Oct 022013
 

Fecal Incontinence is the inability to control the bowel or stool may leak from the rectum unexpectedly, sometimes while passing the gas. It describes the involuntary passage of stool from the rectum.


Several factors influence fecal incontinence like;

  • The ability of the rectum to sense and accommodate stool.
  • The amount and consistency of stool.
  • The integrity of the anal sphincter and musculature and rectal motility.

Incidence:

  • More than 5.5 million American have fecal incontinence.
  • Affects people of all ages.
  • More common in women and older adults.

(But it is not a normal part of aging)
Causes

  • Trauma
  • Neurologic disorders (eg. stroke, multiple scierosis, diabetic neuropathy, dementia)
  • Inflammation, Radiation Rx, fecal impaction.
  • Damage to the anal sphincter, damage to the nerves of the anal sphincter muscles or rectum.
  • Loss of storage capacity in the rectum.
  • Diarrhea.
  • Pelvic floor dysfunction (pelvic floor relaxation)
  • Laxative abuse, advancing age, medications.

Surgical and Nursing Management

Surgical Management:

  • Surgical reconstruction – sphincter repair
  • Fecal diversion – colostomy

Nursing Management:

  1. Nurse should take a thorough health history and complete examination of the rectal area. Information about previous surgical procedures, chronic illnesses, bowel habit and problems and current medication regimen should be obtained.
  2. Develop a regular pattern of bowel movements.
  3. Bio-feed back can be used in conjunction, these therapies to help the patient improve sphincter contractility and rectal sensitivity.
  4. Relieve from Anal discomfort;

Meticulous skin hygiene must be encouraged and taught which includes,

  • wash the area with water, but not a soap after a bowel movement. Soap can dry out the skin, making discomfort worse. If possible, wash in a shower with luke warm water or use a sits bath or try a no-rinse skin cleaner. Try not to use toilet paper to clean up-rubbing with dry toilet paper will only further irritate the skin. Pre-moistened, alcohol free toilet paper are a better choice.
  • let the area air dry after washing. If you don’t have time, gently pat yourself dry with a linkt free cloth.
  • use a moisture barrier cream which is a protective cream to help prevent skin irritation from direct contact with stool. You should first clean the area well to avoid trapping bacteria that could cause further problems.
  • try using non-medicated talcum powder or con starch to relieve discomfort.
  • wear cotton underwear and loose clothes that ‘breathe’, tight clothes that block air can worsen anal problems. Change soiled underwear as soon as possible.
  • If you use pads or disposable under garments make sure they have an absorbent wicking laycrontop. (Products with a wicking layer protect the skin by pulling stool and moisture away from the skin and into the pad).
  • Sometimes continence cannot be achieved and the nurse must assist the patient and family to accept and cope with this chronic situation.
  • Health Education, (some tips)
  • Take a backpack or bag containing clean up supplies and a change of clothing with you everywhere.
  • Locate public restrooms before you need them.
  • Use the toilet before leaving home.
  • If you think an episode is likely, wear disposable undergarment or sanitary pads.
  • If episodes are frequent, use oral fecal deodorants to add your comfort level.
  • If fecal diversion is done then care of colostomy and care of the bag.

Medical Management

Note: Type of Rx depend on the cause of severity of fecal incontinence.
a) Dietary changes:

  • Keep a food diary.
  • Eat small meals more frequently
  • Eat and drink at different times.
  • Eat foods that make stool bulkier.
  • Get plenty to drink.
  • Vitamin supplement.

b) Medication (bulk laxative):
Anti-diarrheal medicines such as loperamide, diaphenoxylate.

c) Bowel training:

  • It helps some people relax how to control their bowel movements. Bowel training involves strengthening muscles and training the bowels to empty at a specific time of day.
  • Use bio-feed back therapy.
  • Develop a regular pattern of bowel movement.

Diagnostic Findings

  • X-Ray studies: Barium enema, computed tomography scans may be helpful in identifying alterations in intestinal mucosa and mucosal tone, or other structural or problems.
  • Anal manometry: Checks the tightness of the anal sphincter and its ability to responds to signals, as well as sensitivity of function of the rectum.
  • MRI: MRI is sometimes used to evaluate the sphincter.
  • Anorectal VSG evaluates the structure of the anal sphincter.
  • Proctography also known a daefecography shown how much the rectum can hold, how well she rectum holds it and how well the rectum can evacuate it.
  • Proctosigmoidoscopy allows doctors to look inside the rectum and lower colon for signs of disease or other problems that can cause fecal incontinence, such as inflammation, tumors or scar tissue.
  • Anal electromyography: Tests for nerve damange is often associated with injury during child birth.

Clinical Features

Patient may have minor soiling, occasional urgency and loss of control or complete incontinence, poor control of flatus, diarrhea or constipation may also be present.

Diagnostic findings:

  • History taking.
  • Physical examination.
  • Test – Analmanometry

– Ano-rectal VSG

  • Protography / daeficography
  • Proctosigmoidoscopy
  • Anal electromyography
  • X-ray strudies – Barium enema

– CT Scan.

Pelvic floor dysfunction

Abnormalities of the pelvic floor and muscles can cause fecal incontinence. Examples include;

  • Impaired ability to sense stool in rectum
  • Decreased ability to contract muscles in the anal canal to defecate
  • Dropping down of the rectum
  • Profusion of the rectum through vagina, a condition called ‘rectocele’.
  • General weakness and ragging of the pelvic floor.

Child birth is often the cause of pelvic floor dysfunction and incontinence usually doesn’t appear until the mid fourties and later.

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Oct 022013
 

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