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Gaining control over fecal incontinence.

Fecal incontinence is physically uncomfortable and emotionally devastating, and has profound effects on quality of life (Brown, Wexner, Segall, Brezoczky, & Lukacz, 2012). Surveys of large populations indicate 6%-8% of Americans experience fecal incontinence monthly and about 2.8% experience it at least weekly. The incidence of fecal incontinence increases with age (Townsend, Matthews, Whitehead, & Grodstein, 2013). The condition also carries a substantial economic burden due to treatment costs and lost income when those afflicted and their caregivers are unable to work (Costilla, Foxx-Orenstein, Mayer, & Crowell, 2013; Palit, Lunniss, & Scott, 2012).

Incontinent stools smell bad, and are difficult to contain and unpleasant to clean. They interfere with all aspects of life, including eating, sleep, employment, sex, and physical exercise (Price & Bradley, 2013). Fecal incontinence causes such shame and embarrassment that affected persons are often reluctant to talk about it (Brown et al., 2012; Patel, Bliss, & Savik,

2010). Additionally, they may consider it just part of getting older, a consequence of disease, or an unfortunate side effect of surgery, and believe they must learn to cope with it on their own. Relationships suffer when people decline invitations or stop attending social events without a valid explanation because they are too embarrassed to explain. Sadly, the situation leaves individuals feeling hopeless, suffering in isolation, and unwilling to leave home so they avoid the humiliation of defecating in public (Yip et al., 2013). Although fecal incontinence is not life threatening, affected people may believe life is over.

The stigma and embarrassment attached to bowel incontinence may make it difficult for health care providers to ask about it and patients to admit they have it. Also, bowel management strategies are time-consuming and therefore easily neglected in today's busy health care systems, where complex, life-threatening problems take priority. Nevertheless, incontinence can cause such profound emotional suffering and physical discomfort that it must be addressed (Brown et al., 2012).

Because patients are reluctant to admit to fecal incontinence and ask for help, nurses need to recognize signs of perineal irritation from feces, identify at-risk persons, and initiate discussions about incontinence in a kind, supportive, nonjudgmental manner (Ness, 2012). An understanding of normal defecation, causes of incontinence, available medical treatments, and strategies for regaining control over bowel function helps nurses more effectively assist patients who have fecal incontinence.

Normal Defecation

Feces are stored normally in the sigmoid colon and the lower rectum is empty (Palit et al., 2012). Defecation is stimulated by meals and follows a regular circadian rhythm, with almost no bowel activity at night. Food enters the stomach when a person eats and stimulates the gastrocolic reflex, which propels a mass movement of feces toward the sigmoid colon. Once the sigmoid colon reaches a critical filling point, feces move into the rectum. Intricate neurological and muscular activities allow individuals to sense feces' presence in the rectum, and then either respond immediately or delay defecation until a more suitable time.

The rectum expands to accommodate the incoming feces and stretch receptors in the expanding walls send a message to the brain which is perceived as the defecation urge. Movement of feces out of the rectum is prevented by the internal and external anal sphincters and the pelvic floor muscles, particularly the pubo-rectalis muscle. The pubo-rectalis muscle forms a sling around the rectum, and usually is contracted to create such a sharp, narrow curve between the rectum and anal canal that feces cannot leak. The angle is sharpest in the standing position, and straightens when squatting (Palit et al., 2012).

Expansion of the rectum triggers a spinal reflex that relaxes the internal anal sphincter so a small amount of rectal contents enters the innermost anal canal. Neurons allow the person to recognize if rectal contents are gas, solid stool, or liquid stool (Ness, 2012). Gas can be released safely and solid stools can be retained easily, but liquid stools are difficult to hold and require the person to find a suitable place for defecation immediately. When the internal sphincter relaxes, the external sphincter contracts to keep the anal canal closed and delay defecation until a socially appropriate time and place are available (Palit et al., 2012). Voluntary defecation occurs when a person feels the defecation urge, finds a toilet, sits on it (preferably in a squatting position to straighten the ano-rectal angle), and then voluntarily relaxes the external sphincter. Strong contractions of the rectum and sigmoid muscles push the feces through the relaxed anal canal and into the toilet. Straining raises intra-abdominal pressure to push feces out of the rectum, but is usually only necessary when stool is hard, dry, and difficult to pass. When the rectum empties, sensory input from the anus sends a signal to stop propulsion and close the sphincters. If a bowel movement is delayed, the external sphincter and pelvic floor contract and the urge is gone until another mass movement sends more feces into the rectum.

Causes of Fecal Incontinence

Incontinence occurs when structures controlling defecation do not function correctly, usually because of diarrhea, trauma to the anatomical structures, or nerve damage (Hayden & Weiss, 2011). Fecal incontinence can occur when an individual has diarrhea, abnormal rectal compliance, anal sphincter dysfunction, an inability to perceive or respond to the defecation urge, or incomplete emptying of the rectum during defecation. Incontinence usually occurs only when a combination of factors is involved (Ness, 2012). For example, a man with weak anal sphincters might experience incontinence only when he has diarrhea.

Diarrhea

Diarrhea is a leading cause of bowel incontinence (Bharucha, Zinsmeister, Schleck, & Melton, 2010). Although defecation can be delayed when feces have normal consistency, diarrhea produces such an intense sense of urgency that the person might not be able to find a bathroom in time. Causes of diarrhea include anything that increases gut motility or decreases water absorption, including medications, certain foods, and diseases that cause intestinal inflammation (Ness, 2012). Overuse of laxative to treat constipation can cause diarrhea inadvertently and thus incontinence (Gage et al., 2011). A cholecystectomy commonly results in diarrhea, possibly because excessive bile salts in the intestines stimulate motility and thus decrease the time available for water absorption. In the case of inflammatory bowel disease (IBD), intestinal inflammation produces diarrhea by interfering with the intestine's ability to absorb water from feces (Bharucha et al., 2010).

Altered Rectal Compliance

The rectum normally stretches to accommodate incoming feces and hold them temporarily without putting undue pressure on the anal sphincters and pelvic floor (Palit et al., 2012). If the rectum loses its ability to stretch, it holds less feces and produces a stronger defecation urge. This results in much less time available to delay defecation and thus a greater likelihood of incontinence, especially if diarrhea is also present. Conditions that decrease rectal compliance include rectal scars from chronic inflammation (e.g., IBD), tissue damage from radiation therapy for cancer, or surgical resection of a diseased rectum and replacement with a new rectum made from intestinal tissue (Bruheim et al., 2010; Bryant, Lunniss, Knowles, Thaha, & Chan, 2012). An overly compliant rectum also contributes to bowel incontinence because it produces a weak defecation urge; retained feces passively leak from the rectum at a later time (Palit et al., 2012).

Anal Sphincter Dysfunction

The anal sphincters and their nerves can be injured during vaginal childbirth (Eogan et al., 2011), trauma, or surgery involving the anus, anal canal, or pelvic floor (e.g., hemorrhoidectomy, prostate tumor resection, colorectal cancer surgery) (Hayden & Weiss, 2011). Anal sphincter tone also is altered by nerve damage resulting from neurologic diseases, such as multiple sclerosis, Parkinson's disease, spinal cord injury, stroke, and diabetic neuropathy (Hayden & Weiss, 2011; Paris, Gourcerol, & Leroi, 2011). Large hemorrhoids may prevent the anal sphincters from closing completely and thus allow leakage of feces. Long-standing obstructive constipation also can weaken anal sphincters when continual pressure from a mass of stool in the rectum puts excessive pressure on the sphincters' nerve supply (Carter & Gabel, 2012).

Inability to Perceive or Respond to the Defecation Urge

The person with intact nerves connecting the rectum to the spinal cord and brain is able to perceive the defecation urge and respond appropriately when motor function is also intact. Incontinence occurs when the signal cannot reach the brain or when the person is physically unable to respond to the defecation urge (Bardsley, 2013; Hagglund, 2010). For example, the person with a brain injury or dementia might not be able to perceive or interpret the defecation urge appropriately, even when all other nerves involved in defecation are intact. Other neurologic diseases (e.g., spinal cord injury, multiple sclerosis, Parkinson's disease, diabetic neuropathy) also prevent the signal from reaching the brain or interfere with nerve functions necessary for controlling the muscles involved in continence and defecation (Paris et al., 2011).

The effect on defecation depends on the extent and location of nerve damage (Krassioukov et al., 2010). With a complete spinal cord injury, the connection between the nerves in the brain and the nerves in the rectum, anus, and pelvic floor is lost, making it impossible to perceive the defecation urge and voluntarily relax the external sphincter. However, predictable defecation is possible for people with spinal cord injuries above the sacral vertebrae because they are likely to have high sphincter tone to keep the anal canal closed to prevent incontinence and an intact defecation reflex that can be stimulated to initiate defecation. The defecation reflex is stimulated digitally by circling the anal canal with the finger or by using small enemas or suppositories to irritate the rectal wall and stimulate contraction of the sigmoid colon and rectum (Paris et al., 2011).

In contrast, both the defecation urge and defecation reflex are lost when the lumbosacral nerves are damaged (e.g., sacral spinal cord injury, cauda equine syndrome). This is the area where nerves from the rectum and anal sphincters connect with the spinal cord. In this case, the anal sphincter is flaccid, the lack of a defecation reflex prevents reflex stimulation of defecation, and feces must be removed digitally (Solomons & Woodward, 2013).

Inability to Empty the Rectum Completely During Defecation

When the rectum does not empty completely, trapped feces can leak later or harden and form an impaction that grows in size and eventually causes overflow incontinence. Incomplete evacuation can occur in a variety of ways. For example, vaginal delivery during childbirth can create a tear in the pelvic floor that allows the rectum to herniate, deforming the normal defecation pathway and making it difficult for the rectum to empty (Fargo & Latimer, 2012). This is called a rectal prolapse and usually requires surgical repair. Patients with Parkinson's disease have decreased intestinal motility as well as difficulty relaxing the pelvic muscles and anal sphincters during defecation; they thus are prone to constipation and impaction (Kim, Sung, Lee, Kim, Sc Kim, 2011). Overflow incontinence from impaction is also common among people who have chronic constipation, use opioids, or are unable to respond to the defecation urge because of cognitive impairment, immobility, or decreased neuromuscular function. Because defecation is voluntary, people also can develop impaction by deliberately and repeatedly delaying bowel movements. Others are thought to retain stool because of an overlying compliant rectum that dampens the defecation urge (Palit et al., 2012).

Treatment

The chosen treatment depends on the cause of fecal incontinence, patient preferences, and the ability, energy, and willingness to engage in a particular treatment. Whenever possible, treatment is directed at the underlying cause (Hayden & Weiss, 2011), and the patient should be referred to a specialist for accurate diagnosis and appropriate treatment. For example, surgery might be used to repair damaged anal sphincters or a rectocele (Fargo & Latimer, 2012), and medications would be used to decrease rectal irritation and diarrhea caused by IBD. Unfortunately, scientists only recently have directed their attention toward treating bowel incontinence and preventing injury to defecation nerves and structures during childbirth and pelvic surgery. Treatments, such as sphincter repair and sacral nerve stimulation, are available but they have had limited success (Chereau et al., 2011).

Even when the underlying cause cannot be treated, the natural regularity of bowel function makes it possible for many people to achieve predictable defecation with few or no periods of incontinence. Strategies include using diet and medications to obtain the ideal stool consistency, removing obstmctions to defecation, improving pelvic muscle and rectal function with exercise, and emptying the bowel at regular intervals. Incontinence products are used to contain any inadvertent leakage. In all cases, the goal is to help the patient and caregivers obtain the greatest possible control over defecation and maintain the highest possible quality of life (Ness, 2012).

Promoting Ideal Stool Consistency

Both diarrhea and constipation can cause bowel incontinence; diarrhea may lead to urge incontinence and constipation may lead to overflow incontinence (Ness, 2012). Sometimes just regaining optimal stool consistency stops incontinence because formed stools are easier to retain and defecate. The ideal stool is formed, but soft enough to mold to the shape of the intestine (log shaped).

Many people with fecal incontinence help manage the situation by modifying their diets (Croswell, Bliss, & Savik, 2010). Although individuals vary in their response, certain foods tend to exacerbate fecal incontinence: alcohol, caffeine, greasy or spicy food, fruit (especially prunes), gas-producing vegetables (e.g., onions, cabbage), and sugar-free products containing sorbitol (Ness, 2012). Dairy products generally are considered constipating but can cause diarrhea in someone who is lactose intolerant. Dietary fiber, especially from wheat bran and other grains, is useful for fecal incontinence because it adds bulk to the stool that promotes optimal propulsion of feces through the colon (Hayden & Weiss, 2011). Adequate fluid intake is also essential because dietary fiber draws water into feces; the person who increases dietary fiber intake without adequate fluid intake will have very dry stools that are difficult to pass. Because eating stimulates defecation, people learn to schedule meals so incontinence is less likely to occur during social activities (Croswell et al., 2010). By using trial and error and recording dietary intake and bowel movement appearance in a diary, people can discover ways to use foods to get the ideal stool for maintaining continence (Ness, 2012).

Individuals also need to be aware of medications' effects on stool consistency. Common constipating drugs include opioids, nonsteroidal anti-inflammatory drugs, diuretics, tricyclic antidepressants, iron, calcium channel blockers, Parkinson's medications, psychotropics, and calcium carbonate (Arnold-Long, 2010). Drugs that commonly cause diarrhea include metformin (Glucophage[R]), nonsteroidal anti-inflammatory drugs, anti-arrhythmics, antihypertensives, antibiotics, colchicine, chemotherapy, metoclopramide (Reglan[R]), and other prokinetic agents (Arnold-Long, 2010). A complete list of the patient's medications should be evaluated to assess if they contribute to incontinence (Price & Bradley, 2013). Also, when a new medication coincides with an onset of diarrhea or constipation, the person should discuss with the health care provider an alternative drug that may be tolerated better. Medications may be used to get the ideal stool consistency. For example, a person with chronic constipation might use a laxative to add water to feces, while a person with chronic diarrhea might use loperamide (Imodium[R]) to make the feces less watery (Christensen & Krogh, 2010). Using liquid forms of the laxatives and loperamide makes it easier to titrate the doses to avoid inadvertently causing diarrhea or constipation (Ness, 2012). Again, a diary helps individuals recognize how medications are affecting their bowel function.

Removing Obstructions to Defecation

Feces become trapped in the rectum when it is overly compliant, or when an impaction or defect in the rectal wall prevents complete rectal emptying. An overly compliant rectum may be treated with biofeedback, and rectal wall defects are treated surgically. Regular defecation prevents impactions. Impactions are treated with enemas to soften the stool and then broken into pieces and removed digitally (Price & Bradley, 2013).

Following removal of the impaction, patient-specific interventions should be implemented to promote healthy defecation. Interventions may include dietary and medication changes to facilitate a soft, formed stool that is easier to pass. Additionally, nurses should teach patients and their caregivers about the importance of a consistent schedule for bowel movements, privacy during defecation, prompt response to the defecation urge, and use of the squatting position (Bliss & Norton, 2010).

Improving Pelvic Muscle and Rectal Function

Weight loss improves continence by removing the excessive burden on the pelvic muscles that support all of the pelvic organs (Costilla et al., 2013; Nazarko, 2013). Because excessive weight interferes with mobility, weight loss may make it easier for people to get to the bathroom and allow more physical exercise that is helpful for bowel tone and motility.

Pelvic muscle function also is enhanced by exercises. Biofeedback helps build pelvic muscle strength by confirming when patients are performing pelvic muscle exercises correctly, and helps them learn to coordinate muscles and sphincters for successful defecation (Bartlett, Sloots, Nowak, & Ho, 2011; Norton, Whitehead, Bliss, Harari, & Lang, 2010). Biofeedback also is used to improve rectal sensory discrimination. When patients have a poor defecation urge, a manometric rectal balloon is inserted into the rectum and filled with progressively smaller amounts of air to help patients develop a stronger urge so they are less likely to delay defecation (Lacima, Pera, Amador, Escaramis, & Pique, 2010).

For treatment to be successful, patients must have some rectal sensation, intact anal sphincters, and adequate pelvic motor function. Because biofeedback requires active participation, patients must be highly motivated, cognitively intact, and cooperative (Schwandner, 2012).

Emptying the Bowels at Regular Intervals

Defecating daily or every other day prevents incontinence in two ways. First, regular defecation prevents impaction, which occurs only when feces remain in the rectum for an abnormally long time. Second, individuals will not be incontinent of feces if the rectum is empty (Emmanuel, 2010). Most people empty their bowels once daily, usually after breakfast, and no more stool enters the rectum for 24 hours.

Regular defecation is accomplished in two major ways. The usual way is to follow a bowel program that includes a healthy diet and exercise with a prompt response to the defecation urge. A second way is used when the defecation urge cannot be felt, as after spinal cord injury. In this case, defecation is stimulated digitally or with irritant suppositories or bowel irrigations. It is important to schedule defecation the same time every day to take advantage of natural body rhythms and the gastrocolic reflex (Paris et al., 2011).

Digital stimulation is performed by inserting a finger in the anal canal and moving it in a circular motion to stretch the walls of the canal (Paris et al., 2011). Irritation of the rectal mucosa with suppositories (e.g., bisacodyl [Ducolax[R]], glycerine) is only effective when the suppository is in contact with the rectal wall. Suppositories cannot sit within a mass of feces and have results.

Rectal irrigations are used commonly in Europe to help people with spinal cord injury or multiple sclerosis to empty their bowels regularly, and also when other methods for treating incontinence fail (McWilliams, 2010). Typically, 5001,000 ml of tap water are given through a tube held in the rectum with an inflated balloon and then the water is allowed to flow out bringing feces with it. The treatment is inexpensive and private, and can be done at home. It is time consuming, but many patients can maintain continence doing rectal irrigation just a few times a week.

Irrigating solution (usually tap water) also can be given through a surgically created opening at or near the appendix. The Malone antegrade enema has been used successfully for children with spina bifida for many years and now is being used for adults with neurogenic bowel (Chereau et al., 2011). No matter what technique is used to stimulate defecation, individuals need to experiment to determine the time of day that works best for their lifestyles.

Incontinence Products

Incontinence products are used when full continence is not achievable and are therefore an integral part of incontinence management. Community-based persons tend to favor feminine hygiene pads or urine incontinence pads (Bliss, Lewis et al., 2011), possibly because they are less visible through clothes, easier to change, and less expensive than incontinence briefs. These products control and contain moisture but do not address the odor issue and potential staining of clothes that can be embarrassing for individuals. Despite their shortcomings, incontinence products are invaluable because they provide a layer of protection and added confidence so individuals can leave home and have a work and social life (Bliss, Lewis et al., 2011; Nazarko, 2013).

Another option is the foam anal plug (Paris et al., 2011). Inserted into the anus, the plug expands with moisture to make a firm seal that prevents leakage of feces and the subsequent odor. However, some people find the anal plug uncomfortable because of the sensation of fullness in the anus.

Fecal Management Systems

Staff in acute care settings and long-term care facilities often are challenged to manage acute episodes of diarrhea as a secondary condition in physically compromised, bedridden patients already susceptible to skin impairment and subsequent wound infection. A fecal management system includes a tube inserted into the rectum, a balloon inflated to hold the tube in place, and a drainage bag. The small-diameter tube is designed for liquid stool (Marchetti, Corallo, Ritter, & Sands, 2011). The devices sometimes injure rectal mucosa and can be used only for a short period of time (Hurnauth, 2011).

A colostomy is an option when everything else has failed and the patient's daily life is restricted severely by fecal incontinence (Paris et al., 2011). For example, a person with a spinal cord injury might choose a colostomy because a time-consuming bowel program impairs quality of life and does not seem worth the trouble. Nevertheless, the individual choosing a colostomy must be well informed about the implications (Coggrave, Ingram, Gardner, & Norton, 2012). Some prefer a colostomy over social isolation from incontinence, and it is truly the last option for them.

Nurses' Role

Nurses' role in incontinence care includes screening high-risk persons, recognizing signs of fecal incontinence, broaching the subject in a sensitive manner, referring affected persons to health care providers who specialize in bowel incontinence, protecting hospitalized patients from incontinence episodes and the effects on the skin, and teaching patients to manage bowel function for good quality of life when normal defecation is not possible (Nazarko, 2013).

Because of its shameful nature, people with fecal incontinence commonly suffer in silence rather than seek help (Ness, 2012). Nurses thus need to recognize persons at risk for incontinence or who show signs of incontinence, and broach the subject sensitively. Patients at high risk for fecal incontinence include frail older adults, anyone with diarrhea, and women who have delivered a baby vaginally. Also at risk are people with nerve or muscle disease, cognitive impairment, rectal prolapse, or chronic constipation, or who have undergone colon resection, anal surgery, or pelvic radiation therapy. Nurses also might notice signs of bowel incontinence, such as unexplained perianal soreness, redness, or itching, or the use of pads to contain leakage. They need to discuss "accidents," "leakage," or "not making it to the bathroom on time" because patients may not understand the term fecal incontinence (Patel et al., 2010). Nurses should approach the topic in a matter-of-fact way because affected patients may be more willing to discuss the problem if they feel safe and maintain their dignity.

Patients with bowel incontinence should be asked about current strategies to manage the situation (Landers, McCarthy, & Savage, 2012). Anyone who has not been evaluated by a specialist in bowel function and defecation disorders should be referred for diagnosis and medical treatment (Price & Bradley, 2013). Patients also need to understand the importance of a regular defecation schedule, proper positioning on the toilet, privacy, and the effects of diet, medications, and activity. Moist wipes are helpful for thorough cleaning after incontinence episodes. Nurses can teach patients to keep a diary of food intake and the appearance of subsequent stools. Using pictures of feces of different consistencies (e.g., the Bristol stool scale) helps people learn the appearance of the ideal stool (Ness, 2012).

When nurses provide strategies for improving feces consistency, promoting regular defecation, and containing stool, they help persons with incontinence regain control over their bowels and their lives. Having a variety of options to try is important because what works for one person might not work for another (Landers et al., 2012; Ness, 2012).

Some people are incontinent if they cannot get to the bathroom on time because they do not perceive the need (e.g., related to dementia), have decreased physical mobility, or cannot control the urge due to diarrhea or rectal inflammation. Bathrooms must be readily accessible. Time and assistance should be provided to facilitate regular bowel movements (Schnelle et al., 2010).

Critically ill patients are especially prone to fecal incontinence because of diminished mobility, cognitive impairment, and diarrhea from enteral tube feedings and medications containing sorbitol. Hospitals must have clearly defined regimens for skin care that include frequent assessment of skin for redness, rashes, and excoriation. The standard of care also should include prompt cleansing of all feces with a product with a pH close to the pH of the skin, as well as application of a moisturizer and barrier cream to protect skin from future incontinence episodes (Bliss, Savik et al., 2011).

Conclusion

Fecal incontinence is uncomfortable and embarrassing, and may have negative effects on quality of life. Strategies that improve the regularity and efficiency of defecation can eliminate or minimize episodes of incontinence, even when medical and surgical therapies are ineffective. Nurses play an integral role in managing fecal incontinence by screening high-risk persons, identifying patients who may benefit from treatment, and teaching strategies for improving effective bowel function.

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Title Annotation:Expert Practice
Author:Gump, Kendra; Schmelzer, Marilee
Publication:MedSurg Nursing
Article Type:Report
Date:Mar 1, 2016
Words:5401
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