997;104:311-5. 42. Khullar V, Damiano R, Toozs-Hobson P, Cardozo L. Prevalence of faecal incontinence among women with urinary incontinence. Br J Obstetrics Gynaecology 1998;105:1211-3. 43. Cukier JM, Cortina-Borja M, Brading AF. A case control study to examine any association between idiopathic detrusor instability and gastrointestinal tract disorder, and between irritable bowel syndrome and urinary tract disorder. Br J Urol 1997;79:865-78. 44. Ludman L, Spitz L, Kiely EM. Social and emotional impact of faecal incontinence after surgery for anorectal abnormalities. Arch Dis Childhood 1994;71:194-200. 45. Rintala R. Faecal continence and quality of life in adult patients with an operated low anorectal malformation. J Pediatr Surg 1992;27:902-5. 46. Caret J. People don’t understand: children, young people and their families living with a hidden disability. London: National Children’s Bureau; 1998. 47. Keating JP, Stewart PJ, Eyers AA, Warner D, Bokey EL. Are special investigations of value in the management of patients with faecal incontinence? Dis Colon Rectum 1997;40:896-910. 48. Read NW, Harford WV, Schmulen AC, Read M, Santa Ana C, Fordtran JS. A clinical study of patients with faecal incontinence and diarrhoea. Gastroenterology 1979;76:747-56. 49. Schussler B, Laycock J, Norton P, Stanton S. Pelvic floor re-education: principles and practice. 1st ed. London: Springer-Verlag; 1994. 50. Wyndaele JJ, Van Eetvelde B. Reproducibility of digital testing of the pelvic floor muscles in men. Arch Phys Medicine Rehabil 1996;77:1179-81. 51. Marcello PW, Barrett RC, Coller JA, et al. Fatigue rate index as a new measure of extemal sphincter function. Dis Colon Rectum 1998;41:336-43. 52. Felt-Bersma RJF, Klinkenberg-Knol EC, Meuwissen SGM. Investigation of anorectal function. Br J Surgery 1988;75:53-5. 53. Ardron ME, Main ANH. Management of constipation. BMJ 1990;300:1400. 54. Frudinger A, Bartram CI, Spencer J, Kamm MA. Perineal examination as a predictor of underlying external anal sphincter damage. Br J Obstet Gynaecol 1997;104:1009-13. 55. Pemberton JH. Anorectal and pelvic floor disorders: putting physiology into practice. J Gastroenterol Hepatol 1990;5(suppl 1):127-43.
A Nursing Assessment Tool for Adults With Fecal Incontinence Christine Norton, MA, RN, and Sonya Chelvanayagam, MSc, RN
Fecal incontinence affects slightly more than 1% of community-dwelling adults. This article describes an assessment format, with a research basis when available, that has been developed in a specialist nursing clinic in the United Kingdom. The focus is on how to obtain the most useful information from the patient to plan appropriate nursing interventions. A subsequent article will describe the biofeedback program developed as part of a package of care to meet individual needs of persons with fecal incontinence. (J WOCN 2000;27:279-91)
F
ecal incontinence is a common health care problem, affecting more than 1% of the adult population.1 It is a particularly embarrassing symptom that is socially unacceptable, yet many with the problem do not seek professional help.2 Fecal incontinence has a major negative impact on physical and psychological health and lifestyle, with severe social restrictions in many instances.3 Fecal incontinence has multiple possible causes, the most common being obstetric trauma.4 Other causes include congenital, traumatic, or iatrogenic sphincter damage; intestinal hypermotility resulting in diarrhea; neurologic disease; local anorectal pathology; and, in immobile individuals, fecal impaction with overflow soiling.5,6 Recent advances in investigation techniques, particularly anorectal manometry and endoanal ultrasound, enable accurate characterization of structural or functional causes of fecal incontinence in individual patients. Nevertheless, treatment options are limited for many who primarily rely on surgery or constipating drugs to alter stool consistency and diminish the risk of subsequent incontinence. Fecal continence is a complex function that involves multiple modulatory mechanisms that influence stool consistency, intestinal motility, rectal vault storage, and anal sphincter function. Therefore, when managing a patient with fecal incontinence, it is essential to define what combination of these factors contributes to soiling. Although previous authors
have stressed the importance of assessment7 and provided general guidelines for management,8,9 our search of the literature found no tool adequate for the assessment of fecal incontinence in a population of independent, communitydwelling adults. We decided that an essential first step when working with patients with fecal incontinence at our hospital specializing in colorectal dysfunction was to define important areas of assessment and pertinent demographic data. The checklist we developed to assess these variables is provided in Figure 1. The main focus is fecal incontinence, although many patients have additional bowel problems, and some questions were designed to explore these aspects of gastrointestinal function. This assessment instrument is not intended to measure formally such important psychosocial aspects of fecal incontinence as coping or quality of life; instead, it provides baseline information intended to direct the formulation of a plan of care. A combination of empiric (clinical) experience and literature review was used to design the instrument. We found this combination necessary because research evidence is not available at this stage to substantiate every aspect of the assessment. Completion of the instrument requires approximately 20 to 30 minutes. This article will review the domains covered in the initial assessment and provide a rationale for the clinical relevance of each item.
Christine Norton is Nurse Specialist (Continence), Physiology Unit, St Mark’s Hospital, North West London Hospitals NHS Trust. Sonya Chelvanayagam, MSc, RN, is Biofeedback Research Nurse, Physiology Unit, St Mark’s Hospital, North West London Hospitals NHS Trust. Sonya Chelvanayagam is funded by Action Research, a UK medical research charity. Reprint requests: Christine Norton, MA, RN, Physiology Unit, St Mark’s Hospital, North West London Hospitals NHS Trust, Watford Road, Harrow, Middlesex, HA1 3UJ, United Kingdom. Copyright © 2000 by the Wound, Ostomy and Continence Nurses Society. 1071-5754/2000/$12.00 + 0 21/1/109082 doi:10.1067/mjw.2000.109082
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BIOFEEDBACK HISTORY SHEET Therapist: Date of first appointment: Name: Date of birth:
Age:
Hospital No.: Address: Telephone home/work: Referred by: GP: Marital status: Single ❏ Married ❏ Lives with partner ❏ Divorced ❏ Widowed ❏ Occupation (former if retired): Ethnic group: White ❏ Asian ❏ Black ❏ Chinese ❏ First language:
Fluency in English:
Main complaint Duration of symptoms/trigger for onset: Usual bowel pattern: Any recent change? Usual stool consistency: 1. Lumps 2. Lumpy sausage 3. Cracked sausage 4. Soft smooth sausage 5. Soft blobs 6. Fluffy, mushy 7. Watery, no pieces Fecal incontinence: How often? Urgency?
How much ? Time can defer for:
Urge incontinence: Never ❏ Seldom ❏ Sometimes ❏ Frequently ❏ Difficulty wiping: Yes ❏ No ❏ Sometimes ❏ Postdefecation soiling: Yes ❏ No ❏ Sometimes ❏ Passive soiling: Yes ❏ No ❏ Sometimes ❏ Events causing incontinence: Amount of flatus: Control of flatus: Good ❏ Variable ❏ Poor ❏ Ability to distinguish stool/flatus? Yes ❏ No ❏ Abdominal pain relieved by defecation? Other pain? Rectal bleeding? Mucus? Nocturnal bowel problems? Evacuation difficulties? Straining? Incomplete evacuation? Need to digitate anally or vaginally or support the perineum?
Painful defecation?
Bloating? Sensation of prolapse? Pads/pants? Bowel medication? Continued on page 281 Figure 1. Bowel history sheet.
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Other current medication: Medical history (include psychological): History of depression/antidepressants? Physical or social difficulties with toilet access? Previous bowel treatments and results: Obstetric history: Difficult deliveries or heavy babies? Dietary influences: Smoker? Weight/height/body mass index: Fluids (caffeine): Skin problems? Bladder problems? Effect on lifestyle/relationships: Emotional/psychological effects: Physiology findings: Biofeedback assessment: Max squeeze Endurance Repetitions of fast twitch Sensitivity to distension Coordination Ability to isolate Plan: Follow up: Figure 1. Bowel history sheet (continued).
THE ASSESSMENT INTERVIEW When managing a patient with a socially and personally sensitive condition such as fecal incontinence, it is important to build a relationship of trust so that symptoms and problems can be openly and frankly discussed. This assessment also requires the patient and nurse to establish a vocabulary of words that are mutually understood and acceptable. Even though all of our patients have been referred specifically for therapy (usually biofeedback) for fecal incontinence, many express embarrassment and find it difficult to report symptoms. The experience seems to be similar to that described for urinary incontinence, another taboo subject that is not openly discussed, even with partners or family.10 The need for a common vocabulary is compounded because some
patients are unaware of medical terms such as “defecation” or even “stool” or “anus”; but they are reluctant to use what they perceive as slang terms when discussing fecal incontinence with a professional. The wording we use for each item is indicated by italics. When reading this article and considering applying this instrument to your practice, it should be remembered that we designed the questions for an English population, and colloquial expressions will require adaptation for use in other patient populations. The essential point is to find a vocabulary that is mutually understood by both nurse and patient.
Chief Symptom What bothers you about your bowels/what is the main problem with your bowels? This item was designed to help the nurse understand the patient’s perspective on
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Figure 2. Bowel action diary form.
the problem and identify which symptoms are most bothersome. We have found that the symptom identified by the patient as most bothersome may be quite different from the primary symptom documented by the referring physician. Circumstances surrounding the onset of the problem can give important clues as to causation. Sometimes a causative event can be clearly identified, such as onset of symptoms immediately after
traumatic childbirth or a hemorrhoidectomy. At other times the patient may not have made a link between potential contributing factors and the onset of fecal incontinence. In these cases, probing questions about a change in medication or onset of menopause may help to identify contributing factors. Many people cope with fecal incontinence for years without seeking professional help. 2 In these patients, we find it useful to explore
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Figure 3. 7-Point visual scale for stool consistency.
what triggered consultation. Have the symptoms worsened? Has the ability to cope with symptoms been compromised?
Bowel Elimination Patterns How often do you move/open your bowels? There is a common misconception among the general population that normal bowel habit is once per day. In fact, function varies between 1 to 3 times a day to once in 3 days.11 A minority of the total population, approximately 40% of men and 33%
of women, move their bowels once on a daily basis.12 Instead, most are irregular in the frequency of bowel movements, with women of childbearing age (25-49 years) being the most irregular. One third of young women move their bowels less than once per day and 1% do so less than once per week. A variable bowel habit is a classic feature of irritable bowel syndrome (IBS).13,14 Knowledge of this variability is important when assessing a patient’s bowel elim-
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Figure 4. Rectal filling results in reflex internal sphincter relaxation.
Figure 5. Continence is maintained by voluntary external sphincter contraction.
ination patterns because of common misconceptions about the frequency of bowel movements and constipation. The term constipation is interpreted differently by various persons.15 Infrequent bowel motions, provided the stool is easy to pass and not hardened, does not meet clinical criteria of constipation and it is not a cause for concern or justification for interven-
tion. Conversely, some very constipated people can produce a stool several times per day, but only at the expense of long periods of straining on the toilet. There is, in the general population, no age-related decrease in the actual frequency of defecation, although there seems to be an increase with age in self-report of constipation and an increase in laxative use.16
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The use of a laxative does not necessarily imply a diagnosis of constipation. A recent change in the frequency of bowel motions should be noted because it may indicate an underlying disease or malignancy. Any recent unexplained change in bowel habit in a patient older than 40 years old should be investigated by barium enema radiograph or colonoscopy. Although fecal incontinence is rarely the sole presenting symptom for intestinal cancer, up to 25% of patients with cancer note occasional bouts of fecal soiling.17 A diary of bowel actions for a week often provides useful baseline information (Figure 2). This diary is routinely sent to patients with their appointment letter, and very few fail to bring it, correctly completed, to the first consultation.
Stool Consistency What is your stool (bowel movement) like? Is it loose, soft but formed, hard or hard pellets? Does this vary? Careful assessment of stool consistency with particular attention to reported changes in consistency or color also provides important information in the evaluation of fecal incontinence. For example, patients with IBS or inflammatory bowel disease are particularly prone to variations in stool consistency. When the patient has difficulty in describing the stool, a visual prompt may be helpful (Figure 3).12 This type of scale is useful because patients have been found to be generally accurate when assessing their own stool consistency.18 When asked to respond to this 7-point visual scale for stool consistency, types 3 or 4 represent the most usual selections. Nevertheless, only 56% of women describe these types as normal, whereas 61% of men describe them as normal. Loose stool is significant because it increases the risk for both passive and urge fecal incontinence; a pelletlike stool consistency is important because it may indicate slow colonic transit and constipation.
Fecal Incontinence A particularly sensitive query is required when asking patients about fecal incontinence because many people are reluctant to admit stool soiling, and it may be difficult to identify terms expressing this sign that are mutually understood and acceptable. Even people consulting a gastroenterologist often refrain from volunteering the symptom of fecal incontinence. In one study, less than half of the patients admitting to incontinence on a
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questionnaire had told their doctor about it.2 In addition to reluctance in identifying the symptom of fecal incontinence, it can be difficult to assess the severity of soiling because many people severely restrict their lifestyle, thus limiting the risk of incontinence. As a result, fecal incontinence may occur infrequently, even though it represents a major concern. Many patients also find it difficult to estimate the amount of stool lost during an incontinent episode. We have found it particularly helpful to question patients about the 2 major types of fecal incontinence: urge or passive.
Urgency and Urge Incontinence When you need to open/move your bowels, do you need to rush to get to the toilet? How long can you hold on for? When the rectum fills, the internal anal sphincter relaxes reflexively to enable “sampling” of the rectal contents by the sensitive nerve endings within the dentate line in the upper anal canal (Figure 4). With normal bowel control, defecation can be deferred for long periods of time because the urge to defecate is opposed by voluntary contraction of the striated external anal sphincter muscle,19 which generates sufficient pressure to prevent immediate stool expulsion and to return the stool to the rectum (Figure 5). Retrograde peristalsis may even remove the stool away from the anal sphincter and back into the sigmoid colon in some cases.20 If bowel control is normal, the urge diminishes, and the patient is typically able to defer defecation for up to several hours. Indeed, it has been shown that voluntarily ignoring the call to defecate can reduce the frequency of defecation by 50% and slow colonic transit.21 In contrast, a reduced squeeze pressure and an inability to sustain a submaximal contraction of the external sphincter has been found to correlate with the symptom of urgency.22,23 Some patients with fecal incontinence generate high amplitude colonic pressure waves (up to 500 cm water pressure).20 Without an adequate sphincter response to oppose this high-pressure bolus contraction, resistance to the expulsion of stool is diminished and urge incontinence is likely. In addition, patients who have diarrhea, such as those with inflammatory bowel disease, are at a particularly high risk of severe urgency and urge incontinence from colonic peristalsis opposing sphincter function and to the loose consistency of the rectal contents.
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Do you ever fail to reach the toilet in time and have a bowel accident? Urge incontinence often reflects a weakness or defect in the external anal sphincter, 24,25 and obstetric trauma is the most common cause of sphincter damage. 26 Urgency may become a particular problem because of a fear of future accidents for the individual who already has had an episode of fecal incontinence. As a result, the patient may respond immediately to any urge to defecate in an attempt to prevent incontinent episodes. This rapid response may create a vicious cycle so that any bowel sensation is interpreted as likely to lead to incontinence. Because of this fear, a sensation of rectal urgency generates intense anxiety, or even panic, which exacerbates the sense of urgency. When a patient reports rectal urgency, it is important to establish how frequently urge incontinence actually occurs and whether restrictions in activities are from actual or feared soiling.
Passive Incontinence Do you have any leakage from your bottom of which you are unaware? Is this liquid or solid? Does this occur at any time or only after you have opened/moved your bowels? The smooth muscle of the internal anal sphincter is responsible for up to 80% of resting tone in the anal canal,5 and passive soiling is associated with internal anal sphincter damage detected by ultrasound.24,25 A weak or disrupted internal sphincter is incapable of completely closing the anal canal. If the stool is loose or soft, some may remain in the anal canal and ooze out after defecation. Incompetence of the internal anal sphincter is often the result of inadvertent surgical damage (particularly after hemorrhoidectomy or sphincterotomy) or idiopathic smooth muscle degeneration.27 Patients with internal anal sphincter incompetence have difficulty cleaning the anus after defecation and experience subsequent soiling, which may persist for several hours. Others have passive soiling at unpredictable times and in the absence of any awareness of stool soiling. In still others, soiling is provoked or exacerbated by physical exertion such as walking or running. Passive loss of solid stool or loss of copious amounts of mucus may result from rectal prolapse.
Flatus Can you control wind? Are you able to tell the difference between wind and the need to
empty your bowels? Although the concept of “wind” is a common expression for the passage of flatus among English patients, nurses from the United States may prefer to ask patients if they are able to control the passage of “gas” from the bowels. In addition, it is important to determine whether patients are able to distinguish between the passage of flatus and stool. This sensory deficit may occur after iatrogenic or traumatic damage to the sensory nerves involved in the “sampling” reflex previously described. Incontinence of flatus may appear a trivial symptom, but many people who are unable to control the passage of flatus experience embarrassment in work, social, or intimate situations.
Pain Do you have pain associated with opening/moving your bowels? Does it occur before moving your bowels and is relieved by opening your bowels, or is it a pain as you actually pass a stool? Abdominal pain in association with altered stool consistency, frequency, or bloating in the absence of organic pathology is diagnostic of IBS,14 which is common among patients with fecal incontinence. Pain with the urge to defecate may occur in these patients, rendering it difficult to defer defecation. They may describe a colicky or spasmodic “stabbing” pain. In contrast, the occurrence of anal pain with defecation is often caused by hemorrhoids or an anal fissure, which are also common among patients with fecal incontinence. Chronically constipated people also tend to report abdominal discomfort; it is usually characterized by a feeling of bloating. Constipation or constipation-predominant IBS is also associated with abdominal bloating; we have observed that some women report the need for two sets of clothes because of this bloating. They have a normal wardrobe, but they also own clothes that are 1 to 2 sizes larger for periods when their bowels have not moved for several days.
Blood and Mucus Do you pass any blood or mucus when your bowels move/open? The passage of blood or stool during defecation occurs with a number of conditions. For example, streaks of bright red blood may occur in patients with hemorrhoids or an anal fissure. The passage of fresh (bright red) or older (darker red) blood may also occur in patients with an underlying malignancy. The presence of blood and mucus in an individual with a
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history of straining may indicate the presence of a solitary rectal ulcer. Copious mucus with normal bowel function may indicate a villous adenoma; the passage of mucus in the presence of variable stool consistency and defecation often occurs with IBS. Passive incontinence of clear or fecal stained mucus also may indicate a rectal prolapse. Whenever a patient reports the passage of blood or mucus, further investigation is warranted. Colorectal cancer is the second most common cancer in the western world, and up to one fourth of patients will have fecal incontinence among their presenting symptoms.17 Therefore symptomatic management for fecal incontinence must be deferred until the reason for passing blood or mucus is determined.
Evacuation Difficulties Do you have difficulty opening your bowels? Do you need to strain? If so, for how long? Do you ever need to insert a finger into your bottom or vagina to help pass stool? Do you need to push on the area by your anus? Does it feel as if you have not completely emptied your bowels? We have found that these questions are helpful when determining whether the patient has difficulty evacuating stool from the rectum. Constipation, the most common cause of evacuation difficulty, will not be covered in detail in this article. Constipation commonly co-exists with fecal incontinence in frail or disabled people.28 We have found that people with chronic constipation often describe defecation as “unsatisfying.” On closer questioning, this dissatisfaction occurs because of difficulty evacuating stool from the bowels leading to a sensation that the bowel is never properly emptied. As a result, many patients with constipation repeatedly return to the toilet and some spend long periods of time (as much as hours) straining in an attempt to evacuate the bowels without adequate results. Persons with a weak pelvic floor may also perceive difficulty evacuating stool from the bowels because of downward movement of the pelvic floor and anus with straining. In addition to pelvic floor muscle weakness, some women have a rectocele develop after childbirth or because of excessive straining when attempting to defecate or urinate. A rectocele causes the anterior wall of the rectum to bulge into the vagina as the woman strains to defecate. Some women find that exerting gentle backward pressure by placing a finger
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in the vagina may promote evacuation of stool “trapped” in the rectocele.
Sensation of prolapse Some people with fecal incontinence report a dragging feeling, or a perception that the rectum protrudes from the anus, particularly during or after straining. These sensations are typically caused by rectal prolapse. In the majority, the prolapse reduces spontaneously after defecation, but occasionally the patient may find it necessary to replace the rectum manually after prolapse. Rectal prolapse is associated with fecal incontinence in approximately 60% of cases.29
Pads or Pants Do you need to wear a pad because of problems with leakage from your bowels? If so, what type of pad? Do you need to change your underwear during the day because of leakage? If yes, how often? Patients may wear pads because of urinary incontinence, and so it is important to identify if pads or underwear are changed because of fecal incontinence. In addition, patients who describe urgency may always wear a pad because of fear of incontinence rather than actual accidents.
Medication Many drugs can influence bowel function, predisposing the patient either constipation or loose stools (diarrhea). For example, analgesics and antidepressants are commonly associated with constipation, whereas nonsteroidal anti-inflammatory drugs and antibiotics often lead to loose stools or diarrhea.30 A detailed discussion of specific medications that affect stool consistency is beyond the scope of this article.
Medical History Questions about the patient’s medical history may give important clues regarding the cause of fecal incontinence. Major neurologic disease, abdominal surgery, diabetes, thyroid disease, psychological disturbances, and many other disorders may have an influence on bowel function. About 4% to 5% of patients with insulindependent diabetes have fecal incontinence caused by diarrhea associated with peripheral and autonomic neuropathies.31 Anal trauma, such as that associated with unwanted anal intercourse, may cause internal anal sphincter damage and subsequent fecal incontinence.32 Many women date the onset of bowel symptoms to gyne-
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cological surgery, especially hysterectomy.33,34
Access to Toileting Facilities For persons with physical disabilities, fecal incontinence may be more attributable to inadequate toilet access than impairments in bowel function.35 Others may have fecal incontinence because of inadequate access to the assistance of care providers. The practicalities of bowel management can be difficult for anyone with a physical impairment. Solutions often need to be imaginative and creative. They must be tailored to the individual’s abilities, lifestyle, physical environment, and the availability of help. Many patients do not feel safe on commode chairs, and transfer from a wheelchair may be difficult. One study found that 37% of 147 patients with a spinal injury did not feel safe and 42% felt that the brakes were ineffective; 35% had falls during transfers and 23% needed hospitalization for the resulting injuries.35,36
fiber diet will soften the stool and may make it more difficult to control. Food containing specific spices may upset intestinal function. Some patients are able to identify specific foods that trigger bowel problems, but others are not. Nicotine is thought to slow upper gut motility and increase total transit time,38 but it may also speed rectosigmoid transit. 39 These observations correlate with clinical reports that smoking a cigarette facilitates the initiation of defecation. It is not known whether obesity has an adverse effect on bowel control. Some people with anorexia become constipated; others abuse laxatives, possibly in an attempt to control weight. Some persons have pelvic floor problems, possibly from excessively strenuous exercise regimes or muscle wasting. Caffeine is known to stimulate smooth muscles within the gastrointestinal tract,40 and we have observed that it may exacerbate urgency in patients with fecal incontinence.
Skin Problems Obstetric History How many babies have you had? Were forceps used for any of these deliveries? Did you tear, or did you have stitches? How heavy were the babies? Was there any problem with bowel control after the deliveries? Women who have had difficult deliveries, particularly when assisted by forceps or deliveries involving a third-degree tear, are at risk for fecal incontinence.4,26 Women with severe anal trauma often report immediate onset of symptoms; others develop symptoms of fecal incontinence years later when an additional factor, such as a surgical procedure or disease, alters a previously predictable and stable bowel elimination pattern. Prolonged labor (particularly the second stage), and heavy babies can cause trauma and damage to the anal sphincter. Postnatal women are frequently asked about bladder function and taught the importance of pelvic floor exercises. Bowel function is much less frequently considered or mentioned. Women with pre-existing IBS are known to be more likely than others without IBS to have postpartum fecal urgency (64% vs 10%) and poor control of flatus (35% vs 13%), at least in the short term.37
Diet, Smoking, Weight, and Fluid Intake Many people find that what they eat influences their bowel function. A high-
Although certain patients with fecal incontinence have few problems with skin irritation, others have severe soreness and itching. Skin problems are common among those with passive soiling of stool or mucus. Diarrhea also may lead to perianal skin problems when digestive enzymes from the small bowel come into contact with the skin. Double incontinence (a combination of urinary and fecal leakage) tends to exacerbate perineal skin problems. In addition to these factors, postmenopausal women may have skin problems because of hormone deficiency.41 When skin problems prove resistant to simple skin care and barrier creams, it is worth seeking a dermatologic opinion because the patient may have a secondary infection or a treatable skin condition.
Urinary Continence Do you have problems with leakage from your bladder? Does urine leakage occur if you cough, sneeze, or laugh? Do you need to rush to the toilet to pass water? Urinary and fecal incontinence may coexist; the presence of double incontinence may be a sign of severe pelvic floor muscle dysfunction. Approximately 25% of women attending a urodynamic clinic for investigation of urinary incontinence will admit to fecal incontinence on a postal questionnaire, but only 15% do so on direct questioning, emphasizing the difficulty many women have in admitting this symptom.42 Al-
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though pelvic floor muscle problems may occur with double incontinence, at least one study found that fecal incontinence was more frequently associated with detrusor instability and urge incontinence compared with genuine stress incontinence. This relation may reflect the overlap of IBS with an unstable bladder.43
Psychosocial Factors If a patient reports symptoms of fecal incontinence, it is important to ascertain how this has affected his or her lifestyle. Some patients report feeling very restricted, and they are forced to plan journeys around toilet facilities. In severe cases, fecal incontinence may cause a person to remain in the home. Clearly such behaviors profoundly affect the individual, partner, and family. Patients with fecal incontinence often report avoiding sexual intimacy because of feeling dirty or fearing that an episode of incontinence will occur during sexual activity. Although it has been postulated that fecal incontinence has a major negative impact on psychosocial well-being, remarkably few formal studies have been done in this area.3 It is known that children born with congenital anorectal abnormalities and with persistent fecal incontinence have an increased risk of behavioral and social problems than their peers.44,45 One qualitative study has documented in detail the difficulties for children and their families of growing up with fecal incontinence,46 but there have been no similar studies in adults. In addition to isolation and embarrassment, depression is common with these patients and we specifically ask about it when assessing patients with fecal incontinence.
Examination A physical examination completes the assessment of fecal incontinence. A general assessment of the patient’s physical abilities is completed because it provides clues to conditions that may influence or impair treatment strategies. A focused examination and detailed history are able to predict the findings of anorectal physiologic studies in some cases.47 A low resting tone in the anal canal on digital examination is associated with passive leakage, and there is often gaping of a “funnel-shaped” anal introitus if gentle traction is applied away from the anal verge.24,25 Many patients with postdefecation soiling have trapping of soft stool in this funnel, which ordinary wip-
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ing with dry paper will not remove. Reduced strength and duration of voluntary contraction of the anus has been found to correlate with the symptom of urgency of defecation.22,24,25 Urge incontinence of stool is also associated with reduced puborectalis squeeze and a reduced anorectal angle; many also report urge and stress urinary incontinence.25 Estimation of resting and squeeze sphincter tone on physical examination has not been found to correlate well with any objective measure of sphincter function or with continence to rectally infused saline.48 Also, no validated scale for assessing the strength or endurance of anal squeeze is currently available. Adaptation of the Oxford grading scale, used for grading of vaginal pelvic floor contraction when treating patients with Kegel exercises for urinary incontinence, may prove useful.49 In men, digital examination has been found to be reliable when assessing multiple aspects of pelvic floor muscle function, with the single exception of endurance.50 This limitation is clinically relevant because of increasing evidence that fatigue of voluntary squeeze is important in the evaluation of pelvic floor muscle function. Fortunately, anorectal manometry can be used to evaluate fatigue.51 In addition to limitations regarding fatigue, digital rectal examination is also poor at estimating resting tone.52 The presence of stool in the rectum during digital rectal examination may suggest constipation or fecal impaction, particularly when noted in a frail or immobile person. However, digital rectal examination alone is an unreliable indicator of a large volume of stool in the colon, particularly if the stools have a soft and puttylike consistency rather than a hard consistency.28,53 When an impaction or large volume of colonic stool is suspected, a plain abdominal radiograph may be helpful. Ideally, every person with unexplained fecal incontinence should have a full medical examination to check for any rectal masses. Physical examination encompasses more than an assessment of anal sphincter and anal sphincter function. The perianal skin should be examined for rashes, the presence of soiling, congenital defects, hemorrhoids, or skin tags (the latter may make perianal cleaning very difficult and lead to minor soiling problems). Wiping the anus with wet cotton wool may show fecal staining not apparent to visual inspection. This maneuver is helpful because it may reveal fecal soiling that is sufficient to cause itching or
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pruritus ani. The perineum should be inspected for scarring from episiotomy or tears. Nevertheless, it must be remembered that perineal inspection does not correlate well with the presence of occult anal sphincter damage as seen on anal ultrasound, and an apparently intact perineum does not preclude underlying sphincter damage.54 Examination of the posterior wall of the vagina is necessary to identify a rectocele. When prolapse is suspected, examination of the anus and rectum must occur with the patient in the upright as well as supine positions. The patient can be asked to sit on a bedside commode or toilet and lean forward. The patient is then asked to strain vigorously. A prolapsing rectum will be visible or can be felt as a protruding bulge at or below the anal verge.55 Perineal descent of greater than 2 cm on straining is considered abnormal.55 The contours of the lower back also must be inspected because abnormalities may indicate previous undiagnosed spina bifida occulta.
CONCLUSIONS The nursing assessment outlined in this article provides a basis on which to plan individual care for adults with fecal incontinence. It includes a detailed review of continence-related bowel symptoms, general medical history, and documentation form for physical examination. This evaluation should be conducted by a nurse with a comprehensive understanding of colorectal symptoms and their clinical relevance in the management of fecal incontinence. This understanding allows the nurse to individualize care, rather than relying strictly on containment of stool with preventive skin care. Although we have found the tool to be both comprehensive and understandable to both patients and health care professionals, we acknowledge that it will require adaptation when used with patient groups in different countries or cultures. REFERENCES 1. Nelson R, Norton N, Cautley E, Furner S. Community-based prevalence of anal incontinence. JAMA 1995;274:559-61. 2. Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol 1996;91:33-6. 3. Rockwood TH, Church JM, Fleshman JW, et al. Fecal incontinence quality of life scale. Dis Colon Rectum 2000;43:9-17. 4.Sultan AH, Kamm MA, Hudson CN, Thomas JM,
Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905-11. 5. Kamm MA. Faecal incontinence. BMJ 1998; 316:528-32. 6. Norton C. Faecal incontinence in adults 1: prevalence and causes. Br J Nurs 1996;5:1366-74. 7. Jensen LL. Faecal incontinence: evaluation and treatment. J WOCN 1997;24:277-82. 8. Doughty D. A physiologic approach to bowel training. J WOCN 1996;23:46-56. 9. Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36:77-97. 10. Ashworth PD, Hagan MT. The meaning of incontinence: a qualitative study of non-geriatric urinary incontinence sufferers. J Adv Nurs 1993;18: 1415-23. 11. Connell AM, Hilton C, Irvine G, Lennard-Jones JE, Misiewicz JJ. Variation in bowel habit in two population samples. BMJ 1965;ii:1095-9. 12 Heaton KW, Radvan J, Cripps H, Mountford RA, Braddon FEM, Hughes AO. Defaecation frequency and timing, and stool form in the general population: a prospective study. Gut 1992;33:818-24. 13. Thompson WG, Dotevall G, Drossman DA, Heaton KW, Kruis W. Irritable bowel syndrome: guidelines for diagnosis. Gastroenterol Int 1989;2: 92-5. 14. Drossman DA, Richer JE, Talley NJ, Thompson WG, Corazziari E, Whitehead WE. The functional gastrointestinal disorders. Reston (VA): Degnon Associates; 1994. 15. Kamm MA, Lennard-Jones JE. Constipation. Petersfield, United Kingdom: Wrightson Biomedical; 1994. 16. Harari D, Gurwitz JH, Avom J, Bohn R, Minaker KL. Bowel habit in relation to age and gender. Arch Intern Med 1996;156:315-20. 17. Curless R, French J, Williams GV, James OFW. Comparison of gastrointestinal symptoms in colorectal cancer patients and community controls with respect to age. Gut 1994;35:1267-70. 18. Bliss DZ, Savik S, Jung H, Jensen LL, LeMoine M, Lowry AC. Comparison of subjective classification of stool consistency and stool water content. J WOCN 1999;26:137-41. 19. Whitehead WE, Orr WC, Engel BT, Schuster MM. External anal sphincter response to rectal distension: learned response or reflex. Psychophysiology 1981;19:57-62. 20. Herbst F, Kamm MA, Morris GP, Britton K, Woloszko J, Nicholls RJ. Gastrointestinal transit and prolonged ambulatory colonic motility in health and faecal incontinence. Gut 1997;41:381-9. 21. Klauser AG, Voderholzer WA, Heinrich CA, Schindlbeck NE, Mueller-Lissner SA. Behavioural modification of colonic function: can constipation be learned? Digest Dis Sci 1990;35:1271-5. 22. Delechenaut P, Leroi AM, Weber J, Touchais JY, Czemichow P, Denis P. Relationship between clinical symptoms of anal incontinence and the results of anorectal manometry. Dis Colon Rectum 1992;35:847-9. 23. Gee AS, Durdey P. Urge incontinence of faeces is a marker of severe external anal sphincter dysfunction. Br J Surg 1995;82:1179-82.
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24. Engel AF, Kamm MA, Bartram CI, Nicholls RJ. Relationship of symptoms in faecal incontinence to specific sphincter abnormalities. Int J Colorectal Dis 1995;10:152-5. 25. Hill J, Corson RJ, Brandon H, Redford J, Faragher EB, Kiff ES. History and examination in the assessment of patients with idiopathic faecal incontinence. Dis Colon Rectum 1994;37:473-7. 26. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric and sphincter tears: risk factors and outcome of primary repair. BMJ 1994;308:887-91. 27. Vaizey CJ, Kamm MA, Bartram CI. Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence. Lancet 1997;349:612-5. 28. Barrett JA. Faecal incontinence and related problems in the older adult. London: Edward Arnold; 1993. 29. Henry MM, Swash M. Coloproctology and the pelvic floor. 2nd ed. London: Butterworth Heinemann; 1992. 30. Non-steroidal anti-inflammatory drugs. In: British National Formulary. London: British Medical Association & Royal Pharmaceutical Society; 2000. 31. Wald A. Systemic diseases causing disorders of defaecation and continence. Semin Gastrointest Dis 1995;6:194-202. 32. Engel AF, Kamm MA, Bartram CI. Unwanted anal penetration as a physical cause of faecal incontinence. Eur J Gastroenterol Hepatol 1995; 7:65-7. 33. Taylor T, Smith AN, Fulton PM. Effect of hysterectomy on bowel function. BMJ 1989;299:3001. 34. van Dam JH, Gosselink MJ, Drogendijk AC, Hop WC, Schouten WR. Changes in bowel function after hysterectomy. Dis Colon Rectum 1997; 40:1342-7. 35. White H. Aids to continence for people with physical disabilities. In: Norton C, editor. Nursing for continence. 2nd ed. Beaconsfield, United Kingdom: Beaconsfield Publishers; 1996. p. 299316. 36. Nelson A, Malassigne P, Amerson T, Saltzstein R, Binard J. Descriptive study of bowel care practices and equipment in spinal cord injury. Sci Nurs 1993;10:65-7. 37. Donnelly VS, O’Herlihy C, Campbell DM, O’Connell PR. Postpartum fecal incontinence is more common in women with irritable bowel syndrome. Dis Colon Rectum. 1998;41:586-9. 38. Scott AM, Kellow JE, Eckersley GM, Nolan JM, Jones MP. Cigarette smoking and nicotine delay postpranial mouth-cecum transit time. Digest Dis Sci 1992;37:1544-7. 39. Rausch T, Beglinger C, Alam N, Meier R. Effect of transdermal application of nicotine on
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colonic transit in healthy nonsmoking volunteers. Neurogastroenterol Mot 1998;10:263-70. 40. Brown SR, Cann PA, Read NW. Effect of coffee on distal colon function. Gut 1990;31:450-3. 41. Donnelly V, O’Connell PR, O’Herlihy C. The influence of estrogen replacement on faecal incontinence in postmenopausal women. Br J Obstetrics Gynaecology 1997;104:311-5. 42. Khullar V, Damiano R, Toozs-Hobson P, Cardozo L. Prevalence of faecal incontinence among women with urinary incontinence. Br J Obstetrics Gynaecology 1998;105:1211-3. 43. Cukier JM, Cortina-Borja M, Brading AF. A case control study to examine any association between idiopathic detrusor instability and gastrointestinal tract disorder, and between irritable bowel syndrome and urinary tract disorder. Br J Urol 1997;79:865-78. 44. Ludman L, Spitz L, Kiely EM. Social and emotional impact of faecal incontinence after surgery for anorectal abnormalities. Arch Dis Childhood 1994;71:194-200. 45. Rintala R. Faecal continence and quality of life in adult patients with an operated low anorectal malformation. J Pediatr Surg 1992;27:902-5. 46. Caret J. People don’t understand: children, young people and their families living with a hidden disability. London: National Children’s Bureau; 1998. 47. Keating JP, Stewart PJ, Eyers AA, Warner D, Bokey EL. Are special investigations of value in the management of patients with faecal incontinence? Dis Colon Rectum 1997;40:896-910. 48. Read NW, Harford WV, Schmulen AC, Read M, Santa Ana C, Fordtran JS. A clinical study of patients with faecal incontinence and diarrhoea. Gastroenterology 1979;76:747-56. 49. Schussler B, Laycock J, Norton P, Stanton S. Pelvic floor re-education: principles and practice. 1st ed. London: Springer-Verlag; 1994. 50. Wyndaele JJ, Van Eetvelde B. Reproducibility of digital testing of the pelvic floor muscles in men. Arch Phys Medicine Rehabil 1996;77:1179-81. 51. Marcello PW, Barrett RC, Coller JA, et al. Fatigue rate index as a new measure of extemal sphincter function. Dis Colon Rectum 1998;41:336-43. 52. Felt-Bersma RJF, Klinkenberg-Knol EC, Meuwissen SGM. Investigation of anorectal function. Br J Surgery 1988;75:53-5. 53. Ardron ME, Main ANH. Management of constipation. BMJ 1990;300:1400. 54. Frudinger A, Bartram CI, Spencer J, Kamm MA. Perineal examination as a predictor of underlying external anal sphincter damage. Br J Obstet Gynaecol 1997;104:1009-13. 55. Pemberton JH. Anorectal and pelvic floor disorders: putting physiology into practice. J Gastroenterol Hepatol 1990;5(suppl 1):127-43.