Fecal Incontinence - Abnormalities of Fecal Elimination

FECAL INCONTINENCE

The term fecal incontinence describes the involuntary passage of stool from the rectum. Several factors influence fecal continence— the ability of the rectum to sense and accommodate stool, the amount and consistency of stool, the integrity of the anal sphinc-ters and musculature, and rectal motility.

Pathophysiology

Fecal incontinence can result from trauma (eg, after surgical pro-cedures involving the rectum), a neurologic disorder (eg, stroke, multiple sclerosis, diabetic neuropathy, dementia), inflamma-tion, infection, radiation treatment, fecal impaction, pelvic floor relaxation, laxative abuse, medications, or advancing age (ie, weakness or loss of anal or rectal muscle tone). It is an em-barrassing and socially incapacitating problem that requires a many-tiered approach to treatment and much adaptation on the patient’s part.

Clinical Manifestations

Patients may have minor soiling, occasional urgency and loss of control, or complete incontinence. Patients may also experience poor control of flatus, diarrhea, or constipation.

Assessment and Diagnostic Findings

Diagnostic studies are necessary because the treatment of fecal in-continence depends on the cause. A rectal examination and other endoscopic examinations such as a flexible sigmoidoscopy are performed to rule out tumors, inflammation, or fissures. X-ray studies such as barium enema, computed tomography (CT) scans, anorectal manometry, and transit studies may be helpful in iden-tifying alterations in intestinal mucosa and muscle tone or in de-tecting other structural or functional problems.

Medical Management

Although there is no known cause or cure for fecal incontinence, specific management techniques can help the patient achieve a better quality of life. If fecal incontinence is related to diarrhea,the incontinence may disappear when diarrhea is successfully treated. Fecal incontinence is frequently a symptom of a fecal im-paction. After the impaction is removed and the rectum is cleansed, normal functioning of the anorectal area can resume. If the fecal incontinence is related to a more permanent condition, other treatments are initiated. Biofeedback therapy can be of assis-tance if the problem is decreased sensory awareness or sphincter control. Bowel training programs can also be effective. Surgical procedures include surgical reconstruction, sphincter repair, or fecal diversion.

Nursing Management

The nurse takes a thorough health history, including information about previous surgical procedures, chronic illnesses, bowel habits and problems, and current medication regimen. The nurse also completes an examination of the rectal area.

The nurse initiates a bowel-training program that involves set-ting a schedule to establish bowel regularity. The goal is to assist the patient to achieve fecal continence. If this is not possible, the goal should be to manage the problem so the person can have pre-dictable, planned elimination (Stone et al., 1999). Sometimes, it is necessary to use suppositories to stimulate the anal reflex. After the patient has achieved a regular schedule, the suppository can be discontinued. Biofeedback can be used in conjunction with these therapies to help the patient improve sphincter contractil-ity and rectal sensitivity.

Fecal incontinence can also cause problems with perineal skin integrity. Maintaining skin integrity is a priority, especial-ly in the debilitated or elderly patient. Incontinence briefs, al-though helpful in containing the fecal material, allow for increased skin contact with the feces and may cause excoriation of the skin. The nurse encourages and teaches meticulous skin hygiene.

Continence sometimes cannot be achieved, and the nurse as-sists the patient and family to accept and cope with this chronic situation. The patient can use fecal incontinence devices, which include external collection devices and internal drainage sys-tems. External devices are special pouches that are drainable. They are attached to a synthetic adhesive skin barrier specially designed to conform to the buttocks. Internal drainage systems can be used to eliminate fecal skin contact and are especially use-ful when there is extensive excoriation or skin breakdown. A large catheter is inserted into the rectum and is connected to a drainage system.