Questions to consider

• What is your normal bowel habit?

Has it changed recently? If so how? Has there been any bleeding from the back passage? Or loss of mucus?

• What is the usual consistency of your stools (bowel motions)? (Refer to stool chart such as the Bristol Stool Chart to assist the patient/carer to describe)

Do the stools vary in consistency?

Do you have to strain to empty your bowels? If so, for how long?

• Are you able to tell the difference between when you are about to pass wind or stool?
• Do you pass much wind?

Can you control this wind?

• Are you able to delay emptying your bowels? 

If so for how long?

• Do you experience any abdominal pain or bloating before passing a bowel motion?

Does that relieve the sensation?

• Do you have a feeling of incomplete emptying after an attempted bowel evacuation?

Do you ever have to assist the passage of stool with your finger?

• Are you able to clean yourself after passing stools?

Do you have to clean yourself several times after passing stools?

• Do you ever leak stools without being aware of it?
• When FI is reported, ask the following:

How often does it happen?      

When has it happened? Is there any pattern to this or any factor that provokes it?

How much leaks? What is the consistency of the leakage? Can it be wiped away easily?

Do you get the sensation of the need to empty your bowels before you leak? Is that sensation an urge to empty your bowels? (urge faecal incontinence)

Does soiling occur after a bowel motion has been passed? (post-defecation soiling)

Do you wear pads (or something else) in your underwear? If so, are they effective in preventing soiling of clothes/surroundings/furnishing?

Previous medical history

• Assess the patient for possible contributory factors:

Constipation/diarrhoea

Acute severe illness

Terminal illness

Severe cognitive impairment

• Assess the patient for limited mobility and toilet access:

Does the patient have adequate toilet facilities (for example, is there limited availability, access problems, lack of privacy, unclean, unsafe?)

Does the patient need assistance for toileting? If so, is there delayed assistance when there is an urgent call to stool?

Is the patient able to communicate when there is a need to defecate?

Are there any physical or environmental difficulties with toilet access, for example, unmarked doors, steps, non-slip shiny floors, potentially confusing floor patterns. carpets. excessive distance?

• Is there a history of a neurological disorder(s)?

If yes - how long has it been present? 

Is it expected to improve? 

Is it permanent?

• Does the patient have an obstetric history and/or history of weak pelvic floor (as appropriate)

Parity

Difficult delivery

Large birth weight

• Is there a history of perianal trauma or surgery?
• Is there a history of urinary incontinence?
• Is there a history of rectal prolapse?
• Is there a history of other comorbidities such as diabetes

Perform a medication review

• Is the patient taking any of the drugs that may exacerbate faecal incontinence (FI) (see table 4)?
• What treatment alterations have already been made in the management of the problem?

How effective were these alterations?

Diet and fluid history

• Enquire about meals and snacks taken.
• Review food intake against the list of foods that may exacerbate FI (see Table 2)

Consequences of FI

• Do you experience itching or soreness around the back passage? 

When is this present?

6.

Impact of symptoms on lifestyle/quality of life

• Do the patient’s bowel symptoms affect the following?

General lifestyle

Family life

Leisure and social activity

Work

Sexual activity

Emotions

Self-image

Relationships, particularly any changes in close relationships

Ability to travel

Ability to manage within place of residence, for example does the patient require any structural changes to be made to their residence?

Physical examination

• General examination (as indicated)
• Cognitive and behavioural assessment (if indicated)
• Assess patient’s ability to use toilet, including:

Access

Mobility

Ability to adjust clothing

Ability to wash after using toilet

• Anorectal examination:

Visual inspection of anus

Assessment of perineal descent

Digital rectal examination for anal tone, ability to squeeze anal sphincter voluntarily

Assessment of faecal loading

Food type

Examples/rationales

Fibre

Current guidelines (DH 1991) are for an average intake of 18 g/day. Some patients may need an intake of up to 30 g/day.

Increase intake of wholegrain cereals, wholemeal, wholegrain bread, or white breads with added fibre

Encourage patient to have extra fluid with cereal fibre-rich foods

Some patients may require a fibre/bulking agent supplement to achieve a normal stool consistency

Fruit and vegetables

Fresh, tinned, dried or frozen

Encourage a minimum of five portions a day (see www.dh.gov.uk)

Drug (and mechanism)

Examples (not exhaustive list)

Drugs altering sphincter tone

Nitrates

Calcium channel antagonists

Beta-adrenoceptor antagonists (beta-blockers)

Sildenafil

Selective serotonin reuptake inhibitors

Broad-spectrum antibiotics (multiple mechanisms)

Cephalosporins

Penicillins

Erythromycin

Topical drugs applied to anus (reducing pressure)

Glyceryl trinitrate ointment

Diltiazem gel

Bethanechol cream

Botulinum toxin A injection

Drugs causing profuse loose stools

Laxatives

Metformin

Orlistat

Selective serotonin reuptake inhibitors

Magnesium-containing antacids

Digoxin

Constipating drugs

Loperamide

Opioids

Tricyclic antidepressants

Aluminium-containing antacids

Codeine

Tranquillisers or hypnotics (reducing alertness)

Benzodiazepines

Tricyclic antidepressants

Selective serotonin reuptake inhibitors

Anti-psychotics