Fecal incontinence (FI) is the loss of control on bowel function that results in involuntary loss of solid or liquid feces. It is common among patients with serious illness, afflicting 40-50% of home hospice patients and nursing home residents.
Age, immobility, dementia, and a prognosis of days to weeks are all associated with FI.
Additional risk factors include:
- severe constipation or fecal impaction leading to overflow diarrhea
- medications: laxatives, antibiotics, and chemotherapeutic agents
- recent abdominopelvic radiotherapy
- spinal cord injuries, including tumor compression of the spinal cord or sacral plexus
- diet high in fruits and milk
- enteral tube feeding
Clinicians often do not raise the subject of incontinence because of a wrong belief that nothing can be done for it. They should routinely screen patients with serious illness if they are experiencing FI, especially if they are elderly or have risk factors (“Do you ever leak stool?”) and if present, they should find out potentially reversible factors (infections, malabsorption, medication side effects, recent hospitalizations, recent use of broad-spectrum antibiotics). A physical exam should focus on cognitive function, mobility, hydration status, abdominal palpation, and auscultation; a rectal exam is suggested when there is clinical suspicion of fecal impaction or impaired anorectal tone.
The fundamental FI management strategies are:
- help the patient get to a proper toilet more easily (use of a commode, call light)
- treating loose stools or diarrhea when present
Additional issues include:
- dietary changes to avoid causative foods, such as excessive milk or fruits
- supplemental fiber via psyllium may reduce FI by providing stool bulk; caution is recommended in patients on opioids where stool bulking via fiber can worsen constipation
- discontinue antibiotics, laxatives, proton pump inhibitors, and other medications with diarrhea as a known side effect, if appropriate.
- antimotility medications, like loperamide, may palliate FI, but they are also associated with constipation in elderly patients with poor mobility and oral intake
For many, FI cannot be eradicated, and clinical efforts are modified to help preserve dignity and well-being. To achieve this, the following should be considered.
- Communication and fostering a trustful relationship with the patient. Care strategies to help privacy and dignity via timely incontinence care (nurse call buttons), keep doors/curtains closed, and hide incontinence products from view.
- Create “cleansing kits” for immediate use.
- Use incontinence pads, deodorants, and local skin ointments to promote hygiene and sacral skin care. Hyper-oxygenated fatty acid barrier creams are available over the counter and have shown benefit in preventing sacral ulcers.
- Ask about toileting routinely during every nursing shift, and scheduling toileting if possible.
Procedural and surgical strategies
- Insertable collection devices, such as rectal tubes and trumpets to channel feces from the rectum, can be used for persistent FI. While they can reduce the risk of sacral wound infections, they can be uncomfortable and prone to leakage, bleeding, rectal perforation, and longer-term side effects (rectal mucosal necrosis, strictures, and fistulas). Avoid them in patients with low platelets, low white blood cell counts, and those recovering from prostate surgery.
- Externally adhesive collection systems are best avoided because, while less invasive, they can cause local rash and skin damage from the adhesive tapes attaching the system to the sacral skin.
- Surgical options, such as sphincteroplasty, ventral rectopexy, and implantable sacral nerve stimulators, may be appropriate for patients with extended prognoses (e.g., patients with spinal cord injuries).
See reference for more information.
Adapted from Habib M H, Arnold R. Fecal incontinence in palliative care settings. Palliative Care Network of Wisconsin. Fast facts and concepts #424. Internet. Available at https://www.mypcnow.org/fast-fact/fecal-incontinence-in-palliative-care-settings/. Accessed on June 18, 2021.