Guidance

Key priorities for implementation

Key priorities for implementation

Good practice in managing faecal incontinence

  • People who report or are reported to have faecal incontinence should be offered care to be managed by healthcare professionals who have the relevant skills, training and experience and who work within an integrated continence service. See the Department of Health and Social Care's National service framework for older people.

  • Because faecal incontinence is a socially stigmatising condition, healthcare professionals should actively yet sensitively enquire about symptoms in high-risk groups (see box 1):

Box 1 High-risk groups

  • frail older people

  • people with loose stools or diarrhoea from any cause

  • women following childbirth (especially following third- and fourth‑ degree obstetric injury)

  • people with neurological or spinal disease/injury (for example, 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.

  • When assessing faecal incontinence healthcare professionals should:

    • be aware that faecal incontinence is a symptom, often with multiple contributory factors for an individual patient

    • avoid making simplistic assumptions that causation is related to a single primary diagnosis ('diagnostic overshadowing').

Baseline assessment and initial management

  • Healthcare professionals should carry out and record a focused baseline assessment for people with faecal incontinence to identify the contributory factors. This should comprise:

    • relevant medical history

    • a general examination

    • an anorectal examination

    • a cognitive assessment, if appropriate.

  • People with the following conditions should have these addressed with condition-specific interventions before healthcare professionals progress to initial management of faecal incontinence:

    • faecal loading (see also section 1.7.3)

    • potentially treatable causes of diarrhoea (for example infective, inflammatory bowel disease and irritable bowel syndrome)

    • warning signs for lower gastrointestinal cancer. See the NICE guideline on the recognition and referral of suspected cancer.

    • rectal prolapse or third-degree haemorrhoids

    • acute anal sphincter injury including obstetric and other trauma

    • acute disc prolapse/cauda equina syndrome.

  • Healthcare professionals should address the individual's bowel habit, aiming for ideal stool consistency and satisfactory bowel emptying at a predictable time.

Specialised management

  • People who continue to have episodes of faecal incontinence after initial management should be considered for specialised management. This may involve referral to a specialist continence service, which may include:

    • pelvic floor muscle training

    • bowel retraining

    • specialist dietary assessment and management

    • biofeedback

    • electrical stimulation

    • rectal irrigation.

Some of these treatments might not be appropriate for people who are unable to understand and/or comply with instructions. For example, pelvic floor re-education programmes might not be appropriate for those with neurological or spinal disease/injury resulting in faecal incontinence.

Long-term management

  • Healthcare professionals should offer the following to symptomatic people who do not wish to continue with active treatment or who have intractable faecal incontinence:

    • advice relating to the preservation of dignity and, where possible, independence

    • psychological and emotional support, possibly including referral to counsellors or therapists if it seems likely that people's attitude towards their condition and their ability to manage and cope with faecal incontinence could improve with professional assistance

    • at least 6‑monthly review of symptoms

    • discussion of any other management options (including specialist referral)

    • contact details for relevant support groups

    • advice on continence products and information about product choice, availability and use

    • advice on skin care

    • advice on how to talk to friends and family

    • strategies such as planning routes for travel to facilitate access to public conveniences, carrying a toilet access card or RADAR key to allow access to 'disabled' toilets in the National Key Scheme.

Specific groups

  • Healthcare professionals should take a proactive approach to bowel management for specific groups of people (see box 2).

Box 2 Specific groups

  • people with faecal loading or constipation

  • patients with limited mobility

  • hospitalised patients who are acutely unwell and who develop acute faecal loading and associated incontinence

  • people with cognitive or behavioural issues

  • people with neurological or spinal disease/injury resulting in faecal incontinence

  • people with learning disabilities

  • severely or terminally ill people

  • people with acquired brain injury.

Surgery

  • All people with faecal incontinence considering or being considered for surgery should be referred to a specialist surgeon to discuss:

    • the surgical and non-surgical options appropriate for their individual circumstances

    • the potential benefits and limitations of each option, with particular attention to long-term results

    • realistic expectations of the effectiveness of any surgical procedures under consideration.