NICE guideline on faecal incontinence in adults highlights the social and psychological impact of this condition, says Dr Kate Owen
Faecal incontinence is a symptom that causes immense psychological and social distress to those who suffer from it, but one that is rarely mentioned by patients or discussed by healthcare professionals. It is very encouraging that NICE has produced guidance on this most Cinderella of subjects.1,2 It is to be hoped that this will raise the profile of this condition, which is estimated to affect 0.5–1.0% of the adult population regularly.1
On reading the guidance, it quickly becomes clear that there is very little research evidence in this area; however, the working group has used consensus opinion to produce some common sense, practically based guidance.2
Diagnosing the cause of faecal incontinence
Three main overriding diagnostic principles can be drawn from the guideline.1 First, faecal incontinence is rarely a symptom that patients will volunteer spontaneously, so healthcare workers need to be prepared to ask about it specifically. This can be done by targeting high-risk groups from which most GPs will see at least one patient a day. These groups include people who:
- are frail or elderly
- have loose stools or diarrhoea have recently given birth
- are frail or elderly
- have loose stools or diarrhoea
- have recently given birth
- have severe cognitive impairment
- have urinary incontinence
- are experiencing pelvic or rectal prolapse
- have learning disabilities
- have been diagnosed with neurological or spinal disease
- suffer from perianal soreness, itching, or pain
- are receiving pelvic radiotherapy
- have undergone colonic resection or anal surgery.
The second principle of diagnosis is that it is necessary to avoid diagnostic overshadowing. This means that patients should not be considered faecally incontinent just because they may have other conditions such as dementia or disability. Faecal incontinence is a symptom not a diagnosis and reasons behind the problem need to be sought. Commonly, faecal incontinence is of multifactorial origin.1
Finally, it is important to consider the psychological and social effects of faecal incontinence on the patient. The NICE guidance gives a voice to patients affected by the condition and demonstrates the immense degree to which it affects many peoples’ lives.
Assessment and treatment
The basic assessment falls under good GP history taking and examination (including cognitive assessment if appropriate) and is clearly set out in a flow chart in the guidance.3 It is important to exclude certain conditions. These include:
- treatable causes of diarrhoea—such as infective inflammatory bowel disease and irritable bowel syndrome
- lower gastrointestinal tract cancer
- acute anal sphincter injury (from obstetric or other trauma)
- acute disc prolapse/cauda equina syndrome.
Initial primary care treatment is set out in clear logical steps in the guideline. Treatment may involve many members of the primary healthcare team, including district nursing staff, midwives, and community psychiatric nurses for the elderly. Initial measures are based around promotion of a regular bowel habit, using both medication and behavioural approaches. Patient education about their bowels and how they work is essential to achieving this—good leaflets can be found at continence-foundation.org.uk and corecharity.org.uk/content/pdfs/Bowelcontroldownloadable.pdf. Thought should also be given to the use of pads, gloves, anal plugs, and to skin care around the rectal area.
Management of groups at particularly high risk of faecal incontinence is dealt with individually in the guideline. Some of this advice is perhaps unrealistic, particularly that relating to patients with severe cognitive impairment—the guideline suggests that these patients be referred for behavioural and functional analysis, including periods of observation,2 which I feel resources are unlikely to support.
If initial simple treatment measures fail, patients should be referred on to a specialist continence service for consideration of further assessment and treatments. These include:1
- pelvic floor training bowel training
- electrical stimulation
- referral to a dietician — as appropriate
- surgery, which may be necessary for a few patients.
Relevance of the guideline
This new guidance is relevant and useful to general practice. In the future I will make sure that I ask high-risk groups about faecal incontinence, particularly at the postnatal examination, and when treating the elderly and those patients suffering from urinary incontinence.
The initial management is straightforward, revolving around the development of a regular bowel habit, something that GPs tackle on a regular basis. If initial measures fail, patients should be referred on. At all times it is essential to consider the psychological and emotional distress that this symptom causes our patients who suffer from it.
- Case finding by targeting relevant questioning of high-risk groups is needed
- A multidisciplinary treatment service is required
- Most of these services currently lie outside the tariff
- A community-based service funded at a local tariff price is likely to be more cost effective than a consultant-led service where the national tariff would apply (even for nurse and therapist consultations)
- Tariff price:1 lower colorectal surgery outpatient = £188 (new), £104 (follow-up)
- National Institute for Health and Care Excellence. Faecal incontinence: the management of faecal incontinence in adults. Clinical guideline 49. London: NICE, 2007.
- National Collaborating Centre for Acute Care. Faecal incontinence: the management of faecal incontinence in adults. London: National Collaborating Centre for Acute Care at the Royal College of Surgeons of England, 2007.
- National Institute for Health and Care Excellence. Faecal incontinence: the management of faecal incontinence in adults. Clinical guideline 49. Quick Reference Guide. London: NICE, 2007. G