Clinical evaluation of faecal
incontinence and constipation
By courtesy of
Christine Norton PhD MA RN
Nurse Consultant (Bowel Control) &
Professor of Gastrointestinal Nursing
St Mark’s Hospital & Kings College
London, United Kingdom
Assessment – the evidence
• No evidence-based assessment protocols
• Informed opinion: history and physical
examination most important
• Clinicians often fail to examine
• Physical environment and carers may be
most important factor for immobile people
What tests are needed?
• Comprehensive history
(Norton & Chelvanayagam, 2000)
• Diary & symptom questionnaire
• Physical examination
• If bowel investigation needed:
colonoscopy
• Anorectal physiology tests?
• Anal ultrasound?
• If indicated: proctogram, bloods
What goes wrong?
• Anal sphincter (childbirth, injury, iatrogenic
damage, degeneration)
Internal anal sphincter - passive soiling
External anal sphincter - urge incontinence
• Gut motility (infection, inflammation,
radiation, hypermotility, emotions)
• Stool consistency (diet, motility, anxiety)
• Local pathology (prolapse, piles, fistula)
• Neurological damage (motor or sensory)
• Lifestyle, toilets, drugs,immobility…
History
• Pre-morbid and current bowel symptoms
• Timing of onset, is it worsening?
• Faecal incontinence:
• Urgency = loose stool or EAS problems
• Passive loss = IAS problems or incomplete
evacuation
• Constipation:
• Slow transit or evacuation difficulty (or both)?
History
• Co-morbidities and general health
• Diet (amount, type and pattern)
• Fluids (amount, type and pattern)
• Toileting abilities, mobility, carers and toilet
facilities
• Medications
• Lifestyle & psychosocial support
• Depression and anxiety
• Stool form can give
clues as to pathology
• Loose stool more
difficult to control
• Hard stool suggests
evacuation difficulty
• Must ask about
bleeding (bowel
cancer second
commonest cancer in
UK) - refer to rectal
bleeding clinic
• Do not assume
bleeding is piles
• One week diary gives
a baseline
• Tick in shaded column
when open bowels in
toilet
• Tick in white column
for incontinence or
pad change
• More complex diaries
may be needed for
special groups
Physical examination
• Abdomen (masses, bladder)
• Anal inspection (soiling, prolapse,
scarring, haemorrhoids, gaping)
• Digital anal (resting tone and squeeze)
• Digital rectal (loading, masses)
• Examine for prolapse on toilet
• Vaginal (rectocele)
Observing the perianal area
• Rectal or vaginal prolapse
• Haemorrhoids or skin tags
• Wounds, lesions, discharge
• Gaping anus
• Skin condition
• Bleeding
• Stool, infestation and foreign bodies
Rectal Prolapse