Managing Fecal Incontinence: SELF-CARE PRACTICES OF OLDER ADULTS

Dietary Intake and Symptom Severity in Women with Fecal Incontinence

INTRODUCTION AND HYPOTHESIS

The goal of this study was to determine whether dietary fat/fiber intake was associated with fecal incontinence (FI) severity.

METHODS

Planned supplemental analysis of a randomized clinical trial evaluating the impact of 12-week treatment with percutaneous tibial nerve stimulation versus sham in reducing FI severity in women. All subjects completed a food screener questionnaire at baseline. FI severity was measured using the seven-item validated St. Mark's (Vaizey) FI severity scale. Participants also completed a 7-day bowel diary capturing the number of FI-free days, FI events, and bowel movements per week. Spearman's correlations were calculated between dietary, St. Mark's score, and bowel diary measures.

RESULTS

One hundred and eighty-six women were included in this analysis. Mean calories from fats were 32% (interquartile range [IQR] 30-35%). Mean dietary fiber intake was 13.9 ± 4.3 g. The percentage of calories from fats was at the higher end of recommended values, whereas fiber intake was lower than recommended for adult women (recommended values: calories from fat 20-35% and 22-28 g of fiber/day). There was no correlation between St. Mark's score and fat intake (r = 0.11, p = 0.14) or dietary fiber intake (r = -0.01, p = 0.90). There was a weak negative correlation between the number of FI-free days and total fat intake (r = -0.20, p = 0.008). Other correlations between dietary fat/fiber intake and bowel diary measures were negligible or nonsignificant.

CONCLUSION

Overall, in women with moderate to severe FI, there was no association between FI severity and dietary fat/fiber intake. Weak associations between FI frequency and fat intake may suggest a role for dietary assessment in the evaluation of women with FI.

Diet Intake After Diet Modification Intervention in Women With Fecal Incontinence

IMPORTANCE

Older women with fecal incontinence (FI) who underwent diet modification intervention (DMI) showed significant improvement in FI symptoms. It is unclear whether improvement in symptoms was associated with objective changes in dietary intake quality.

OBJECTIVES

The primary aim was to determine if improvement in overall dietary intake quality was associated with improvement in FI symptoms. Our secondary aim was to evaluate whether individual food group consumption changes were associated with changes in FI symptoms.

STUDY DESIGN

This was an ancillary analysis of a prospective cohort study of women aged 65 years and older with FI who underwent DMI. Seven-day diet-and-bowel diaries at baseline and 6 weeks after DMI were examined for how frequently participants consumed food categories and FI triggers. Adherence to recommended dietary guidelines was assessed between 2 and 4 weeks using a 24-hour diet recall. Baseline and postintervention consumption were compared using the Wilcoxon signed rank test. Spearman correlation was used to compare dietary intake changes with FI symptom changes.

RESULTS

Twenty-four women completed the 24-hour diet recalls, and 17 women completed the 7-day diet-and-bowel diaries at baseline and 6 weeks. More participants who were adherent had clinically significant improvement in symptoms compared with those who were not adherent (70% vs 30%, P=0.57). Decreased consumption of saturated fats (P=0.01) and fried foods (P<0.001) was associated with improvement in FI symptoms.

CONCLUSIONS

In this small population, overall dietary intake quality was not associated with change in FI symptom improvement. Decreased intake of saturated fat and fried food was associated with FI symptom improvement.

Men and women experience different barriers to care seeking for fecal incontinence

BACKGROUND

Despite effective treatments for fecal incontinence (FI), FI remains underdiagnosed and undertreated. This study sought to characterize and compare rates of, delays in, experiences with, and barriers to care seeking for FI among men and women.

METHODS

This study was a secondary analysis of electronic survey data collected from adults with FI. The survey included the use of a validated instrument to assess FI severity and questions that now comprise a validated instrument for assessing barriers to care seeking for FI in women. Descriptive analyses characterized differences between men and women. χ2 testing for categorical variables and t-testing for normally distributed continuous variables compared statistical differences.

RESULTS

The sample (N = 548) was predominately female (84%), non-Hispanic White (90%), and insured (96%), with a mean Vaizey score (13.4 ± 5.3) consistent with moderate or severe FI. Care seeking rates (p = 0.81) and symptom duration before care seeking (p = 0.23) did not differ between women and men, but women were more likely than men to be told that effective treatments exist; most male and female respondents who sought care were offered treatment. Very few respondents had been asked about FI by a healthcare provider. Whereas normative thinking, limited life impact, and believing that a healthcare provider could not help were more common barriers to care seeking among men, avoidance, fear, and discouragement were more common in women.

CONCLUSIONS

Men and women with FI seek care at similar rates and after experiencing symptoms for a similar duration of time. Very few patients with FI have been screened for it by a healthcare provider. Barriers to FI care seeking are different for women and men, and men are less likely than women to be informed about effective treatments by a healthcare provider.

Is Fluid Intake Associated With Fecal Incontinence in Women?

OBJECTIVE

The primary aim of this study was to determine if fecal incontinence (FI) is associated with self-reported fluid intake in women seeking care for pelvic floor disorders. The secondary aim was to determine the association between bowel symptoms and fluids associated with FI.

METHODS

We conducted a retrospective cross-sectional study of women presenting for evaluation of pelvic floor disorders from 2009 to 2015. The presence of FI was defined as an affirmative response of any frequency to the question, "During the last 4 weeks, how often have you leaked or soiled yourself with stool?" Data on fluid intake and bowel symptoms were collected using the Questionnaire-based Voiding Diary and Colorectal-Anal Distress Inventory short form, respectively. The relationship between FI and quartiles of fluid intake, as well as the relationship between bowel symptoms and fluids associated with FI, was analyzed.

RESULTS

Nine hundred twenty-four women were included: 379 (41%) with and 545 (59%) without FI. There was an association between FI and increasing total carbonated fluid intake (P = 0.009) and decreasing water intake (P = 0.009). The associations between FI and carbonated fluid intake and FI and water intake remained significant after controlling for patient characteristics (P < 0.05). There was a significant association between the symptom of straining to defecate and carbonated beverage intake (P = 0.046), which remained significant after controlling for patient characteristics (P < 0.001).

CONCLUSIONS

Consumption of carbonated beverages is associated with FI in women. Intake of carbonated fluids is associated with bowel symptoms that may exacerbate FI symptoms.

Self-management of accidental bowel leakage and interest in a supportive m-Health app among women

INTRODUCTION

Self-management with clinician guidance is a cornerstone of successful conservative treatment for accidental bowel leakage (ABL). There are currently few resources to assist patients with that essential self-management. The purpose of this study was to describe self-management of ABL and explore interest in a mobile health application (m-Health app) for supporting ABL self-management among community-living women.

METHODS

Using an observational/descriptive design, women (18+ years) previously seen in a urogynecology clinic for ABL were mailed a survey containing eight multiple-choice questions and an open-ended prompt for comments.

RESULTS

Survey responses were received from 161 women (18% response rate). The highest percentage of participants was aged 61-70 years (39%). Nearly half of the participants (47%) "did not know anything" about ABL self-management before visiting a clinician. Only 4% "knew a lot." Of those who have been trying to self-manage their ABL (n = 132), 37% reported that it was not effective, and only 5% thought their self-management was "very effective." Half (50%) of the participants had "a lot of" interest in an m-Health app to support managing ABL, and 30% had "some" interest. The vast majority (89%) thought that it was "very important" to have ongoing guidance and support for self-managing ABL.

CONCLUSIONS

Before visiting a clinician, most women with ABL lacked knowledge about ABL self-management, and their self-management was not very effective. Women thought having guidance to self-manage ABL was important. There would be good interest among women in an m-Health app supporting self-management of ABL if one were created.

The anatomy of Trans-Obturator Posterior Anal Sling (TOPAS) and dynamics of potential mechanism of action

BACKGROUND

The aim of this study was to investigate the course of the transobturator posterior anal sling and its relationship to anatomical structures.

METHODS

The transobturator anal sling procedure was performed in four fresh-frozen pelvises. The pelvises were dissected and the structures adjacent to the sling and the course of the sling were identified and measurements obtained.

RESULTS

The transobturator posterior anal sling was inserted 2 ± 0.5 cm posteriorly to the anus, and 2.5 ± 0.5 cm caudal to the coccyx under the levator plate at the level of the puborectalis muscle. The tape was 3.5 ± 0.5 cm from the pubic symphysis and 2.3 ± 0.3 cm from the obturator canal at entry into the pelvic cavity. The tape passed 2.3 ± 0.3 cm inferior-medial to the obturator canal. At entry, the sling passed lateral to the ischiopubic ramus through the following structures: gracilis, adductor brevis, obturator externus, obturator membrane, and beneath the obturator internus muscle. The sling traveled 2-3 ± 0.5 cm over the iliococcygeus muscle and perforated the iliococcygeus fibers 0-2 cm medial to arcus tendinous levator ani. The posterior division of the obturator nerve was 2.8 ± 0.7 cm from the tape. The anterior division of the obturator nerve was 3.4 ± 0.8 cm from the tape. The device passed 1.1 ± 0.4 cm from the most medial branch of the obturator vessels.

CONCLUSIONS

The transobturator posterior anal sling travels mostly in the avascular area of the ischiorectal fossa and posterior to the puborectalis muscle as intended.

Fecal Incontinence Symptoms and Impact in Older Versus Younger Women Seeking Care

BACKGROUND

The differential impact of aging on fecal incontinence symptom severity and condition-specific quality of life remains unclear.

OBJECTIVE

The purpose of this study was to characterize differences in symptom distress, quality of life, and anorectal physiology assessments in older versus younger women with fecal incontinence.

DESIGN

This was a cross-sectional study.

SETTINGS

This study was conducted at a tertiary genitorectal disorder clinic.

PATIENTS

Women presenting for fecal incontinence evaluation between 2003 and 2016 were classified as older or younger based on age ≥65 or <65 years.

MAIN OUTCOME MEASURES

The main outcomes were symptom-specific quality of life and distress measured by validated questionnaires (the Modified Manchester Health Questionnaire containing the Fecal Incontinence Severity Index); anorectal physiology and anatomy were assessed by manometry and endoanal ultrasound.

RESULTS

Of 879 subjects, 286 and 593 were classified as older and younger (mean ages, 71.4 ± 5.3 y and 51.3 ± 10.5 y). Solid stool leakage was more frequent in older women (83.2% vs 76.7%; p = 0.03), whereas liquid stool leakage (83.2% vs 82.8%; p = 0.88) and fecal urgency (76.9% vs 78.8%; p = 0.54) did not differ between groups. Mean symptom severity scores were similar between groups (28.0 ± 11.9 and 27.6 ± 13.5; p = 0.69); however, there was greater negative impact on quality of life among younger women (46.3 ± 22.0 vs 51.8 ± 21.8; p < 0.01). Multivariable linear regression controlling for pertinent covariates revealed younger age as an independent predictor for worse condition-specific quality-of-life scores (p < 0.01). Squeeze pressures were similar between groups, whereas younger women had greater resting pressures and higher rates of sphincter defects (external, 7.7% vs 20.2%; internal, 12.2% vs 26.8%; both p < 0.01).

LIMITATIONS

This study was limited by its lack of patient obstetric history and the duration of their incontinence symptoms.

CONCLUSIONS

Characteristics differ between older and younger women seeking care for fecal incontinence. The differential impact and age-related phenotypes may provide useful information for patient counseling and developing management algorithms for women with fecal incontinence. See Video Abstract at http://links.lww.com/DCR/A910.

Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence

BACKGROUND

Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes.

OBJECTIVE

To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes.

DESIGN

A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders.

DATA SOURCES

The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register.

RESULTS

The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population.

LIMITATIONS

The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids.

CONCLUSIONS

This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful.

FUTURE WORK

Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014009902.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A prospective "bottom up" study of the costs of faecal incontinence in ambulatory patients

BACKGROUND AND AIM

The few studies that have examined direct costs of faecal incontinence are limited in that they employed retrospective databases, postal surveys, and focused upon institutionalised patients or post partum women. The aim of the current study was to identify the direct pre-treatment costs of faecal incontinence expended by a range of home dwelling patients and identify relationships between costs and severity of incontinence.

METHODS

Consecutive patients attending an outpatient clinic for treatment of faecal incontinence were interviewed using a questionnaire, modeled on the Dowel Bryant Incontinence Cost Index. The information collected included costs of: (i) basic personal hygiene: pads, laundry, wipes, cleansers; (ii) medication: loperamide, creams and stool bulking agents; and (iii) diagnostic: medical attendance, anorectal physiology, colonoscopy. Costs were broken down into personal expenses, government costs, and costs to health funds. A St Mark's Faecal Incontinence Severity Score was recorded.

RESULTS

A total of 100 consecutive patients consented (15 males, 85 females) mean age 70.8 (SD12) years. Mean St Mark's score was 12 (SD4.5). The median total patient cost was $437.72 AUD (range 0-2807) per annum. Government costs were $537AUD (range 135-1657), and health fund median $0 AUD (0-1628). Incontinence severity correlated with personal expense only median $283.75AUD (range 0-2350). The aged were more incontinent but costs did not increase in relation to age.

CONCLUSION

Faecal incontinence results in a substantial financial burden for both patients and Government. Effective treatments which relieve the financial burden of faecal incontinence, are likely to be economically advantageous into the future for both patients and Government.

Living with constipation--older people's experiences and strategies with constipation before and during hospitalization

BACKGROUND

Constipation is a common problem among older people. This study aimed to explore how older patients experience constipation and which strategies they used in handling the condition before and during hospitalization.

METHODS

A qualitative exploratory research design was used. Fourteen semi-structured interviews were conducted with patients (61-91 years of age) during hospitalization. Data were analyzed by using content analysis.

RESULTS

Themes concerning experiences were Bodily signs and symptoms of constipation; the participants described severe pain during constipation, as well as pronounced relief after bowel movements, Impact on well-being and social activities; being constipated negatively impacted their mood and limited social activities, Striving for bowel balance; the participants experienced an ongoing strive for balancing between constipation and diarrhea. Themes related to strategies were Struggling to find a solution; they were aware of different strategies to prevent and treat constipation, though the most common solution described was the use of laxatives, Wait and see; the participants were awaiting to take action until they experienced constipation symptoms, Constipation is a private problem being challenged during hospitalization; constipation was considered a private issue rarely discussed with health-care professionals.

CONCLUSION

This study illuminates the need for health-care professionals to be attentive to this issue and initiate the conversation with patients in order to advise on the management of constipation.

Role of diet in fecal incontinence: a systematic review of the literature

INTRODUCTION AND HYPOTHESIS

The objective was to perform a systematic review of the literature to examine original research on the role of diet in fecal incontinence (FI) with a dual focus on dietary differences in FI and dietary treatments for FI.

METHODS

We searched the PubMed and Embase databases for any peer-reviewed original research in English on the role of diet in FI.

RESULTS

We identified 172 unique citations. After title review and exclusion of articles not reporting original research, 9 publications were included in the final review: 4 focused on dietary differences and 5 focused on dietary treatments for FI. Limited evidence indicates that macro- and micronutrient intake does not differ significantly in those with and without FI. However, certain foods were perceived to improve or exacerbate FI symptoms and these varied and were adjusted as part of self-care practices. A high-fiber diet may reduce incontinence frequency.

CONCLUSIONS

Data on the pathogenesis of FI from a dietary perspective are scant. Based on the limited data, dietary differences between those with and without FI provide little insight with the exception of fiber. Further studies are needed to elucidate treatments for FI using fiber and dietary modifications.

The design and initial patient evaluation of an integrated care pathway for faecal incontinence: a qualitative study

BACKGROUND

Faecal incontinence is a common, distressing and debilitating condition which remains largely hidden, leading to social isolation and loss of confidence. Patients with faecal incontinence experience delays in accessing appropriate treatment services due to embarrassment and lack of enquiry from primary care health professionals. Despite the publication of three government documents related to continence services in the last decade, these services are still fragmented with asynchronous delivery and poor inter-professional integration. The aim of the study was to describe a novel integrated care pathway for the management of faecal incontinence and examine the experiences of patients with faecal incontinence in relation to this pathway.

METHODS

A focus group (eight participants) and narrative, qualitative individual interviews (five participants) were used to explore the views of patients with faecal incontinence, relating to access and quality of incontinence services and the new integrated care pathway. Emerging themes were identified from the transcribed focus group and interviews via the thematic analysis method.

RESULTS

The concept of an integrated care pathway is attractive for increasing accessibility, streamlining of the patient pathway and providing a dedicated service for the management of faecal incontinence. Patients' initial experiences of the pathway are positive.

DISCUSSION

A new ICP was developed and the initial patient evaluation of it was positive. Service users made various suggestions how the FI pathway could have been improved. The issues that patients were most concerned about were access to continence services, GP awareness of continence services and prompt, effective management of their condition. This service was set up within the pelvic floor dysfunction unit with BFNS and an integrated community continence team. The authors are aware that this is not a standard service setup across the country. The fact that it may be uncomfortable for patients to talk about their condition may have led to potential bias when discussing their beliefs or experiences. As with most qualitative studies, our aim was to identify a range of experiences rather than define our participant sample as being representative. Our participant sample was diverse in the key characteristics but a longitudinal study may reveal further important aspects of an ICP for FI.

CONCLUSIONS

An integrated care pathway for faecal incontinence appears to have potential to address the long-standing service delivery issues that have blighted continence services historically.

Conservative treatment for anal incontinence

Anal incontinence (AI) in adults is a troublesome condition that negatively impacts upon quality of life and results in significant embarrassment and social isolation. The conservative management of AI is the first step and targets symptomatic relief. The reported significant improvement with conservative treatments for AI is close to 25% and involves prescribed changes in lifestyle habits, a reduced intake of foods that may cause or aggravate diarrhea or rectal urgency, and the use of specific anti-diarrheal agents. The use of a mechanical barrier in the form of an anal plug and the outcomes and principles of pelvic kinesitherapies and biofeedback options are outlined. This review discusses a gastroenterologist's approach towards conservative therapy in patients referred with anal incontinence.

Geriatric gynecology: promoting health and avoiding harm

Age increases vulnerability, commonly accompanied by greater reliance on others and susceptibility to maltreatment. Physiologic processes become less resilient; the potential for harm from medical care increases. Awareness of frailty, functional, social, and potential maltreatment issues enables early referrals to help the patient maintain her independence. Health issues that may impede both gynecologic care and self-sufficiency include sensory deficits, physical disability, and cognitive impairment. Speaking slowly and providing contextual information enhance patient comprehension. Cancer screening depends on life expectancy. Osteoporosis treatment requires managing fall risk. Gynecologic symptoms more likely have multiple contributing factors than one etiology. Incontinence is a particularly complex issue, but invariably includes bladder diary assessment and pelvic floor muscle training. Function and frailty measures best predict perioperative morbidity. Communication with the patient, her family, other providers, and health care organizations is an important frontier in avoiding errors and adverse outcomes.

Self-care strategies for the management of bowel symptoms following sphincter-saving surgery for rectal cancer

The primary aim of this article is to identify the self-care strategies that patients use to manage bowel symptoms experienced following sphincter-saving surgery for rectal cancer. Comparisons will be made with self-care strategies used by patients to manage chronic fecal incontinence and the bowel symptoms associated with other chronic bowel diseases, such as irritable bowel syndrome and inflammatory bowel disease. Published studies and conceptual literature from 2000-2010 were the data sources. Three major themes emerged from the literature reflecting the self-care strategies used by patients to manage bowel symptoms: functional self-care strategies (e.g., taking medication), social activity-related self-care strategies (e.g., planning social events), and alternative self-care strategies (e.g., complementary therapies). An analysis of studies highlighted that, through the process of trial and error, patients learned the strategies that were most effective in the management of their bowel symptoms. Knowledge of such strategies will be beneficial to healthcare professionals when educating patients about effective management of bowel symptoms following sphincter-saving surgery.

Use and evaluation of disposable absorbent products for managing fecal incontinence by community-living people

PURPOSE

The use of disposable absorbent products by community-dwelling people with fecal incontinence (FI) was described.

METHODS

A survey was administered to 189 community-living individuals with FI at the start of a clinical trial about the effects of dietary fiber on FI.

RESULTS

Forty-five percent of respondents (86/189) used an absorbent product to manage FI. More women (88%, 76/86, P = .009) and persons aged 65 years and older (44%, 38/86, P = .001) wore an absorbent product. Participants who wore an absorbent product for FI had a higher (worse) FI severity score (median, 4.75; range, 1-27; P = .006). Sixty-three users wore pantiliners and they were the only ones who used more than 3 products per day. Feminine hygiene products were worn more than incontinence products. Half of users were satisfied with the product they used. Evaluations of product features differed by type of product; odor control had some of the lowest ratings.

CONCLUSIONS

Community-living individuals with FI, especially women and older individuals, tend to wear absorbent products. Perceptions of FI severity, preference, leakage of liquid stool, and presence of urinary incontinence influence the product type and pattern of wear. Participants report that modification of several features of absorbent products might make them more suitable for FI and increase satisfaction.

Diet and eating pattern modifications used by community-living adults to manage their fecal incontinence

PURPOSE

The study aimed to describe modifications in diet and eating patterns made by community-living people to manage fecal incontinence (FI), and to compare these differences according to sex, age, and FI severity.

SUBJECTS AND SETTINGS

Subjects were 188 community-living adults (77% female, 92% white, 34% aged 65 years or older) in the upper Midwest who participated in a study about managing FI with dietary fiber.

METHODS

Subjects were interviewed about diet and eating pattern changes that they made to manage FI, and self-reported demographic data. FI severity was recorded daily.

RESULTS

Fifty-five percent of participants perceived that some foods worsen their FI (eg, fatty or spicy foods and dairy products). More women than men (40% vs 18%, P = .008) reported avoiding foods to manage FI. A greater percentage of younger than older people believed that fatty/greasy foods (15% vs 4%) and alcohol (14% vs 3%) worsened their FI. Subjects with a higher FI severity score appeared to wait until FI was more severe before restricting caffeine than those with lower severity scores (22.2 ± 9.8 vs 11.69 ± 8.3, P = .034). One-third of subjects consumed foods rich in dietary fiber to prevent FI. Subjects also reported altered eating or cooking patterns, skipping meals, or eating at consistent times to manage FI.

CONCLUSIONS

Diet modification for managing FI incorporates restriction of some foods, along with adding others foods to the diet. Nursing assessments of self-care practices for FI should include diet and eating pattern changes when developing a plan of care.

Goals of fecal incontinence management identified by community-living incontinent adults

The purpose of this study was to identify goals of fecal incontinence (FI) management and their importance to community-living adults if complete continence would not be possible. Participants expressed their goals of FI management in a semistructured interview, selected others from 12 investigator-identified goals, and rated their importance. Five thematic categories emerged from the 114 participant-identified goal statements: Fecal Incontinence/Bowel Pattern, Lifestyle, Emotional Responses, Adverse Effects of Fecal Incontinence, and Self-Care Practices. Participants selected a median of seven investigator-identified goals (range = 2 to 12). Goals selected by the most participants were decreased number of leaks of stool and greater confidence in controlling fecal incontinence. These goals also had the highest importance along with decreased leakage of loose or liquid stool. The type and number of management goals identified by participants offer a toolbox of options from which to focus therapy when cure is not possible and promote patient satisfaction.

Raising awareness about fecal incontinence

There is a lack of awareness about fecal incontinence despite its prevalence and adverse impact on quality of life. Inadequate knowledge about fecal incontinence deters help-seeking, therapeutic consultation, and clinical research about effective prevention and management strategies. A systematic, evidenced-based approach to raise awareness of fecal incontinence is essential to forward progress and overcome multiple barriers. In this manuscript, strategies of this approach are prioritized and focus on increasing continence literacy and communication, emphasizing prevention and screening, disseminating evidenced-based management interventions, and promoting larger scale impact through effective partnerships.

Comparing community and specialty provider-based recruitment in a randomized clinical trial: clinical trial in fecal incontinence

Recruitment of participants to clinical trials remains a significant challenge, especially for research addressing topics of a sensitive nature such as fecal incontinence (FI). In the Fiber Study, a randomized controlled trial on symptom management for FI, we successfully enrolled 189 community-living adults through collaborations with specialty-based and community-based settings, each employing methods tailored to the organizational characteristics of their site. Results show that using the two settings increased racial and ethnic diversity of the sample and inclusion of informal caregivers. There were no differential effects on enrollment, final eligibility, or completion of protocol by site. Strategic collaborations with complementary sites can achieve sample recruitment goals for clinical trials on topics that are sensitive or known to be underreported.

Health literacy and emotional responses related to fecal incontinence

PURPOSE

The primary purpose of this study was to examine continence literacy of individuals with fecal incontinence (FI) by identifying terms they used to refer to FI and to explore their emotional responses to FI. A secondary aim was to compare differences based on gender and age in younger (<65 years) versus older persons (>65 years) with FI.

DESIGN

Secondary analysis of data collected prospectively in a clinical trial of fiber supplementation for FI.

METHODS

Content analysis of participants' statements reported in field notes of data collectors and their responses to data forms and questions.

RESULTS

Only one participant used the term fecal incontinence to describe FI. Alternate terms described stool characteristics, named other gastrointestinal problems, or respondents referred to FI, using a term that seemed to depersonalize the problem. Emotional responses to FI focused on the influence of bothersome symptoms, interference with social activities, and need for control. Some participants used humor to cope with FI and reported emotional benefits gained through participation in a study. Women were impacted by the social limitations of having FI more than men. Younger people were more likely to express feelings of emotional upset than were older respondents.

CONCLUSION

There is a need to increase health literacy about FI. WOC nurses are well qualified to educate patients about FI and to evaluate if higher continence literacy increases reporting of FI. Understanding the various emotional responses to FI may guide the optimal support that WOC nurses can provide and facilitate better management of FI.

Management of fecal incontinence in adults

This article summarises the findings from the Conservative Management of Faecal Incontinence in Adults Committee of the International Consultation on Incontinence. We conducted comprehensive literature searches using the following keywords combined with the relevant intervention: "anal, anorectal, bowel, faecal, fecal, rectal, stool" and "continent$ or incontinent$," Prevalence etimates for faecal or anal incontinence vary widely, from 2.2% to 2.5%. Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification, but the evidence base is small. Unlike urinary incontinence, few "lifestyle" associations have been identified with FI and little is known about whether interventions designed to reduce potential risk factors might improve FI. The article summarises the evidence and recommendations from the committee for clinical practice and future research.

Pelvic floor consequences of cesarean delivery on maternal request in women with a single birth: a cost-effectiveness analysis

BACKGROUND

The potential benefit in preventing pelvic floor disorders (PFDs) is a frequently cited reason for requesting or performing cesarean delivery on maternal request (CDMR). However, for primigravid women without medical/obstetric indications, the lifetime cost-effectiveness of CDMR remains unknown, particularly with regard to lifelong pelvic floor consequences. Our objective was to assess the cost-effectiveness of CDMR in comparison to trial of labor (TOL) for primigravid women without medical/obstetric indications with a single childbirth over their lifetime, while explicitly accounting for the management of PFD throughout the lifetime.

METHODS

We used Monte Carlo simulation of a decision model containing 249 chance events and 101 parameters depicting lifelong maternal and neonatal outcomes in the following domains: actual mode of delivery, emergency hysterectomy, transient maternal morbidity and mortality, perinatal morbidity and mortality, and the lifelong management of PFDs. Parameter estimates were obtained from published literature. The analysis was conducted from a societal perspective. All costs and quality-adjusted life-years (QALYs) were discounted to the present value at childbirth.

RESULTS

The estimated mean cost and QALYs were $14,259 (95% confidence interval [CI] $8,964-$24,002) and 58.21 (95% CI 57.43-58.67) for CDMR and $13,283 (95% CI $7,861-$23,829) and 57.87 (95% CI 56.97-58.46) for TOL over the combined lifetime of the mother and the child. Parameters related to PFDs play an important role in determining cost and quality of life.

CONCLUSIONS

When a woman without medical/obstetric indications has only one childbirth in her lifetime, cost-effectiveness analysis does not reveal a clearly preferable mode of delivery.

Faecal incontinence in older people

Faecal incontinence in older people is a distressing and socially isolating symptom and increases the risk of morbidity, mortality and dependency. Many older individuals with faecal incontinence will not volunteer the problem to their general practitioner or nurse and, regrettably, health care providers do not routinely enquire about the symptom. Even when older people are noted by health care professionals to have faecal incontinence, the condition is often managed passively, especially in the long-term care setting where it is most prevalent. The importance of identifying treatable causes of faecal incontinence in older people, rather than just managing passively, is strongly emphasized in national and international guidance, but audit shows that adherence to such guidance is generally poor. This article describes epidemiology, causes, assessment, diagnosis and treatment of faecal incontinence in older people.

Comparison of recall and daily self-report of fecal incontinence severity

PURPOSE

Fecal incontinence (FI) severity is determined by self-report, and most tools rely on recall of symptoms. This study examined whether recall of FI severity differed from daily reports on a diary and the factors influencing any difference. INSTRUMENTS AND DESIGN: Data of 96 participants (mean age 59 years, 78% female) reported on 3 data collection forms (a demographics form, a bowel history, and a stool diary) were analyzed. Data collected during an initial bowel history when participants reported FI severity using recall were compared to similar data participants recorded on a 14-day daily stool diary during a baseline period of a study investigating the effects of different types of dietary fiber on FI.

RESULTS

The total FI severity score from the daily stool diary (median 5.0, range 1.2-15.5; P = .04) was significantly higher (worse FI) than the recalled bowel history (median 3.0, range 0.36-27.5). A higher, more positive difference in scores between recall and daily diary reporting indicated greater underreporting on recall. Caregivers underreported FI severity on recall compared to noncaregivers (P = .003).

CONCLUSIONS

Reasons for underreporting FI are probably multifactorial; findings suggest that being a caregiver and having double incontinence are contributing factors. Clinicians should inquire about FI with a discerning yet sensitive approach. Use of a daily stool diary is recommended in research and may be useful in practice.

Fecal incontinence and biofeedback therapy

Biofeedback as delivered in most clinical settings in Western medicine has been consistently reported to improve symptoms of fecal incontinence. Closer scrutiny of the elements of the intervention and controlled studies, however, have consistently failed to find any benefit of the biofeedback element of this complex package of care; nor has any superiority been found for one modality over another. There is a need for further well-designed and adequately powered randomized controlled trials. Meanwhile, there can be little doubt that conservative interventions improve many patients with fecal incontinence to the point where most report satisfaction with treatment and do not wish to consider more invasive options, such as surgery.

Use of an absorbent dressing specifically for fecal incontinence

PURPOSE

Use of an absorbent product is a self-care strategy for managing fecal incontinence that protects against visible soiling. The purpose of this study was to examine use of a small surgical dressing that can be placed between the buttocks to absorb leaked feces.

DESIGN

Cross-sectional survey.

SUBJECTS AND SETTING

A survey was mailed to 75 randomly selected community-living people in 25 states and the District of Columbia, who ordered the dressing more than once within the past year. Thirty-six people (age = 55 +/- 16 years mean +/- SD), 57% men and 94% white responded.

INSTRUMENT

A 48-question survey that included questions asked about demographics and general health, emotional states (eg, anxiety and depression), bowel pattern and incontinence, quality of life, and use of an anorectal dressing was developed for this study. The survey also contained 2 tools, the Fecal Incontinence Severity Index and the Fecal Incontinence Quality of Life instrument. The Fecal Incontinence Severity Index is a tool that enables valid assessment of fecal incontinence severity using patient recall of symptoms of frequency and type of bowel leakage. The Fecal Incontinence Quality of Life instrument results in a valid and reliable evaluation of fecal incontinence-specific quality of life using 4 domains of lifestyle, coping/behavior, depression/self-perception, and embarrassment.

RESULTS

The fecal incontinence severity score was 28 +/- 14 (mean +/- SD); 79% leaked loose/liquid feces, 50% leaked daily, and leaked feces remained between the buttocks in 64%; 21% also leaked urine. Eighty-five percent experienced incontinence-associated dermatitis. Of those who used the dressing, 50% were men. The anorectal dressing was preferred to a pad by 92%, prevented soiling in 88%, and its ability to stay in place was rated very good or good by 76%. Eighty percent of respondents rated the dressing's comfort very good or good; 85% rated its overall effectiveness very good or good. Use of the dressing lessened anxiety about fecal soiling in 81% and was thought to improve quality of life in 76%.

CONCLUSION

An anorectal dressing offers an effective, comfortable alternative to a pad for absorbing leaked feces that seems acceptable to men.

The experience of community-living women managing fecal incontinence

Although many women suffer from fecal incontinence (FI), little is known about their day-to-day experiences. The aims of this phenomenological study were to understand the experience of women living with FI from their perspective and to elicit women's self-care and management strategies for FI. Ten women participated in audiotaped, unstructured interviews that were transcribed into a written text. The text was analyzed using Van Manen's approach for deriving themes. The findings display the women's experience of lived time, lived space, lived relationships, and lived body and the essential theme of "controlling the body out of control." The findings demonstrate that FI is a problem that affects women in all dimensions of their lifeworld experience and describes the continual attention and self-management FI requires.

Pharmacotherapy for fecal incontinence: a review

Fecal incontinence is a common clinical problem that often is frustrating to the patient and treating physician. Nonsurgical management for fecal incontinence includes dietary manipulation, Kegel exercises, perianal skin care, and biofeedback therapy. Pharmacotherapies often are used to assist in management of fecal incontinence. A variety of pharmacotherapies have been utilized for the management of fecal incontinence; limited data from randomized, placebo-controlled trials are available. This is a review of the existing literature on clinical trials of several classes of drugs and other medical therapies that may be beneficial for patients with fecal incontinence. The information in this article was obtained by a MEDLINE search for all clinical trials of drug therapy for fecal incontinence. These treatments and the existing data on their use are summarized. Treatments reviewed include stool bulking agents, with an emphasis on the most promising effect obtained with calcium polycarbophil, constipating agents, including loperamide, codeine, amitriptyline, atropine, and diphenoxylate agents injected into the anal sphincter, drugs to enhance anal sphincter function, including topical phenylepherine and oral sodium valproate, and trials of fecal disimpaction. A new classification to easily remember the treatment categories for this condition, based on the "ABCs of treatment for fecal incontinence," has been introduced into the structure of this review.

Community-based recruitment and enrollment for a clinical trial on the sensitive issue of fecal incontinence: the Fiber study

The recruitment of community-living participants for clinical trials of sensitive topics, when the population is largely hidden and reluctant to self-identify, and the study protocols and procedures intensive, creates significant challenges to researchers. The Fiber Study is an ongoing randomized controlled clinical trial conducted to compare the effectiveness of three dietary fibers with different levels of fermentability for symptom management in community-living adults with fecal incontinence. The researchers developed a staged approach to recruitment using three primary recruitment methods and a three-phase approach to the enrollment process. We have been successful in reaching, recruiting, and enrolling participants in a clinical trial, as well as in effectively managing study resources and staff time.