05/08/2018

FECAL INCONTINENCE: THE DIRTY SECRET DISPELLED

DEBRA NETSCH, DNP, APRN, FNP-BC, CWOCN, CFCN

DISCLOSURES

• The presenter and content developers for this educational offering report no relevant financial relationships with any commercial interests related to this content. They further disclosed that no off-label/unapproved uses of drugs and/or devices are discussed in this presentation.

OBJECTIVES

1. Describe normal defecation pathophysiology. 2. Identify 3 causes of fecal incontinence. 3. Discuss 3 fecal incontinence management and treatment interventions.

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Fecal incontinence is a common problem: • Occurs in approximately 2 out of 100 children. • Affects approx. 1 in 3 people who see a primary health care provider. • More common in older adults. THE FACTS Occurrence:

• Community dwelling adults: 7 to 15 out of 100. • Hospitalized adults: 18 to 33 out of 100. • Nursing home dwelling adults: 50 to 70 out of 100 have.

DEFINITION

• Fecal incontinence definition: – Accidental passing of bowel movements (including solid stools, liquid stools, or mucus) from the anus

• Also referred to as: – Accidental bowel leakage – Bowel incontinence – Encopresis—a term used mostly when occurs in children

NORMAL DEFECATION

• Critical factors required: – Normal intestinal absorption and peristalsis – Intact sensory awareness and sphincter function – Normal and intact muscular function – Normal rectal capacity and compliance – Absence of psychologic disorders

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DEFECATION PATHOPHYSIOLOGY

TYPES OF FECAL INCONTINENCE:

• Urge incontinence

• Passive incontinence

RISK FACTORS

• Older than 65 years old • Inactivity • Chronic diseases, medical conditions, or health problems • Previous cholecystectomy • Current smoker

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CAUSES • Overall deconditioning • Chronic diseases and disorders such as – Irritable bowel syndrome – Type 2 diabetes – Inflammatory bowel disease • Muscle damage or weakness of rectal, anus or pelvic floor • Nerve damage to rectal, anus or pelvic floor • Urinary incontinence • Proctitis • Diarrhea – Lactose intolerance – Fat malabsorption (bile acid deficiency) – Osmotic – Thyroid disease

MUSCLE INJURY OR WEAKNESS

• Surgical – Removal cancer in the anus or rectum – Removal hemorrhoids – Treat anal abscesses and fistulas • Pelvic floor prolapse • Trauma – Childbirth – Etc. • Obesity

NERVE DAMAGE

• Nerve damage causes rectal, anal and pelvic floor muscle dysfunction.

• Nerve damage leads to abnormal reflexes – Inhibitory

• Causes of nerve damage: – Long habit of straining to pass stool – Neurological diseases

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NEUROLOGICAL DISEASE • Dementia • Multiple sclerosis • Parkinson’s disease • Stroke • Type 2 diabetes • Brain injury • Spinal cord injury • Trauma, i.e. childbirth

DIARRHEA • Most common risk factor of FI. • Loose, watery stool consistency • Causes: Digestive tract problems such as – Inflammatory bowel disease – Irritable bowel syndrome – Proctitis – Fat malabsorption (bile salt deficiency) • Diet selection – Tube feedings – Poor diet – Lactose intolerance • Medications

CONSTIPATION

Causes: • Inactivity • Dehydration • Lack of dietary fiber • Defecation dyssynergia • Endocrine disorders • Medications

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COMPLICATIONS

• Perianal discomfort or irritation (IAD) • Increased risk of pressure injury development • Emotional and social distress • Quality-of-life issues

ASSESSMENT

Questions:

Was there indication of need for toileting (urge)? Was there adequate time to reach the toilet? Does the BM occur at the same time every day? Any leakage of stool before or after toileting?

ASSESSMENT

• Bowel diary

• Stool consistency

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ASSESSMENT: PHYSICAL EXAMINATION

• Visualize • Rectal exam

CONDITIONS: RECTAL PROLAPSE

• The rectum telescopes dropping through anus.

CONDITIONS: RECTOCELE

• Causes the rectum to bulge out through your vagina. Stool may stay in the rectum because the rectocele makes it harder to push stool out.

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CONDITIONS: HEMORRHOIDS

CONDITIONS: IAD Symptoms: • Redness, ranging from light pink to dark red, or darker pigment depending on skin tone • Patches of inflammation or a large, continuous area of inflammation • Warm and firm skin • Skin erosion • Pain or tenderness • Burning • Itching

CONDITIONS: PRESSURE INJURY

Symptoms: • Pink, Red, Yellow or Black Tissue if open • Purple or darkened pigment if DTI • Pain • Burning • Drainage

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FI MANAGEMENT

Goal: Restore normal or near normal function

• Normalization of stool volume and consistency • Bowel management program • Rectal disimpaction • Biofeedback • PTNS/Sacral Stimulator • Treatment of underlying condition

FI MANAGEMENT NORMALIZATION OF STOOL VOLUME AND CONSISTENCY

CONSTIPATION: • Increase water intake – 1 oz. /kg/day – (unless contraindicated) • Increase dietary fiber – Foods high in fiber – Supplemental fiber intake – (28-30 gm/day) • Increase activity • Review medications

FI MANAGEMENT NORMALIZATION OF STOOL VOLUME AND CONSISTENCY DIARRHEA: • Eliminate lactose • Increase bulking foods – BRAT diet • Add fiber bulking agents – 1-3 teaspoons in 4 oz of fluid • Add medications to reduce transit time • Review medications • Review diet • Probiotics

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FI MANAGEMENT BOWEL MANAGEMENT PROGRAM Goal: Stimulate a BM at approximately the same time of day every day; evacuate the rectum

• Have patient walk if able • Give suppository • Place on commode or toilet 15 minutes later

• If SCI or neurologic disease: – Give suppository – Digital stimulation 15 minutes later – Place on incontinence pad, commode or toilet

FI MANAGEMENT RECTAL DISIMPACTION

• Digitally remove impaction – Give fiber/laxative for short period of time – Follow constipation management – Add bowel management program if not having regular BMs with constipation management

FI MANAGEMENT PELVIC FLOOR EXERCISES/BIOFEEDBACK

• Kegel (30 per day) • Biofeedback objective measurement

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FI MANAGEMENT PTNS/SACRAL STIMULATOR

FI MANAGEMENT TREATMENT OF UNDERLYING CONDITION

• Inflammatory bowel diseases • Rectal prolapse • Rectocele • Hemorrhoids • Etc.

SKIN MANAGEMENT: PREVENTION IAD • After every incontinence episode as soon as aware: – Cleanse with pH cleanser – Moisturize if skin is dry – Protect with incontinence barrier or liquid skin barrier (may be all combined into one product) • Use diapers only when up • Use incontinence pads on bed when in bed

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SKIN MANAGEMENT: TREAT IAD • If prevention does not work or IAD exists: • Blot with pH balanced cleanser OR saline • Puff on ostomy powder – (do not use unless needed) • Cover with ointment that is heavier barrier ointment

QUESTIONS

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