Fecal Incontinence Management

Fecal incontinence, the involuntary passage of feces, may occur gradually (as in dementia) or suddenly (as in spinal cord injury). It usually results from fecal stasis and impaction secondary to reduced activity, inappropriate diet, or untreated painful anal conditions. It can also result from chronic laxative use; reduced fluid intake; neurologic deficit; pelvic, prostatic, or rectal surgery; and the use of certain medications, including antihistamines, psychotropics, and iron preparations. Not usually a sign of serious illness, fecal incontinence can seriously impair an elderly patient's physical and psychological well-being.

Patients with urinary or fecal incontinence should be carefully assessed for underlying disorders. Most can be treated; some can even be cured. Treatment aims to control the condition through bladder or bowel retraining or other behavior management techniques, diet modification, drug therapy, pessaries, and, possibly, surgery. Corrective surgery for urinary incontinence includes transurethral resection of the prostate in men, urethral collagen injections for men or women, repair of the anterior vaginal wall or retropelvic suspension of the bladder in women, urethral sling, and bladder augmentation.

Equipment

Bladder retraining record sheet • gloves • stethoscope (to assess bowel sounds) • lubricant • moisture barrier cream • antidiarrheal or laxative suppository • incontinence pads • bedpan • specimen container • label • laboratory request form • optional: stool collection kit, urinary catheter.

Implementation

Whether the patient reports urinary or fecal incontinence or both, you'll need to perform initial and continuing assessments to plan effective interventions.

For fecal incontinence

• Ask the patient with fecal incontinence to identify its onset, duration, severity, and pattern (for instance, determine whether it occurs at night or with diarrhea). Focus the history on GI, neurologic, and psychological disorders.
• Note the frequency, consistency, and volume of stools passed in the past 24 hours. Obtain a stool specimen if ordered. Protect the patient's bed with an incontinence pad.
• Assess for chronic constipation, GI and neurologic disorders, and laxative abuse. Inspect the abdomen for distention, and auscultate for bowel sounds. If not contraindicated,
  check for fecal impaction (a factor in overflow incontinence).
• Assess the patient's medication regimen. Check for drugs that affect bowel activity, such as aspirin, some anticholinergic antiparkinsonian agents, aluminum hydroxide, calcium carbonate antacids, diuretics, iron preparations, opiates, tranquilizers, tricyclic antidepressants, and phenothiazines.
• For the neurologically capable patient with chronic incontinence, provide bowel retraining.
• Advise the patient to consume a fiber-rich diet that includes lots of raw, leafy vegetables (such as carrots and lettuce), unpeeled fruits (such as apples), and whole grains (such as wheat or rye breads and cereals). If the patient has a lactase deficiency, suggest that he take calcium supplements to replace calcium lost by eliminating dairy products from the diet.
• Encourage adequate fluid intake.
• Teach the elderly patient to gradually eliminate laxative use. Point out that using laxatives to promote regular bowel movement may have the opposite effect, producing either constipation or incontinence over time. Suggest natural laxatives, such as prunes and prune juice, instead.
• Promote regular exercise by explaining how it helps to regulate bowel motility. Even a nonambulatory patient can perform some exercises while sitting or lying in bed.

Special considerations

• For fecal incontinence, maintain effective hygienic care to increase the patient's comfort and prevent skin breakdown and infection. Clean the perineal area frequently, and apply a moisture barrier cream. Control foul odors as well.
• Schedule extra time to provide encouragement and support for the patient, who may feel shame, embarrassment, and powerlessness from loss of control.

Complications

Skin breakdown and infection may result from incontinence. Psychological problems resulting from incontinence include social isolation, loss of independence, lowered self-esteem, and depression.

Documentation

Record all bladder and bowel retraining efforts, noting scheduled bathroom times, food and fluid intake, and elimination amounts, as appropriate. Document the duration of continent periods. Note any complications, including emotional problems and signs of skin breakdown and infection as well as the treatments given for them.