1. Faecal incontinence is a sign or symptom, not a diagnosis.

1.2 Faecal incontinence, also called accidental bowel leakage,or accidental passing of bowel movements resulting in involuntary soiling - including solid stools), liquid stools, or mucus.

1.3 The most common type of faecal incontinence is called urge incontinence. When you have urge incontinence, you feel a strong urge to have a bowel movement but cannot stop it before reaching a toilet. If you have urge incontinence, the pelvic floor muscles may be too weak to hold back a bowel movement due to muscle injury or nerve damage.

1.4 Another type of faecal incontinence is called passive incontinence. When you have passive incontinence, leakage occurs without you knowing it. If you have passive incontinence, your body may not be able to sense when your rectum is full.

1.5 Common causes of faecal incontinence include diarrhoea, constipation, and muscle or nerve damage. The muscle or nerve damage may be associated with ageing or with giving birth.

1.6 Therefore, it is important to diagnose the cause or causes for each individual. Because it is a stigmatising condition, active case finding will often be needed, probably targeted at high-risk groups.

1.7 Current epidemiology information shows that between 1% and 10% of adults are affected with faecal incontinence, depending on the definition and frequency of faecal incontinence used. It is likely that 0.5-1.0% of adults experience regular faecal incontinence that affect their quality of life.

1.8 For understandable reasons, faecal incontinence has remained a largely hidden problem, with many patients feeling too embarrassed or ashamed to admit their symptoms to healthcare professionals, or even to family and friends.

2.1 People who report or are reported to have faecal incontinence should be offered care to be managed by healthcare professionals who have relevant skills, training, and experience.

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

4.1 Healthcare professionals should ensure that people who report or are reported to have faecal incontinence are offered.

• Focused baseline assessment to identify the contributory factors before any treatment is considered.

• Assessment should compromise

• A relevant medical history

• A general examination

• An anorectal examination

• A cognitive assessment, if appropriate

4.2 People with the following conditions should have these addressed with condition specific intervention before healthcare professionals progress to complete an initial management of faecal incontinence

• Faecal Loading

• Potentially treatable causes of diarrhoea, e.g., infective, inflammatory bowel disease and irritable bowel syndrome.

• Warning signs for lower gastrointestinal cancer. Appropriate investigations such as CT abdomen pelvis, CT colonography, or colonoscopy, depending on a patient’s comorbidities and performance status, may be used to exclude lower gastrointestinal cancer

• Rectal prolapse or third-degree haemorrhoids

• Acute disc prolapse /cauda equina syndrome

5.1 Medical History

The patient’s history can be obtained from the patient and or carers (as appropriate) and from other clinicians. Additional information may be obtained from a bowel diary.

Questions to ask patients:

What is your normal bowel habit?

Has it changed recently? If so, how?

Has there been any bleeding from the back passage or loss of mucus?

What is the usual consistency of your stools (bowel motions)?

(Refer to stool chart such as the Bristol Stool chart to assist the patient/carer to describe) Do the stools vary in consistency?

Do you have to strain to empty your bowels? If so, how long?

Are you able to tell the difference between when you are about to pass wind or stool?

Are you able to delay emptying your bowels? If so, for how long?

Do you experience any abdominal pain or bloating before passing bowel motion? Does that relieve the sensation?

Do you have a feeling of incomplete emptying after an attempted bowel evacuation? Do you ever have to assist the passage of stool with your finger?

Are you able to clean yourself after passing stools?

Do you have to clean yourself several times after passing stools?

Do you ever leak stools without being aware of it?

When faecal incontinence is reported ask the following:

How often does it happen?

When has it happened? Is there any pattern to this or any factor that provokes it?

How much leaks? What is the consistency of the leakage? Can it be wiped away easily?

Do you get the sensation of the need to empty your bowels before you leak? Is that sensation an urgent need to empty your bowels? (urge faecal incontinence)

Does soiling occur after a bowel motion has been passed? (post defecation soiling)

Do you wear pads (or something else) in your underwear? If so, are they effective in preventing soiling of clothes / surroundings / furnishing?

5.2 Previous medical history

Assess patient for possible contributory factors?

Constipation/diarrhoea Acute severe illness Terminal illness Severe cognitive impairment

Assess the patient for limited mobility?

Does the patient have adequate toilet facilities (e.g., is there limited availability or access problems?) Does the patient need assistance for toileting? If so, is there delayed assistance when there is an urgent call to stool? Is the patient able to communicate when there is a need to defecate? Are there any physical or environmental difficulties with toilet access, for example, anonymous doors, steps, non-slip shiny floors?

Is there a history of a neurological disorder(s)?

If yes - how long has it been present?

Is it expected to improve?

Is it permanent?

Does the patient have an obstetric history and /or history of weak pelvic floor (as appropriate)?

Parity? Difficult Deliveries? Large birth weight?

Is there a history of urinary incontinence? Is there a history of rectal prolapse? Is there a history of other co-morbidities, e.g., diabetes? Is there a history of perianal trauma or surgery?

5.3 Perform a medication review

• When reviewing medication, health care professionals should consider alternatives to drugs that might be contributing to faecal incontinence.

• Antidiarrheal medication should be offered to people with faecal incontinence associated with loose stools once other causes (such as excessive laxative use, dietary factors, and other medication) have been excluded.

• Antidiarrheal medication should be prescribed in accordance with the summary of products characteristics.

6.1 Appropriate follow-up must be provided for all patients discharged with faecal incontinence. The follow up may be with a specialist service within the acute hospital or it may be with District Nursing services, GP or Nursing and Residential Home teams.

6.2 Ensure arrangements have been made for further provision of appropriate containment products for use on discharge. This can be through referral to District Nursing teams for a continence assessment for provision of pads. Some products are not provided by the local continence teams.

7.1 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 a person's attitude towards and ability to manage and cope with his or her 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.

7.2 Specific Groups

Healthcare professionals should take a proactive approach to bowel management for specific groups of people, not waiting until problems arise.

• 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

1. Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA, Mott L, Rogers RG, Zinsmeister AR, Whitehead WE, Rao SS, Hamilton FA. (2015) Epidemiology, pathophysiology, and classification of faecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol. 110(1):127-36
2. NICE (2014) Faecal Incontinence in adults. QS54. Available at National Institute for Health and care excellence. http://www.nice.org.uk/guidance/qs54
3. NHS UK (2021) Bowel incontinence treatment. www.nhs.uk/conditions/bowel-incontinence/treatment
4. NHS Scotland (2019) Scottish palliative guidelines: Diarrhoea. https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Diarrhoea.aspx
5. Norton.C, Chelvanayagam. S (2004) Causes of faecal incontinence in Norton, Chelvanayagam S (Eds) Bowel continence nursing. Beaconsfield: Beaconsfield Publishers, pp. 23-32

To complete the Community Nurse referral for a Continence Assessment on Epic

• Create a ‘New Note’

• Note ‘Type’ – Discharge Referral

• Note ‘Specialty’ – state relevant specialty

• Note ‘Smart Text’ – FHFT Referral to Community Nursing

• Complete all sections and provide additional information if required, suggestions for which are noted on the Community Nurse referral form

If the referrer has the relevant access, a PDF copy of the referral can be created using the ‘Referral Release’ function on Epic.

If the referrer does not have access to the ‘Referral Release’ function a copy of the referral will need to be printed, scanned then emailed to the respective community hubs.

Referrals are to be sent to:

Berkshire: integratedhub@berkshire.nhs.uk Berkshire Integrated Hub – 0300 365 1234

Buckinghamshire: buc-tr.communityspa@nhs.net Community Care Co-ordination Team (CCCT) – 0800 177 7789

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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