Education Category: Bowel

What is faecal incontinence?

Faecal incontinence is when someone can’t control their bowel motions or wind (flatus, farts) from their anus. People with faecal incontinence aren’t able to hold on when they feel the need to open their bowels, which means they have to get to the toilet as soon as they feel the urge to go.

This sudden need can be severe or involve minor accidents with ‘skid marks’ in their underwear. Incontinence can happen occasionally or every day, and can be difficult to clean up after an accident. Many people with faecal incontinence use a continence pad or pants to contain the bowel motions.

It’s difficult to know exactly how many people have faecal incontinence, but we estimate it to be about five per cent of Australians. It’s more common in older people and people in nursing homes.

Important

People who have a long-term problem with faecal incontinence should see their general practitioner (GP) or other health care professional for further assessment and treatment. Unfortunately, many people find it embarrassing and don’t get medical help, which means they miss out on the many available treatments. If you support someone who has a problem with faecal incontinence, you can be supportive and encourage them to ask for help.

What causes faecal incontinence?

 Common causes of faecal incontinence include:

• damage to the muscles or nerves around the anus when having a baby
• congenital – when babies are born with a bowel or anus problem, such as spina bifida
• long-term constipation, which damages the muscles around the anus
• long-term faecal impaction, where backed-up bowel motions cause the rectum to stretch so the person loses feeling in their anus
• prolapse, when the small or large bowel sags through the anus.
• injury to the anus caused by an accident, surgery, radiotherapy treatment or haemorrhoids.
• bowel diseases, such as irritable bowel syndrome, inflammatory bowel disease, fistulas or fissures
• conditions such as diabetes, multiple sclerosis, spinal cord injury, Parkinson’s disease, stroke and dementia
• some medicines, e.g antibiotics.

Who is at risk of developing faecal incontinence?

• Older people – it’s more common in middle-aged and older adults.
• Women – particularly women who have had a baby.
• People with nerve damage caused by conditions such as diabetes, spinal cord injury or multiple sclerosis.
• People with dementia – it’s common in the later-stages of Alzheimer’s disease.
• People with limited mobility who may struggle to reach the toilet in time.
• People with physical disabilities, such as arthritis, cerebral palsy, upper limb disabilities, multiple sclerosis or muscular distrophy, who may not be able to take off clothing quickly when needed.

How is faecal incontinence treated?

People with faecal incontinence may need to see their GP or other health care professional for further investigation and treatment. The treatment plan may include:

• diet changes to add more healthy food choices
• medicines and ‘bulking agents’ to slow down the large bowel and increase water absorption
• pelvic floor muscle exercises to strengthen the sling of muscles that support the bowel
• surgery to repair or tighten the anus if it’s damaged
• colostomy surgery.

Need more help? Call the National Continence Helpline on 18OO 33 OO 66 and talk to a continence nurse advisor.

Extra Resources

• Looking after your bowel
• Poor bowel control
• Caring for someone with bladder or bowel problems

What are haemorrhoids?

Haemorrhoids (also called piles) are enlarged veins around the anus. They are caused by an increases in pressure around the anus, which results in a swelling of the veins and tissue.

Types of haemorrhoids

Haemorrhoids have different names depending on where they are. Internal haemorrhoids can’t be seen unless they come out when the person is passing a bowel motion. External haemorrhoids are on the outside of the anus. A person can have internal and external haemorrhoids at the same time.

Internal haemorrhoids:

• are inside the rectum so you can’t usually see them
• can squeeze out of the anus when the person passes a bowel motion, but then usually go back in again when they are finished
• usually don’t cause pain
• can bleed, especially when the person is on the toilet.

External haemorrhoids:

• feel like hard lumps under the skin around the anus
• are caused by a stretching of the veins under the skin
• can make it hard to clean properly after passing a bowel motion.

What causes haemorrhoids?

Haemorrhoids can be the result of:

• constipation and straining (pushing) to pass a bowel motion. This is the most common cause.
• pregnancy
• heavy manual work or lifting
• a hereditary (passed on through the family) condition
• sitting on hard surfaces for a long time
• not using the right, or enough, lubricant when inserting enemas and suppositories.

What are the symptoms of haemorrhoids?

Symptoms of haemorrhoids can include:

• bright red blood when passing bowel motions, which can be seen on the toilet paper, in the toilet bowl or in the bowel motion
• itching around the anus
• pain or aching in the anus, especially when sitting down
• autonomic dysreflexia for those with spinal cord injury. For more information go to Autonomic dysreflexia.
• pain when passing bowel motions, if the haemorrhoids are large
• hard lumps around the anus, which might feel sore when touched.

How can haemorrhoids be prevented?

Haemorrhoids can be prevented or stopped from getting worse by some simple lifestyle changes. They include:

• drinking plenty of fluids and eating a high-fibre diet with plenty of cereals, fruit and vegetables. This keeps the bowel motions soft and easier to pass.
• sitting in the right position on the toilet to help pass bowel motions. For more information go to Correct toileting position.
• using lubricant if inserting enemas or suppositories (usually done by a nurse)
• not sitting on the toilet or on hard surfaces for a long time. This can increase the pressure on the anus and can make the veins and tissues swell into haemorrhoids.

Need more help? Call the National Continence Helpline on 18OO 33 OO 66 and talk to a continence nurse advisor.

How does diarrhoea affect a person?

Diarrhoea is when bowel motions are watery, soft or mushy. Sometimes there can also be stomach cramps or pain and a sick feeling. Diarrhoea can cause a person a lot of stress because their bowel motions are hard to hold on to. Many people who have regalar diarrhoea:

• avoid situations where they are not sure where they can find and use toilets quickly
• are at risk of social isolation and depression.

When people with diarrhoea need to leave the house, they usually need to plan their trip carefully. They may need to:

• take spare pads, plastic bags to throw away used pads, washing equipment, and spare clothes and underwear
• wear a continence pad or pants, as well as underwear
• look into where they are going using the National Public Toilet Map so they know where to find toilets
• look for toilets when they first get somewhere so they know where to go if they need to
• avoid public transport, in case they need to quickly get to a toilet.

What causes diarrhoea?

Short-term diarrhoea can be caused by:

• food poisoning, lactose intolerance or infections
• eating too much fruit
• not eating enough fibre
• eating certain foods (especially spicy, greasy or oily foods) or drinks (e.g. too much coffee).

Long-term diarrhoea can be caused by:

• medical conditions, such as bile acid malabsorption, dumping syndrome, irritable bowel syndrome, coeliac disease, Crohn’s disease, ulcerative colitis, hyperthyroidism
• taking too many laxatives
• taking some medicines, such as antibiotics or chemotherapy.

What should you do if a person you support has diarrhoea?

• Start recording the bowel motions on a bowel diary using the Bristol Stool Chart.
• Avoid food and drinks that cause problems – the person may need to visit a dietitian to work this out.
• Increase fibre intake and make sure the person drinks more water.
• Treat their constipation if they are constipated. Constipation sometimes causes an ‘overflow’ of wet bowel motions, which can be like diarrhoea

Important cautions:

• Don’t restrict fluid intake. This won’t help the diarrhoea and may cause dehydration.
• Don’t give the person medicines for their diarrhoea unless a doctor has prescribed it.

What can a health care professional do?

Book an appointment with a health care professional. They can:

• diarrhoea and organise treatment for any medical conditions that are causing the diarrhoea
• treat the diarrhoea, possibly involving some anti-diarrhoea medicines
• adjust other medicines and supplements
• provide pelvic floor muscle training to help strengthen the pelvic floor muscles.

Need more help? Call the National Continence Helpline on 18OO 33 OO 66 and talk to a continence nurse advisor.

Extra Resources

• Caring for someone with bladder or bowel problems
• Poor bowel control
• Looking after your bowel

What is constipation?

Constipation is when a person has bowel motions which are hard to pass, has fewer bowel motions than normal, or has no bowel motions at all.

What is normal?

• The number of times, or time of day, that a person goes to the toilet to pass faeces is different for each person.
• ‘Normal’ can be one to three times a day to three times a week.
• It is important to know what is normal for the person you support. This will help you notice if something changes.

What causes constipation?

There are a lot of reasons why constipation happens including:

• not eating enough fibre (see Healthy Diet and Bowels resource)
• eating too much fibre without drinking enough fluid
• not drinking enough fluids
• not exercising or moving enough
• side effects of some medicines – especially ones used for pain, some mental health conditions or to manage urinary incontinence
• not being able to get to the toilet on their own or quickly enough when they need to
• if the person has a disability, because it can affect:
  • how well they can sit on the toilet or commode
  • how much they can eat of drink.
• some medical conditions such as:
  • nervous system disease e.g. spinal cord injury, spina bifida, multiple sclerosis, or Parkinson’s disease – these can affect how quickly the stool moves through the bowel and how well the rectum can empty
  • bowel disease, e.g. irritable bowel syndrome, haemorrhoids or diverticular disease.
• refusing to sit on the toilet because of:
  • a lack of understanding or fear
  • pain when faeces are passed
  • lack of privacy or embarrassment.
• poor toilet habits:
  • not sitting on the toilet in the right position
  • standing over the toilet seat (hovering) instead of sitting down
  • ignoring or not understanding the urge to go
  • not sitting long enough on the toilet or rushing.

How is constipation treated?

There are a lot of ways to treat and manage constipation. Talk to your supervisor, care coordinator, or a health care professional if you are not sure what to do, or are worried about the person’s health.

Here are some things you could try.

1. Make changes to their diet.

• Make sure the person is eating enough fibre every day.
• Think about getting help from a dietitan to change or make a diet plan.
• Think about getting help from a speech pathologist if the person has trouble chewing or swallowing their food.
• Think about getting help from an occupational therapist if the person has trouble using their hands and can’t cut up food.
• A visit to the dentist may be needed to see if bad teeth are causing pain. This might be why the person isn’t eating enough fibre.

2. Help the person to drink more fluids.

• Monitor how much fluid the person drinks each day. For more information see Fluids.
• If fibre increases in a person’s diet, make sure they have more fluids as well.
• Make sure any meal plans designed for the person are being followed.
• Offer fluids regularly, especially in hot weather (unless the person is on fluid restrictions).
• Give the person fluids that they enjoy, such as their favourite drinks, icecream or frozen fruit drinks.
• Important: always check with a health care professional before giving more fluids to make sure it is safe for the person.

3. Help the person be more active.

• Help or encourage them to walk when possible.
• If someone uses a wheelchair or mobility equipment, moving them regularly can help, e.g. the use of standers when possible to maximise gravity.
• Follow exercise and positioning plans if the person has them.
• A referral to a physiotherapist might be needed.

4. Help the person to use the toilet when needed.

• Make sure you are following the person’s toileting or bowel management plan if they have one.
• Most people need to go to the toilet first thing in the morning or about 2O minutes after eating. This is a good time to try and help the person go.
• For some people, a hot drink in the morning can be helpful to get the bowels moving.
• Look at how the person is sitting on the toilet. They should sit with their knees bent above the level of the hips and have their feet flat on the floor. They might also need a small footstool under their feet.
• If the person has a physical disability, make sure any supportive devices are used. Look at their use in case their needs have changed.

5. Know what is normal for the person and take action if this changes.

• Ask the person, their family or other support workers what is normal for them if you can’t tell from their care, toileting or bowel management plan.
• Keep a record of bowel movements on a bowel chart.
• Look at any signs that the person is uncomfortable. If the person is non-verbal, look at their bowel chart regularly.
• Look in the toilet bowel after they have had a bowel motion. Compare the bowel motion to the Bristol Stool Chart and see if there is a change. Record any changes on their bowel chart.

6. Medicines can be looked at by a general practitioner (GP) or nurse practitioner to see if any are causing constipation. If possible, the medicine might be changed or a laxative might be prescribed.

7. If they have been ordered a laxative by a GP or nurse practitioner, make sure that they have taken them.

• If the bowel motion becomes too runny or the person won’t take the laxative, tell your supervisor, care coordinator, or their GP so they can look at the plan.

8. If there are changes in the person’s bowel habits, talk to your supervisor, the person’s care coordinator or a health care professional. Constipation can get worse and be a serious problem if it is not treated.

If the person you support has a spinal injury above T6, make sure that you know the signs and symptoms of autonomic dysreflexia. 

Need more help? Call the National Continence Helpline on 18OO 33 OO 66 and talk to a continence nurse advisor.

Extra Resources

• Constipation and bladder and bowel control

What is autonomic dysreflexia?

Autonomic dysreflexia is a condition that is most common in people with spinal cord injuries above T6. Some people with multiple sclerosis can also experience this condition. It happens when stimuli below the level of the injury causes the blood vessels to constrict. This then causes the person’s blood pressure to rise very quickly. If you take away the stimulus, the autonomic dysreflexia usually stops.

If you are supporting someone with these conditions, you need to know the signs and symptoms of autonomic dysreflexia and what to do. It’s also important that you follow the person’s toileting management plan. You need to know what is normal for the person you support. This will help you to notice if something changes.

Autonomic dysreflexia is a medical emergency. It can be life threatening and lead to:

• stroke
• retinal haemorrhage
• cardiac arrest.

What are the signs and symptoms of autonomic dysreflexia?

Raised blood pressure. Important note: an adult with a spinal cord injury above T6 usually has a low blood pressure, such as 9O/6O or 1OO/7O. So, someone like this can experience autonomic dysreflexia when their blood pressure reaches what is considered normal in most people (12O/8O).

As well as raised blood pressure, the person may experience one or more of these symptoms:

• a very bad headache
• flushed blotchy skin above the level of their injury
• sweating above the level of their injury
• blurred vision
• blocked nose
• feeling anxious or worried.

If the person you support has the above signs and symptoms, get medical help straight away.

They don’t need to have all of the symptoms above to experience autonomic dysreflexia.

What causes autonomic dysreflexia?

Autonomic dysreflexia can happen if the person:

• isn’t able to pass urine, causing their bladder to be overfull (this is the most common cause)
• has a blocked urinary catheter, that stops urine draining from the bladder
• has a kinked catheter
• has a urinary tract infection
• has constipation or has a bowel impaction
• has haemorrhoids.

Autonomic dysreflexia can also happen during a person’s routine bowel management. Rectal or digital stimulation during bowel care or if the bowel motion is difficult to pass, can cause autonomic dysreflexia. This may be short-term and stop with no harmful effects when the stimuli has been taken away, e.g. the bowel motion has been passed. If the symptoms don’t get better as soon as the stimuli has been taken away, get medical help straight away.

What should you do if the person you support has autonomic dysreflexia?

• Help the person into a sitting position and lower their legs.
• Loosen any tight clothing.
• Look for the stimuli causing the autonomic dysreflexia and take it away if you can e.g. if the catheter is kinked, unkink it.

If you can’t find and remove the cause, call for medical help. You shouldn’t ignore autonomic dysreflexia.

How can you stop it from happening?

Long-term treatment and management should look at what causes autonomic dysreflexia for that person. This could be different for each person. Always follow a toileting management plan developed by a health care professional. If there isn’t a toileting plan in place, talk to your supervisor, the person’s care co-ordinator or other health care professional.

Need more help? Call the National Continence Helpline on 18OO 33 OO 66 and talk to a continence nurse advisor.