Faecal incontinence (FI) is the recurrent involuntary loss of solid or liquid stool. It affects adults of all ages and is often under-reported due to embarrassment. Symptoms may result from altered stool consistency, pelvic floor dysfunction, anal sphincter injury or neurological disease. Initial management in primary care should focus on identifying reversible causes, optimising stool consistency and commencing conservative management before referral where appropriate.
Majority of patients will not require surgical intervention for their incontinence symptoms and conservative treatment could be commenced and continued in community – see Primary Care Management Tab.
Specialist management may include dietary intervention, bowel retraining, pelvic floor rehabilitation, biofeedback, transanal irrigation, neuromodulation and surgery where appropriate.
B.C & H.E – 5-10-26
Who to refer:
Refer patients with:
- Persistent faecal incontinence despite appropriate conservative management (typically 8–12 weeks) – see Primary Care Management Tab
- Suspected anal sphincter injury (e.g. obstetric or surgical)
- Rectal prolapse
- Complex pelvic floor dysfunction
- Faecal incontinence associated with neurological disease where specialist assessment is required
- Diagnostic uncertainty or symptoms requiring specialist investigation
If referral is for symptom management or Surgical referral is not appropriate, e.g. if patient not fit for surgical intervention or not wishing this, then consider referral to the Bowel and Bladder Nursing Team (BBNT). See link:
Bowel and Bladder Nursing Team
Who not to refer
Referral is not usually required where symptoms are attributable to:
- Acute infective diarrhoea
- Overflow faecal incontinence secondary to constipation that resolves with treatment
- Mild symptoms responding to conservative management
Refer via the appropriate USOC pathway if there are features suggestive of:
- Suspected colorectal cancer
How to refer
Refer routinely via SCI Gateway to the Colorectal Service.
Primary Care Assessment
History
Assess:
- Exclude malignancy – check for red flags – rectal bleeding, persistent change in bowel habit > 4weeks, rectal mass, abdominal mass, abdominal pain with weight loss
- Exclude other medical conditions as appropriate – infective diarrhoea, constipation with overflow, thyroid dysfunction, coeliac disease, IBD, bile salt malabsorption.
- Medication review –frequent offenders including laxatives, metformin, antibiotics, SSRI, statins, PPI, allopurinol, colchicines, magnesium-containing antacids, high dose vitamin C
Relevant history:
- Frequency and type of FI (urge/passive) to gas/stool/liquid.
- Duration and severity of symptoms, impact upon QOL.
- Stool consistency using the Bristol Stool Chart
- Obstetric history (including obstetric anal sphincter injury)
- Previous anorectal or pelvic surgery
- Pelvic radiotherapy
- Neurological disease
- Diabetes mellitus
Examination
- Abdominal examination
- Perianal inspection
- Digital rectal examination to assess:
- Faecal loading
- Anal tone
- Voluntary squeeze
- Rectal masses
- Other anorectal pathology
Initial investigations
Consider:
- FBC – exclude Anaemia, or if inflammatory pathology is suspected
- Coeliac serology or thyroid function tests where clinically indicated
- HbA1c where Diabetes is suspected or poorly controlled
- Stool investigations if clinically indicated from history – stool culture, faecal calprotectin, elastase
Primary Care Management
Initial treatment should focus on correcting reversible causes and improving stool consistency.
- Encourage regular bowel habits and avoidance of prolonged straining.
- Treat diarrhoea appropriately.
- Review medications contributing to diarrhoea or constipation.
- Treat constipation and overflow faecal incontinence – see link to Bowel and Bladder Dysfunction page for guidelines
OPTIMISE STOOL CONSISTENCY
Stool = fibre and water and microbiome! Therefore diet is important.
Diet and fluid
- Limit caffeinated drinks:
- coffee, tea, coke, irn bru, energy drinks, green tea
- caffeine is a bowel stimulant, beware of diet drinks which often contain sorbitol, mannitol which also cause diarrhoea
- Reduce other bowel stimulants
- spicy foods, alcohol, lentils/pulses
- Encourage adequate fluid intake
- Optimise dietary fibre according to stool consistency – See section on fibre below
Fibre – aim for 30g per day
Insoluble fibre passes through the body without being broken down – bran, whole grains. Main function is to keep us full and bulk up stools. Insoluble fibre is dry fibre and difficult to move through colon if have slow transit. Focus more on soluble fibre.
Soluble fibre gets broken down in our gut by bacteria and ferments, binds bile acids– prune, kiwi, rhubarb, figs, oats, avocado, flax seeds, chia seeds
See East Region Formulary for more information
Ispaghula Husk: One sachet contains 3.5g ispaghula husk so one or two sachets daily.
Other options to consider if patient chooses to purchase:
Psyllium husk powder (soluble fibre.) Sprinkle 1-2 teaspoons (approx 5-7g) in morning on breakfast
Psyllium capsules (500mg) can also be used if preferable/more convenient and titrated up accordingly but need lots more to be equal to one teaspoon of powder.
Resource Optifibre. This is a powder containing well tolerated soluble fibre (partially hydrolysed guar gum) which can be mixed with food or drink. It has no taste. This is usually taken as one scoop (approx 5g powder provides 4.3g fibre) once or twice a day.
Medication:
Loperamide:
To slow the whole process, treat urgency, solidify liquid motion. Loperamide rests bowel by inhibiting peristalsis for 3 to 4 hours. Can be used to stop loose stools and prevent accidents as required or regularly once or twice daily to have regular bowel motions. If a 2mg tablet is too strong, liquid loperamide can be more easily titrated to a small dose regularly using syrup form if available (5mls is 1mg) or loperamide melts can be cut in half. The dose could be increased up to 16mg/day. Start with lowest dose and titrate upwards slowly.
Codeine:
Use if above is insufficient. 15mg bd (max 30mg qds). Slows motion down and helps solidify.
If evacuation of stool is an issue: (incomplete emptying, smearing, post defecatory soiling) try suppositories or enemas to manage evacuation and/or ensure complete evacuation
Glycerol suppositories:
These are recommended for patients who feel they are not completely emptying their bowel. After their usual bowel motion advise patients to insert a suppository, sit on toilet seat with lid closed for 5 minutes then empty bowels again.
Some patients may use suppositories to help them start a bowel motion to manage the timing of evacuation more conveniently.
Mini-enema (e.g. Micralax)
These can be used if glycerol suppositories have not worked.
Other treatments for symptom control, which may be available through the BBNT if deemed appropriate, could be tried prior to referral to the Colorectal service. These include anal plugs and inserts and rectal irrigation.
Pelvic floor exercises and rehabilitation
Pelvic floor exercises can be accessed online. See Resources and Links for useful links.
There are also useful apps, such as “Squeezy” that patients can download and use.
See MSK Physiotherapy Services Overview – RefHelp for more information on referral for Women’s Health Physio.
It is important that pelvic floor exercises are done daily and need to be continued indefinitely.
Refer to specialist pelvic floor physiotherapy where available for:
- Pelvic floor muscle training
- Bowel retraining
- Biofeedback therapy where appropriate
