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The prevalence of faecal incontinence in adults living in the community is 1-10%, depending on the definition used.1 2 Faecal incontinence is a neglected problem that receives limited medical attention, and despite its profound negative impact most patients do not tell their doctor about it.3 4 Simple, low cost interventions will often improve or even cure symptoms. More sophisticated second line investigations and treatments are available, but referral for these is not common. This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on managing faecal incontinence in adults.5
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).
All staff working with people with faecal incontinence should be aware of the physical and emotional impact this condition can have on patients and their carers. Consider patients' needs and preferences when planning treatment and ensure they have the opportunity to make informed decisions in partnership.
Healthcare professionals should actively yet sensitively inquire about symptoms of faecal incontinence in high risk groups (box).
Faecal incontinence often has several contributory factors. Assumptions that it is caused by a single primary condition are therefore not appropriate.* Before starting treatment, perform a focused baseline assessment as follows*:
Treat the following specific conditions (if identified from the assessment), before progressing to more general measures*:
Once the above conditions have been excluded or treated, offer initial conservative measures, tailored to the patient's presenting symptoms, as follows:
If symptomatic patients do not wish to continue active treatment or have intractable symptoms*:
If symptoms continue, consider referral to a specialist continence service for options such as a pelvic floor re-education programme, bowel retraining, specialist dietary assessment and management, biofeedback, electrical stimulation, or rectal irrigation.* These interventions will usually need to be individually tailored and monitored closely (for example, by digital reassessment). Some of these treatments may not be appropriate for people who cannot understand and/or comply with instructions. Pelvic floor re-education programmes, for example, may not be appropriate for those with neurological or spinal disease or injury that results in faecal incontinence.*
If specialised investigation is needed, a combination of anorectal physiology tests and endoanal ultrasonography will assist selection of patients for surgery.* Where endoanal ultrasonography is not available, magnetic resonance imaging or endovaginal ultrasonography and perineal ultrasonography may be considered.*
Refer patients considering surgery to a specialist surgeon to discuss the potential benefits and limitations of surgical and non-surgical options, particularly long term expectations of effectiveness. Most surgery should be conducted in specialist centres. Anal sphincter repair has limited long term efficacy and should be reserved for patients with major symptoms and an external anal sphincter defect of 90 degrees or more. Neosphincters, such as an implanted inflatable artificial anal sphincter or a transposition of the gracilis muscle around the anus, are generally associated with high complication rates (such as infection, erosion, or equipment failure); no long term data are available yet for sacral nerve stimulation. Training and long term support are needed when implants are used.*
Adopt a proactive approach to bowel management for the following patient groups, who are prone to faecal incontinence or constipation*:
The most crucial barriers to implementing this guideline may be traditional taboos associated with discussing defecation and the stigma of faecal incontinence. Many people (including some health professionals) do not find it easy to talk about this subject. Local and national campaigns may raise awareness and help to break down taboos on discussing bowel function.
As a symptom, faecal incontinence does not fall under the responsibility of any one professional group. A multidisciplinary approach is recommended.* Most nurse continence advisers focus on urinary incontinence, and many of them may need additional training to take a lead on faecal incontinence. Specialised investigation and management facilities are also lacking.
Although most of this guideline is based on consensus methods rather than high quality research evidence, the guideline development group believes that the commonsense recommendations it contains provide a practical approach to managing the common and neglected problem of faecal incontinence. We hope this guideline will stimulate both clinical and research interest in this topic, and that future updates will have an expanded evidence base on which to work.
The guideline was developed according to NICE guideline methodology (see www.nice.org.uk/page.aspx?o=114219) by the National Collaborating Centre for Acute Care. The collaborating centre convened a development group of clinicians and patient representatives to oversee the work and help to develop the recommendations.
The group conducted an extensive systematic review of the clinical and economic literature and assessed the quality of this literature.
The guideline went through an external consultation with stakeholders. The development group assessed the comments, reanalysed the data where necessary, and modified the guideline.
NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG049) or the National Collaborating Centre for Acute Care's website (www.rcseng.ac.uk/surgical_research_units/nccac/).
Future updates of the guideline will be produced as part of the NICE guideline development programme.8
The guideline development group highlighted several areas for future research:
The members of the guideline development group were James Barrett, David Bartolo, Susan Bennett, John Browne, Anton Emmanuel, Saoussen Ftouh, June Gallagher, Clare Jones, Jennifer Hill, Peter Katz, Julie Lang, Christine Norton, Kathryn Oliver, Veena Paes, Marlene Powell, Carlos Sharpin, Louise Thomas, Judith Wardle, David Wonderling.
LT was a project manager at the National Collaborating Centre for Acute Care until December 2006. She now works for the National Patient Safety Agency.
Contributors: All authors contributed to reviewing the evidence and writing and correcting the article. CN is the guarantor.
Funding: The National Collaborating Centre for Primary Care was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Competing interests: None declared.
Provenance and peer review: Commissioned; not peer reviewed.