Faecal incontinence (FI) has a huge impact on patient quality of life. It can lead to feelings of shame and degradation and affect relationships, self-esteem and body image. Its causes are multi-factorial, but so much can be done to improve or cure this embarrassing symptom. Despite this, it can take many years for patients to open up and admit to friends, relatives or healthcare professionals that they are suffering. FI should never be accepted as normal – all too often in the author’s experience this is seen to be the case. There are treatment options even for those patients who are bedbound. This article reviews the latest research and highlights the need for sensitive and supportive consultations with this patient group.  

FI always has an underlying cause (Harari, 2009). It is defined as any involuntary loss of faeces that is a social or hygiene problem (National Institute for Health and Care Excellence [NICE], 2007). Faecal incontinence occurs in approximately 50% of nursing home residents and up to 10% of older people living at home (Potter et al, 2007). In the world of bladder and bowel management, FI is considered the most underreported due to the shame and embarrassment associated with it (Sbeit et al, 2021). It is reported to be linked to depression, low self-esteem and restriction of normal daily activities (Camilleri-Brennan, 2020). It leads to increased care home admissions, urinary tract infections (UTIs) and skin issues (Potter et al, 2007; Harari, 2009; Norton et al, 2010).  

Despite a plethora of management options, some bladder and bowel nurses feel inadequately trained to manage FI (Leo et al, 2017). A recent survey of 250 general practitioners in the United Kingdom also found 75% lacking in adequate skills to assess and manage FI (Shinkwin et al, 2021). Several national audits of continence care in the United Kingdom have persistently highlighted poor continence care and gaps in provision. A national audit specifically focusing on FI in 2007 found deficiencies in carrying out basic assessments and a lack of integrated working, as well as poor management options (Potter et al, 2007). The NHS Long Term Plan aims by 2024/25 to reduce Gram-negative bloodstream infections (GNBSIs) by 50% and promotes tackling faecal incontinence as a key driver to achieving this target (NHS Improvement, 2017; NHS England, 2019). Escherichia coli (E.coli) originates from the gut and when patients are faecally incontinent, this increases the risk of E.coli bacteraemia.  

This paper explores the causes and treatments of FI, as well as the barriers that can lead to sub-standard management of the condition. In the author’s opinion, it is sometimes considered normal and not managed effectively, if at all. Indeed, an audit of care homes in the author’s workplace found that up to 97% of residents in one care home suffered with faecal incontinence.  


Basic requirements to maintain bowel continence include a compliant rectum with adequate capacity, intact internal and external anal sphincters, puborectalis muscle of the levator ani complex, normal rectal distension, anal sensation, reflex contractions and coordination of central and peripheral nervous systems. According to Bliss et al (2017), there are three types of faecal incontinence, namely:  
  • Passive incontinence when there is the involuntary loss of stool or flatus without awareness  
  • Urge incontinence, when there is loss of faecal matter, even with rectal sensation and an intact pelvic floor and faecal soiling resulting in staining of underwear  
  • Sudden FI, with symptoms consistent with cauda equina syndrome (a rare but serious condition which occurs when nerves at the bottom of the spinal cord are compressed), which requires urgent assessment and intervention (Shaw and Wagg, 2016). 
There is also functional incontinence, where the patient may be continent but unable to toilet themselves.  

In 2007, NICE produced guidance for managing FI based on systematic reviews of the evidence available at that time. The guidance highlighted the profound effect FI has on physical and mental health, leading to patients remaining undiagnosed, caregiver fatigue and admission to 24-hour care facilities. To get an accurate diagnosis, all possible contributory factors should be considered. Several conditions are linked to FI, such as anal sphincter dysfunction, rectal disorders, such as anismus and rectocele, malignant diseases, neurological disease, and psychiatric conditions (Duelund-Jakobsen et al, 2016).  

Causes of FI are usually categorised as non-traumatic or traumatic. Non-traumatic causes due to anal sphincter or evacuatory dysfunction are most prevalent. These are seen commonly in neurological diseases, where there can be abnormal anorectal reflexes and/or reduced or absent anorectal sensation. Patients with central nervous system dysfunction often experience constipation, FI and evacuatory issues (Scott et al, 2021). Widely used are the clinical recommendations of the Neurologic Incontinence Committee 2013 consultation document, which provide clear pathways for the management of FI (Cotterill et al, 2018). More recent expert consensus was produced by Abrams et al in 2018, in the 6th International Consultation on Incontinence.  
Other factors include neuropathy related to conditions such as diabetes, obesity, rectal surgery, overflow incontinence, congenital abnormalities and radiotherapy (Kim et al, 2021). One study of 256 morbidly obese women found 67% suffered with FI, suggesting an increased stress on the pelvic floor musculature associated with obesity (Wasserberg et al, 2008). A recent systematic review of obese patients suffering with FI found a significant reduction in FI episodes post bariatric surgery (Mohamed et al, 2021).  

Traumatic causes of FI are related to obstetric trauma during childbirth and reconstructive anorectal surgery, and, as Potter (2007) states, it becomes more common with disability and advancing age. In the literature, the prevalence of FI varies widely due to populations sampled and different definitions. In a study with 71,000 American participants, Menees et al (2018) found that one in seven had suffered with bowel incontinence and that there was an increased prevalence associated with ageing. They also found little difference in gender, suggesting that childbirth-related trauma causing FI could be overestimated. Concomitant diarrhoea and constipation, inflammatory bowel disease and diabetes were other high-risk factors. Another recent, large cross-sectional study of 4,027 patients, 83% of whom were female, found that 41% of patients reported coexistent symptoms, such as constipation, using established international diagnostic (Rome) criteria (Drossman et al, 2016), meaning that constipation was diagnosed and not necessarily picked up on before referral into the study (Vollebregt et al, 2020).  

According to Norton et al (2007), holistic baseline assessment should cover a detailed medical history, as well as abdominal and rectal examination to assess any anorectal abnormalities. It should also differentiate between urge, passive or functional incontinence. Objective evidence should be obtained using a week-long bowel diary using the Bristol Stool scale (Figure 1). Consideration of diet and fluid consumption should be noted, along with which medication is prescribed and or bought over the counter. Cognition and mobility status are also important factors. Aside from a digital rectal examination, investigations may include a plain film X-ray to rule out impaction, stool cultures, or faecal immunochemical tests (FIT). 

Figure 1. Bristol stool chart.
Specialist diagnostic centres may perform endo-anal ultrasound, which assesses the anatomy of the anal canal to look for structural and or sphincter abnormalities and offer biofeedback. Biofeedback consists of anal exercises and manometry. Norton and Cody (2012) found biofeedback using computer equipment or rectal balloon to be more beneficial than exercises alone. Anorectal manometry allows the assessment of resting and squeeze anal pressures, which represent the function of the external and internal anal sphincters.  

According to NICE in their clinical guideline of 2007, multiple randomised controlled trials (RCTs) using biofeedback have elicited few statistically significant results. Despite clear guidance, a national audit looking at adherence to national guidance showed clear deficits in the diagnosis and management of adults with FI (Harari et al, 2014).  

The diagnostic criteria for FI were made more restrictive in the latest Rome IV questionnaire, and a large virtual study of nearly 6,000 adults in three countries by Whitehead et al (2020) showed that this dramatically affected prevalence rates. They concluded that regardless of the frequency of FI, impact on quality of life was the same. This was echoed in another study in 2017 by Helewa et al, who measured success in improvement in quality of life, not a reduction in incontinence episodes.  


There may be many specialists involved in treating patients with FI, including bladder and bowel teams, surgeons, physiotherapists and specialist units. Ultimately, the aim of treatment is to improve subjective symptoms and quality of life. Once any red flags have been ruled out and a cause found, a management or care plan should be created with the patient.  
Red flag symptoms  
Red flag signs suggestive of bowel cancer require urgent investigation. These include:  
  • ● Unexplained weight loss  
  • ● Nausea  
  • ● Recent and persistent change in bowel habit  
  • ● Abdominal pain  
  • ● Anorexia (NICE, 2011).  
Medications for FI do not treat the underlying cause, they merely alter the stool consistency to reduce the risk of incontinence. In 2002, Cheetham et al published a Cochrane review of drug treatments for FI comparing randomised trials available at the time. They found that most of the included trials rather than looking at faecal incontinence, focused on the treatment of diarrhoea and called for more rigorous trials in patients with FI, not necessarily associated with diarrhoea. They found little evidence with which to assess the use of pharmacological preparations for the management of faecal incontinence.  

Omar and Alexander (2013) published a later Cochrane review of drug treatments for use in the management of FI and found again there was limited evidence that anti-diarrhoeal drugs, such as loperamide, and drugs that enhance anal sphincter tone, such as sodium valporate, reduce faecal incontinence in patients with liquid stools. Moreover, loperamide was found to be associated with significant side-effects, such as headache and abdominal pain. The review found the study sample sizes to be small and called for larger and more rigorous trials.  

The synthetic opioid, loperamide hydrochloride, has been shown to be more effective than placebo at controlling FI episodes (Omar and Alexander, 2013), but if the side-effects of loperamide are intolerable, patients should be offered codeine phosphate or co-phenotrope (NICE, 2007). Some patients will be sensitive to the sedative side-effects of the opioid codeine. The active ingredient of co-phenotrope, diphenoxylate, shares the same side-effect profile as loperamide and should be used in caution due to the potential effects on the central nervous system (Ede, 2014). Other studies have found the use of synthetic fibre gives similar results in terms of firming stools, with less constipating side-effects compared to loperamide (Markland et al, 2015). Synthetic fibre can be helpful for patients whose dietary fibre intake is low.  

Skin care and hygiene are important factors for patients with FI, with containment products, barrier creams and sprays being crucial for dignity and skin protection. Anal plugs have been on prescription for many years and studies as far back as 1991 have found that their use stopped FI in 82% of the periods during which the plug was in place (Mortensen and Humphreys, 1991). Anal plugs provide a barrier to prevent stool leakage and, if there is no rectal sensation, are well tolerated (Norton and Kamm, 2001).  
Newer inserts sit in the anal canal rather than the rectum, thus they do not mimic stool which can cause anorectal discomfort and irritation. A recent review paper by How et al (2021) found that, when tolerated, anal inserts significantly improved continence, quality of life and in some cases bowel function. They highlight the need for longer term studies to assess compliance.  

In the author’s clinical experience, initial management should aim to regularise stool frequency and consistency and maintain skin integrity and personal hygiene. Reversable factors, such as toilet access, toileting programmes, or medication side-effects, should be addressed. Management strategies in FI should start with conservative management, including lifestyle and behavioural interventions (Norton et al, 2010). 

In the author’s experience, controlled bowel movements with suppositories can improve continence in bedbound patients who are unable to be toileted. If this fails to improve and/or cure, pharmacological and then surgical management options should be considered. Lifestyle interventions include avoiding osmotic agents, e.g. fatty foods, artificial sweeteners and caffeine (Shaw and Wagg, 2016).  

Herbert (2019) outlines several first-line conservative approaches aside from pelvic floor muscle training (PFMT) that can be used, including patient education about how the bowel functions, bowel habit training, advice about diet and eating pattern changes and dietary fibre supplements, and the use of medications such as loperamide to firm the stool.  

Where available, containment products should be provided for the patient’s dignity and they should be advised on coping strategies, such as locating toilets, carrying spare clothes and cleansing kits. Pelvic floor muscle training has been widely researched in relation to urinary incontinence, but less so in the case of FI. A Cochrane review in 2012 of biofeedback and/or sphincter exercises to treat FI concluded that the limited number of trials did not elicit a definitive outcome of their role in treating FI (Norton and Cody, 2012). This was also found to be the case in a more recent review in 2020 of pre and post-natal FI (Woodley et al, 2020). Despite this, in the author’s clinical experience, PFMT is widely suggested in the literature as a conservative treatment.
Should these conservative measures fail, transanal irrigation (TAI) is the next non-surgical intervention to aim to cure according to a best practice consensus review of transanal irrigation in adults (Emmanuel et al, 2013). There are several TAI kits on prescription, i.e. Peristeen® (Coloplast, which is supported by NICE guidance [2018]). During TAI, water is instilled into the rectum using a lubricated cone or rectal catheter. This facilitates emptying of the recto-sigmoid, with some studies showing the whole of the descending colon being cleared of stool. One of the first academic papers on TAI published by Christensen et al in 2003 proved this with scintigraphic assessment.  

Mekhael et al (2021) systematic review looked at the clinical effectiveness of TAI in patients with neurogenic bowel disease, faecal incontinence, constipation or low anterior resection syndrome. It found TAI to be beneficial in terms of relieving FI and improving quality of life, but the authors acknowledged that a limitation to the studies reviewed was the missing reporting of clinical significance.  

Patients may need assistance to perform TAI if unable to do so independently, and healthcare professionals should be competent to assess suitability, teach and monitor compliance and effectiveness. Community nursing teams, however, can often be too stretched to take on this role, even though it takes only 15 minutes approximately. In the author’s experience, most care agencies will decline to perform TAI, but are often needed to assist community nursing teams with hoist transfers etc, and therefore coordinating visits can be challenging. Specialist carers looking after tetraplegic clients will usually be competent in all aspects of bowel care, including irrigation. Emmanuel et al (2013) reported that it can take up to 12 weeks to establish an effective irrigation regimen. Supporting the patient through the early stages of TAI is crucial, as there can be high discontinuation rates of up to one-third of patients (Juul and Christensen, 2017).  

More recent innovation in the gastroenterology world is the use of probiotics, the composition of gut microbiota, and how it influences those with neurogenic bowel dysfunction (NBD). A 2021 systematic review by Faber et al found that most of the 14 studies excluded aspects such as diet and antibiotic use, and only a few studies assessed the gut microbiota. They concluded that more research is needed in larger data sets with multiple samples taken over a prolonged period of time to assess how microbial composition alters, and how changes in diet, bowel function and antibiotic use affects this.  

Sacral neuromodulation (SNM), the stimulation of the S2–S3 nerve root, can be achieved via the sacral nerve or peripherally via the tibial nerve. There are limited studies in its use in the management of FI, as most have focused on the bladder. A landmark multi-centre prospective study of 120 patients by Wexner et al (2010) who were treated with SNM found it to be effective and safe. Forty percent of patients achieved complete continence, and FI episodes decreased from nine to two per week. A more recent study looking at long-term outcomes reported a sustained response to SNM (Varghese et al, 2020).  

Posterior tibial nerve stimulation (PTNS) is electrical stimulation of the tibial nerve at the ankle. Randomised controlled studies have shown that for some patients who have not responded to conservative treatment, there is a modest benefit (Ferri-Morales, 2018).  

Surgical interventions are second line. These include sphincteroplasty and the creation of an artificial anal sphincter. However, while initial continence is achieved, results worsen over time (Glasgow and Lowry, 2012). As a last resort, formation of a colostomy or ileostomy can be a reasonable option for symptoms of FI, as the procedure reduces time spent with bowel care and can provide independence, improving quality of life for patients (Preziosi et al, 2018).  


The All-Party Parliamentary Group for Continence Care in 2011 stressed how crucial it is to reduce the negative impact and improve quality of life for patients with bladder and bowel dysfunction.  

Continence care has been under scrutiny for many years. Last year, it was highlighted by the Pelvic Floor Society that across the UK patients are presented with an inequality of access to care resulting from the patchy nature of services for continence and functional pelvic conditions — thus, there is work to do here. 

Some studies have found that up to 50% of patients do not disclose their FI with anyone, not even a close relative, let alone a healthcare professional (Bharucha et al, 2005). Feelings of shame, repulsion, embarrassment, and in some cases, denial, are common. To understand why a patient would suffer for so long in silence, it is important to consider how belief systems create a barrier and delay in patients seeking help and explore the research in terms of patient-centred care for patients with FI.  

According to Cichowski et al (2014), patient-centred care can be defined as care that considers the patient’s preferences, needs, and values and ensures that patient values guide all clinical decisions. Driven by the NHS Five Year Forward View, NHS England (2014) has made a commitment to improving patient-centred care through involving patients and giving them the power to manage their own health and allowing them to make informed decisions about their care and treatment, relying on healthcare professionals to work collaboratively with patients who use the services. Thus, in practicing patient-centred care with patients with FI, it is vital to consider the implementation of management strategies from the patient’s point of view, as well as the healthcare professional’s clinical point of view.  

Barriers to patients seeking treatment for FI have been identified consistently in the literature, including gender, ethnicity, culture, understanding of illness, health, financial status, psychology and personal experience of healthcare provision (Rizk, 2017). Many surveys have shown that several years will pass before patients admit they are suffering with FI to a healthcare professional, sometimes because they think it is a normal part of ageing or are too embarrassed and do not know what treatments are available (Taylor et al, 2014). Interestingly, Taylor et al (2014) small pilot of care home residents with FI found 80% did not think of themselves as being incontinent, as if that word only applied to bladder leakage.  
In the case of the frail and elderly population in nursing or care homes, FI is often accepted as a normal part of the ageing process and not seen as a chronic long-term condition. As Norton et al (2010) state, FI in this group is socially isolating and associated with increased dependency, morbidity and mortality. Frailty, described as having multiple chronic illnesses and physical limitations, is itself a risk factor for FI.  

Dementia is known to have a negative impact on sphincter control. A 62-paper synthesis of the evidence of how FI should be managed in people with dementia in care homes was published in 2017 by Goodman et al. They concluded that dementia was a well-known risk factor for FI, yet staff working with patients with FI lacked the skills and knowledge needed to improve and manage the condition. They stressed the importance of care home staff understanding their responsibilities with regard to intimate and personal care, and the challenges continence aids can bring. In the author’s clinical opinion, the concept of patient-centred care with clinician-led assessment from general practitioner’s, community nurses, matrons or bladder and bowel teams is vital to reduce FI in this patient group.  

Studies have also looked at the way screening for FI is performed or not, citing lack of physician knowledge as an issue alongside patients not wanting to discuss their FI face to face, preferring to use questionnaires (Brown et al, 2018). A small qualitative study conducted by Brown et al in 2017 found 12 barriers to seeking help when suffering with FI, including lack of knowledge of the condition, its treatments, denial, fear of tests and provider barriers. Many similar barriers are found in patients with urinary incontinence, but a common theme in the study was a lack of knowledge that many others suffer with FI too, highlighting the sense of isolation people with FI can feel.  
Practice point 

Developing a relationship with the patient, educating and motivating them to aid concordance with conservative measures is key. 



Although treatments and strategies exist for FI, systematic reviews agree that there is no consensus on the best treatment strategy, with RCTs producing contradictory results and many finding no significant differences between treatments (Lal et al, 2019). According to Lal et al (2019), there is an element of placebo effect in the treatments for FI. The outcome of another systematic review concluded that to permit comparison between FI treatments, it is imperative to standardise the inclusion criteria, methodology, follow-up period, and outcome measures across studies in the field (Simillis et al, 2019). Bliss et al (2017) called for more awareness of FI, citing a lag compared to other long-term conditions. By doing so, it could reduce the stigma and isolation which so many patients feel.  

Healthcare professionals should be skilled in assessment and management of FI and have the knowledge to know when to refer on. Patients with FI should be supported with self-management tools. It is important that healthcare professionals help patients to make decisions, set goals, start and modify treatment options and thus empower them to improve their condition. Much of the research focuses on the reduction of the physical symptoms of FI and fails to highlight its psychological impact on the patient.  

The concept of patient-centred care with clinician-led assessment from general practitioner’s, community nurses, matrons or bladder and bowel teams is vital to reduce FI, particularly for those with frailty or dementia. The same multidisciplinary approach must also apply to acute trusts.  

The stigma of faecal incontinence needs to be replaced with well-researched treatment options delivered with compassion, empathy and respect. 
Key points: 
  • ● Faecal incontinence (FI) has a huge impact on patient’s quality of life. It can lead to feelings of shame and degradation and affect relationships, self-esteem and body image. Its causes are multi-factorial but so much can be done to improve or cure this embarrassing symptom 
  • ● Despite a plethora of management options, some bladder and bowel nurses feel inadequately trained to manage FI 
  • ● It is important that healthcare professionals help patients to make decisions, set goals, start and modify treatment options and thus empower them to improve their condition 
  • ● The stigma of faecal incontinence needs to be replaced with well-researched treatment options delivered with compassion, empathy and respect. 


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This piece was first published in the Journal of Community Nursing. To cite this article use: Young J (2022) Assessment and management of faecal incontinence. J Community Nurs 36(2): 51-58