Mistakes in faecal incontinence and how to avoid them

Figure 1 | Definition of faecal incontinence according to the ROME IV criteria.

Assuming patients will spontaneously provide the healthcare professional with all the necessary information to make an informed management plan is a mistake. Often FI (figure 1) causes feelings of shame resulting in hesitance to disclose information and sometimes even hesitance to seek professional help. ^{2, 7, 8} Consequently, healthcare professionals need to ask the right questions during history taking. Suppose the patient hints at complaints suggesting faecal incontinence. In that case, this is an opening for the healthcare professional to ask relevant questions and determine if unwanted loss of faeces is present. After it has been established that the patient suffers from FI, the characteristics and severity of the condition should be established (e.g., changes in bowel habit, straining to empty bowels, incomplete emptying of bowel, feeling an urge or not, ability to delay defecation). Any possible contributing or causative factors should be determined, some of which are presented in figure 2.

Figure 2 | Examples of disorders which can present with faecal incontinence.

Consideration should also be given to any red flag features that may indicate a severe underlying organic cause, such as colorectal cancer or inflammatory bowel disease, as presented in figure 3. It should be further determined whether concomitant pelvic floor dysfunction or any gastrointestinal issues are present. It should clarify which treatment options have been tried before, if any, and which case-specific characteristics would suggest suitability for one treatment. ⁶

Figure 3 | Red flag symptoms to look out for which could be indicative of an underlying organic cause such as colorectal cancer or inflammatory bowel disease.

Focusing merely on reducing episodes of involuntary faeces loss is often a mistake when treating FI. Faecal incontinence should be managed as the complex multi-layered anorectal problem it is. The often heterogenous and multi-factorial causes of FI should be acknowledged. The concomitant gastrointestinal dysfunction, pelvic floor dysfunction, and psychological and social impacts should be considered and treated where possible.^{6, 8} As shown in figure 4, when treating FI, other gastrointestinal symptoms such as diarrhoea, constipation, bloating, cramps, abdominal pain, or a combination of these should be considered.^9-11 Additionally, concomitant pelvic floor problems such as obstructive defecation disorder, pelvic organ prolapse, chronic pelvic pain, urinary incontinence, and sexual dysfunction are common in this patient group.^{2, 8} Other examples of common physical problems related to suffering from FI are recurrent urinary tract infections and incontinence-associated dermatitis.² Besides the physical problems that FI causes, this condition's enormous social and psychological impact should not be forgotten.

Figure 4 | Examples of health aspects related to faecal incontinence: predisposing factors, related complaints, pathophysiological mechanisms and the psychological and social impact.

When treating FI, it would be a mistake to merely focus on reducing physical symptoms. Patients with FI often feel like their whole lives revolve around their symptoms, feeling the need to plan their day around their defecation needs and avoiding many ‘normal’ daily activities and social interaction leading to isolation and a reduction in quality of life.^{2, 7, 8} Activities such as shopping, exercise, sexual intercourse, going on long trips or vacations, and avoiding public transport, among others, may be avoided.^{2, 8} Additionally, feelings of embarrassment, anxiety and depression are frequently described.^{12, 13} Thus, the additional impact that FI carries should be determined. Understanding this may help guide which treatment options should be discussed with the patient and which suggestions can be given on dealing with the problem. If available in your region, referring to a support group for discussions with fellow patients may be beneficial.

Not performing a digital rectal examination (DRE) when someone presents with complaints suggestive of FI is a mistake. Although a diagnosis of FI can be made via a thorough clinical history without performing a DRE, DRE may be useful for multiple other reasons.⁶ Inspection of the anorectal region and digital insertion is needed to check for any other abnormalities that may cause or contribute to the onset of FI. These abnormalities should be addressed before starting with symptomatic treatment. DRE allows you to determine (to a certain extent) the function of the anal sphincters and/or the puborectalis muscle and allows checking for the presence of faecal impaction or palpable masses (indicative of malignant neoplasm). Perianal abscesses or fistulae upon anal inspection and/or a painful DRE may suggest an underlying inflammatory bowel disorder. Additionally, we decide to proceed to a diagnostic test. In that case, DRE can help guide which test may be most suitable and decide which treatment options may be optimal for this patient.

Taking the time to discuss with the patient what results they can realistically expect and within which time frame is something which is often forgotten. Although in some, certain treatment options result in a complete resolution of symptoms, often treatment options merely result in a reduction in severity and not a complete cure.^{6, 14} Being transparent about this may prevent disappointment later. They may find it comforting to know multiple different types of treatment options are available starting with less invasive treatment options, and in case symptom reduction is not yet sufficient, more invasive options can be chosen as shown in figure 5.

Figure 5 | Flowchart summarising current treatment options for faecal incontinence as discussed in the ‘’guideline for the diagnosis and treatment of faecal incontinence – A UEG/ESCP/ESNM/ESPCG collaboration’’(6).

This way, if initial management does not help sufficiently, patients are aware of other available options and may return to their physician to discuss further treatment plans. If a treatment has, resulted in partial symptom reduction, additional treatment options can be tried along with the initial approach. Often times, multiple different treatment options at any given time are used to manage symptoms. Alternatively, if initial treatment did not help at all, a different treatment option should be tried on its own.

When treating FI, it is important to remember that this is a heterogenous disorder in terms of aetiology, pathophysiology, and patient characteristics. Most cases do not have a single cause for their condition, and the exact aetiology may remain unclear. FI is associated with varying symptoms and complaints that may come about at different times during the day. Because aetiology and pathophysiology usually differ between persons, which specific treatment will be successful will likely also differ. This reiterates the importance of thorough medical history taking. Reports of a liquid consistency of stool may point to an optimising treatment with psyllium or loperamide. Modifying this element may be helpful if the symptoms are associated with a change in diet or medication intake.

It is essential to understand the treatment goals, the patient’s preferences regarding treatment options, and what would be feasible for each case. Transanal irrigation may be a good option for a pensioner who can plan their days as they wish, but it may not be a good fit for a person with commitments early in the morning and a busier life. A stoma may sound like a last resort to most, but it may be the best approach for relief in those refractory cases severely impacted by their symptoms. The activities that had to be put on hold due to FI and would ideally be resumed may also differ between people. Whilst one person may wish to rerun a marathon without being burdened by their FI, another may wish to be able to visit a friend outside the comfort of their own home. For this reason, it is crucial to evaluate the patient’s needs and goals to develop the best-individualised treatment plan.

It has been well established that stool consistency which may result in diarrhoea, constipation, or a combination of these is a significant contributing factor or cause of FI.^15-17 Optimisation of stool consistency via products such as psyllium fibre or loperamide should be the first step in the management of this pathway of faecal incontinence. The correct instructions must be followed when prescribing these products to ensure optimal results. Psyllium should ideally be taken without sweeteners such as sorbitol, which can cause diarrhoea. It is a bulking agent that, through its chemical structure, can take up large amounts of water. As it does not readily dissolve in water, it should be taken together with oatmeal, yoghurt, or custard, for reasons of palatability. Directly after ingestion, fluid intake should be limited, allowing psyllium to take up any excess fluid in the colon.

Loperamide can also be taken to firm up the stool in case of liquid stool consistency. This should be taken cautiously and at the lowest possible dose, as this can easily cause constipation.

The overall lack of solid evidence in FI research, in combination with the heterogeneous and multi-layered nature of the condition, can make it challenging to decide the best treatment pathway for each case. Most healthcare professionals will feel comfortable starting any first-line treatment options as described in figure 5. However, a multidisciplinary approach is preferred when these options fail or do not lead to a sufficient reduction in symptoms. If you do not have a multidisciplinary- or expert team available in your vicinity, it is important to find out where a team like this is available in your region. This way, any cases can be discussed and referred to when necessary to ensure the best help possible is given.

Since its introduction in 1995 in the faecal incontinence field, many patients have benefitted from sacral neuromodulation (SNM).^{6, 18} Often a decrease in FI symptoms is seen, in some cases even to the extent that no more symptoms are present. In either event, this results in a significant improvement in quality of life. For optimal use, the settings on the device should be changed depending on the symptoms experienced. The upside is that individuals are in control of their devices. However, some could also see this as a downside or difficulty.

Although SNM is the perfect solution for several people, for others, it works only for a short period or not at all. The sustained efficacy of SNM is between 43.9 and 86%, generally showing a decrease over time.^19-21

Furthermore, possible side effects include general surgical risks and pain or discomfort from the implant.

Moreover, lead migration and eventual battery replacement should be noticed as both require reoperation.^{6, 21}

It is essential to assess whether SNM would suit each individual and discuss the possible risks with patients whilst stressing that. In contrast, SNM can be an effective treatment option for some but lacks efficacy for others.