Fecal incontinence is a common and often underreported problem; prevalence rates in community-dwelling adults vary from 7% to 15%.1 In 2014, the Centers for Disease Control and Prevention published a report on the Prevalence of Incontinence Among Older Americans.2 The report provided prevalence estimates based upon the data collected between 2007 and 2010 from 4 different sources: the National Health and Nutrition Examination survey, the 2010 National Survey of Residential Care Facilities, the 2007 National Home and Hospice Care Survey, and the 2009 long-term care Minimum Data Set. Prevalence in these populations ranged from 17% in community dwelling adults to nearly 60% of residents in long-term care. These numbers are a sobering reminder for the WOC nurse that maintaining trispecialty certification is important to our patients. Fecal incontinence in women 65 years or older is projected to increase by 38% in next few decades.3 The challenges this presents to our health care system further reinforces the need for knowledgeable and skilled CWOCNs. The specialty nurse needs to have a strong working knowledge of bowel dysfunction that includes types of dysfunction, such as fecal incontinence, etiology, contributing factors, basic management techniques, principles of patient/caregiver education, and management of complications.4 Fortunately, up to 25% of patients with fecal incontinence will become continent with conservative management techniques. Interventions such as patient education, dietary modifications, such as increasing fiber, antidiarrheals, and behavioral therapy such as toileting and pelvic muscle exercises can have positive effects.5 Conservative management strategies are what CWOCN nurses carry in their arsenal. In the practice questions below, you will have the opportunity to test your knowledge about fecal incontinence and its conservative management.
1. Bharucha AE, Dunivan D, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence. State of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol. 2015:127-136. [Context Link]
2. Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older Americans. National Center for Health Statistics. Vital Health Stat. 2014;3(36). [Context Link]
3. Administration on aging: profile of older Americans 2008. http://www.aoa.gov/prof/Statistics/profile/profiles.aspx. [Context Link]
4. WOCNCB Examination Handbook. https://www.wocncb.org/pdf/exam_handbook.pdf?v=Mar-2015. [Context Link]
5. Whitehead WE, Rao SS, Lowry A, et al. Treatment of fecal incontinence: state of the science summary from the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Am J Gastroenterology. 2015;110:138-146. [Context Link]
Practice Questions
1. An orthopedic postoperative patient complains of new-onset liquid stool leakage. The abdominal assessment reveals normal bowel sounds and a soft but distended abdomen. What other information would best help in the initial evaluation of these new signs and symptoms?
a. The results of the last colonoscopy
b. Review of medications
c. Stool studies
d. Vital signs and Weight
Content Outline: 030702
Cognitive Level: Analysis
Answer B: All the information in the answer options have the potential to reveal information about bowel function but only 1 option correctly identifies information pertinent to new-onset fecal incontinence experienced by a postoperative patient. This question is an analysis-level question requiring the test taker to evaluate each option and understand the implications of each related to fecal incontinence. Analysis of option B includes knowledge that postoperative orthopedic patients are commonly administered constipating analgesics that increase the risk for fecal impaction. A sign of fecal incontinence associated with fecal impaction is the seeping of liquid stool around the obstructing fecal mass. The other options can reveal information about bowel function such as a colonoscopy report indicating diverticula or removal of a suspicious polyp. Stool studies would be very helpful in the evaluation of suspected infectious diarrhea but this type of diarrhea would not typically start after surgery. A review of vital signs and weight loss might help in the evaluation of long-term diarrheal illness.
Bliss DZ, Mellgren A, Whitehead WE, et al. Assessment and conservative management of fecal incontinence and quality of life in adults. In: Abrams P, Carsozo L, Khoury S, Wein A, eds. Incontinence: 5th International Consultation on Incontinence. 5th ed. European Association of Urology/ICUD. 2013:1443-1485.
2. When is the best time to schedule toileting for bowel retraining?
a. In the morning after breakfast
b. Before bed
c. Only when the patient has a strong urge
d. Before meals
Content outline: 030703
Cognitive level: Recall
Answer A: One of the important principles in bowel retraining is to establish a regular pattern of evacuation. The best time to teach a patient or caregiver to toilet for bowel continence is when peristaltic contractions are the strongest. In most cases, peristalsis is strongest in the morning after awakening and after meals. Toileting with a strong urge is not often successful.
Bliss DZ, Mellgren A, Whitehead WE, et al. Assessment and conservative management of faecal incontinence and quality of life in adults. In: Abrams P, Carsozo L, Khoury S, Wein A, eds. Incontinence: 5th International Consultation on Incontinence. 5th ed. European Association of Urology/ICUD; 2013:1443-1485.
3. What is the best treatment for a patient with chronic diarrhea who has erythematous, inflamed skin, and scattered areas of denudation of the inner thighs, buttocks, perianal area, and labia?
a. Antifungal powder
b. Emollient product
c. Skin protectant
d. Hydrocolloid dressing
Content Outline: 030704
Cognitive level: Application
Answer C: This question describes a classic presentation of incontinence-associated dermatitis (IAD). The test taker is required to apply what is known about IAD treatments in order to select the correct option. The choice of a skin protectant is appropriate because it will adhere to the denuded skin providing absorption of moisture. There is no information in the stem to indicate the presence of candidiasis though Candia is common in IAD. An emollient is inappropriate when skin is already overhydrated and denuded. A hydrocolloid is inappropriate due to the extent of the area to be covered, location of injury, and that it would become easily soiled from the diarrhea.
Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39(3):303-315.