Faecal incontinence in adults: management

Search and selection strategy

Previous surveillance in 2010 identified 49 studies that were considered to have no impact on recommendations.

Using the static list process, we searched for new Cochrane reviews related to the whole guideline. We found 9 relevant Cochrane reviews published between August 2010 and January 2018.

We also identified 1 NIHR signal on a relevant study.

We considered these studies in conjunction with 5 additional relevant studies from a total of 29 identified by topic experts. Many of the studies identified by topic experts were not eligible for consideration because they were general narrative reviews of a topic rather than systematic reviews, or were advice.

Two studies were identified in comments received during consultation on the 2018 surveillance decision.

From all sources, we considered 66 studies to be relevant to the guideline.

The recommendations in this guideline were largely based on consensus because of inadequate quantity and quality of evidence. The evidence base does not appear to have progressed enough to support an update of this guideline. Most of the new evidence was consistent with current recommendations.

Views of topic experts

We considered the views of topic experts, including those who helped to develop the guideline.

Two topic experts indicated that uptake and implementation of the recommendations is low. However, there was no information to suggest that this was because of unclear or controversial recommendations.

Views of stakeholders

Stakeholders are consulted on all surveillance decisions except if the whole guideline will be updated and replaced. Because this surveillance decision was to not update the guideline, we consulted on the decision.

Overall, 8 stakeholders commented; of these, 5 represented industry, 2 were patient organisations, and 1 response was received from a professional body.

Six of the 8 stakeholders disagreed with the decision to not update the guideline.

One stakeholder suggested adding a section on managing incontinence associated dermatitis. Of the studies suggested by the stakeholder, only 2 were suitable for inclusion in surveillance (Park 2014, Heidegger et al. 2016). However, the evidence in these studies was deemed insufficient to inform new recommendations in this area.

Three stakeholders suggested that the guideline should be updated to refer to NICE's medical technologies guidance on the Peristeen transanal irrigation system for managing bowel dysfunction. The guideline recommends rectal irrigation as an option and the NICE Pathway includes the medical technologies guidance at the appropriate place. We therefore consider rectal irrigation to be adequately covered by existing NICE guidance.

One stakeholder suggested updating the guideline to include percutaneous tibial nerve stimulation. NICE's interventional procedures guidance on percutaneous tibial nerve stimulation for faecal incontinence recommends this intervention only with special arrangements for clinical governance, consent and audit or research. We will share the 8 studies identified by the stakeholder with the interventional procedures team for consideration.

One stakeholder suggested adding a specific brand of anal plug to the guideline. However, the guideline does not mention any anal plug brands. No evidence to support the use of one brand of anal plug over another was identified.

One stakeholder noted that the guideline may be poorly implemented. Again, there was no information to suggest that this was because of unclear or controversial recommendations.

We asked stakeholders whether they knew of new sources to refer people to for information about toilet access cards and RADAR keys. Several sources for both items were suggested, but there was no information to guide choosing a particular source over the others. Additionally, the variety of sources indicates that patients should be able to find this information in many places. Therefore, we decided to remove the out-of-date references about these items.

One stakeholder suggested an extension to the scope – this related to faecal incontinence caused by obstetric trauma. The stakeholder wished this topic to be covered by a separate guideline. However, it was unclear how the management of faecal incontinence due to obstetric injury differs from that due to other causes. Therefore, a separate guideline in this area is not justified.

This stakeholder also suggested that NHS England's guidance on conditions for which over the counter items should not routinely be prescribed in primary care would restrict prescription of anti-diarrhoeal drugs. NHS England's guidance refers specifically to acute diarrhoea, and so should not impact on prescription of appropriate drugs for people with chronic diarrhoea that may cause faecal incontinence.

See appendix A for full details of stakeholders' comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Equalities

One stakeholder suggested that specific groups of people with faecal incontinence, such as those with neurological causes, would be protected by the Equalities Act 2010, and should have specific guidelines for different populations.

Government guidance on defining disability suggests that faecal incontinence would be considered to be a disability covered by the Act irrespective of the cause. The guideline has recommendations aimed at specific groups, and we have found no evidence to inform new recommendations.

Editorial amendments

During surveillance of the guideline, we identified the following points in the recommendations that should be amended.