Abstract
Background
Fecal incontinence (FI) is the loss of control on bowel function resulting in involuntary loss of solid or liquid feces. 1 It is common among patients with serious illness,2–4 afflicting 40%–50% of home hospice patients and nursing home residents.2,5 FI has been linked to social distress, isolation, embarrassment, caregiver distress, health care costs, and reductions in quality of life (QOL). 6 It may even correlate with a worse prognosis in older populations. 7 This Fast Fact assimilates the published evidence on FI to describe risk factors and management options for patients with serious illness.
Risk Factors for FI in Patients with Serious Illness
Age, immobility, dementia, and an anticipated prognosis of days to weeks are all associated with FI.2,8,9 Additional risk factors include:
Severe constipation or fecal impaction leading to overflow diarrhea Polypharmacy Medications such as 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.
History and Physical Examination
Clinicians often do not broach the subject of incontinence because of a mistaken belief that nothing can be done for it. 8 Also, they may not appreciate the impact FI has on QOL. Similarly, patients may not volunteer the symptom. 8 Clinicians should routinely screen patients with serious illness if they are experiencing FI, especially if they are elderly or have risk factors. For example, “Do you ever leak stool?” If present, clinicians should ascertain for potentially reversible factors (e.g., infections, malabsorption, medication side effects). 10 Asking about recent hospitalizations and recent use of broad-spectrum antibiotics is important to assess risk for c diff infection. Physical examination should focus on mentation, mobility, hydration status, abdominal palpation, and auscultation. A rectal examination is recommended when there is clinical suspicion for fecal impaction or impaired anorectal tone. 9
Treatment Strategies
The fundamental FI management strategies are (1) help the patient get to the proper toilet more easily (e.g., use of a commode, call light) and (2) treating loose stools or diarrhea when present so that the patient has more time and better warning signs to prevent FI. Additional considerations include:
Dietary changes to avoid causative foods such as excessive milk or fruits. 9
Supplemental fiber through psyllium may reduce FI by providing stool bulk. Caution is recommended in patients on opioids where stool bulking through fiber can worsen constipation. 11
Discontinue antibiotics, laxatives, proton-pump inhibitors (PPIs), and other medications with diarrhea as a known side effect if appropriate. Collaborate with a pharmacist to better identify those medications.
Antimotility medications, such as loperamide, may palliate FI. However, they are also associated with equally distressing constipation in elderly patients with poor mobility and oral intake. They also can worsen symptoms from infectious diarrhea (e.g., c diff). 11
Living with FI
For many, FI cannot be eradicated, and clinical efforts are modified to help preserve dignity and well-being for those living with FI. To achieve this, clinicians should consider the following:
Communication and fostering a trusting relationship with the patient are crucial. Adopt care strategies to promote privacy and dignity through timely incontinence care (e.g., nurse call buttons), keep doors/curtains closed, and conceal incontinence products from easy view. 12
Create “cleansing kits” for immediate use. This can prevent staff from needing to look for individual items while the patient waits after an accident.
Utilize supportive care agents such as incontinence pads, deodorants, and local skin ointments to promote hygiene and sacral skin care as appropriate. 2 Hyperoxygenated fatty acid barrier creams are available over the counter and have shown benefit in preventing sacral ulcers. 13 Silicone and antiseptic additives have not shown superiority to barrier cream preparations without them. 13
Ask about toileting needs routinely (every nursing shift) and scheduling toileting if possible.12,14
Acknowledging and supporting the efforts of the caregiver. 15
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 at the end of life. 9 Their use comes with a difficult harm to benefit ratio that must be individualized. Although they can reduce the risk of sacral wound infections, 16 they can be uncomfortable and prone to leakage, bleeding, and rectal perforation. 17 They have also been attributable to longer term side effects such as rectal mucosal necrosis, strictures, and fistulas. 9 Avoid them in patients with low platelets, low white blood cell counts, and those recovering from prostate surgery. 9
Externally adhesive collection systems, although less invasive, can cause local rash and skin damage from the adhesive tapes attaching the system to the sacral skin, and are best avoided. 9
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). 10
Conclusion
FI is common and associated with QOL concerns and caregiver burnout. Effective communication, maintaining patient dignity, and providing caregiver support are paramount. Invasive options such as rectal tubes should be used as a last option, when lack of mobility, distress from moving in bed, and persistent fecal leakage preclude other options of management.