What Is Faecal Incontinence?
Faecal incontinence (FI) occurs when a person loses the ability to control their anal muscles and bowel movements, resulting in leakage of faeces or gas. If left untreated or mismanaged, FI can lead to severe skin irritation as well as depression, causing affected individuals to withdraw from their families and society.
How Prevalent is FI in Singapore?
The first local prevalence study (conducted by our specialist) published in 2014 showed that approximately 4.7 per cent of the adult population – or some 200,000 individuals – may have this condition.
This is a staggering number, yet it may be an underestimate as the incidence is often even higher among the elderly staying in care facilities like nursing homes. The same study also showed that women are three times more likely to be affected by bowel incontinence, with childbirth-related injuries being the main cause. In fact, those over 50 years old are five times more vulnerable. Men are not spared from the condition.
How Does FI Affect Quality Of Life?
Most sufferers are unaware of the available treatment options, and the resulting negative effects on their overall physical and psychosocial wellbeing are often overlooked. In addition, the accompanying embarrassment and fear of social stigmatization cause the afflicted most of whom are elderly to suffer in silence, setting up a vicious cycle that perpetuates the misinformed notion that faecal incontinence is simply ‘part-and-parcel’ of ageing. Consequently, sufferers are relegated to suboptimal quality of life.
What Are The Risk Factors For FI?
The risk factors for women include instrument-assisted delivery (e.g. forceps and vacuum-assistance), and a prolonged second stage of labour.
Risk factors affecting both genders include anal muscle (sphincter) injuries due to anorectal surgical procedures e.g. for conditions such as haemorrhoids, anal fissures/fistula or colorectal cancer. Radiation treatment for conditions like cervical or prostate cancer can also contribute to faecal incontinence in women and men, respectively.
Other risk factors include surgery for colorectal cancer or benign conditions, in which part of or the entire rectum is removed, and trauma to the lower abdomen or pelvis, such as pelvic fractures after road traffic accidents or penetrating injuries.
Rectal prolapse, a condition commonly seen in the elderly female population, where the rectum/lower large intestine descends due to a loss of strength of supporting tissues, can also present with FI. Occasionally, injuries associated with sexual assault can result in faecal incontinence.
What Are The Available Treatment Options for FI?
FI results from either damage to the muscles directly, or to the nerves supplying these muscles around the anus, or both. After a thorough history taking and examination, specialised tests are performed including anorectal manometry, ultrasound and nerve stimulation tests, to identify the possible site(s) of injury so that treatment can be directed appropriately.
Regardless, the majority of sufferers can benefit from conservative measures such as dietary modification, tailored medical therapy and pelvic floor rehabilitation. Skin care and hygiene is also essential to maintain a good quality of life. However, when the above measures fail, surgery may be the only means of providing adequate relief of symptoms.
The importance of skin care
The mainstay of skin care is to ensure patients are well-nourished, mobile and their skin is kept clean and hydrated. As such, those who are particularly susceptible to skin problems are those who are bed-bound or with reduced mobility, malnourished, with poor dexterity; most commonly the elderly and infirmed. This same at-risk group also has skin that is thinner and produces less natural oils which compromise the protective function of the skin.
The main reasons why skin problems occur with faecal incontinence is that it causes an increase in the skin pH, excessive hydration and increased permeability, leading to increased incidence of skin ulcers and dermatitis or infections. Presence of faeces on the skin can also lead to urine infections, particularly in women where the urinary opening is closer to the anus. The increase in pH is due to the ammonia produced from the breakdown of faecal urease. The resulting high pH of the skin allows the increased activity of the faecal enzymes, which can lead directly to skin damage. Skin occlusion from adjuncts such as incontinence pads can, ironically, also contribute to problems for the same reasons. As such, they must be regularly checked to minimise contact of faeces on the skin. Incidentally, soap is known to strip the skin of sebum, therefore overzealous washing of the skin with excessive amounts of soap renders the skin more at risk. The skin should be washed gently immediately after episodes of faecal incontinence, with small amounts of unperfumed soap ensuring that it is well rinsed. An emollient such as aqueous cream can be used as a soap substitute.