Fecal incontinence is more common than many clinicians and laypeople realize. Characterized as the "unvoiced symptom" in 1982,1 it reains a taboo subject 28 years later. Interviews with community-dwelling women who have fecal incontinence reveal that they are cautious about disclosing the problem, often not informing close friends or family members.2,3 In fact, recent reports show that many patients fail to inform even their health care providers about the condition.3,4 Perpetuating the stigmatization associated with fecal incontinence, health care providers seldom inquire about it.

Historically, urinary incontinence has received more clinical and research attention than fecal incontinence. It's only within the past 10 to 15 years that fecal incontinence has been widely studied and that its prevalence, characteristics, and risk factors have been identified. Because research into the effectiveness of management strategies has been limited, those who are incontinent often rely on trial and error in developing self-care practices.5,6 In fact, a survey of elderly patients at four primary care clinics in the midwestern United States found that a third of those with fecal incontinence had no self-management strategies whatsoever.5

When feces enter the rectum, the internal anal sphincter relaxes reflexively, enabling the anal canal to "sample" and categorize the contents as solid or liquid. This action is simultaneously accompanied by the reflexive contraction of the external sphincter, which may be augmented by a voluntary squeeze (see Figure 1). The rectum is capable of storing feces until their volume stimulates stretch receptors in the mucosa, which produce an urge to defecate. The person then chooses a socially appropriate place to do so; assumes a sitting or squatting position, which straightens the anorectal junction from its normally acute angle; and voluntarily relaxes the external anal sphincter (see Figure 2). Abdominal pressure is raised as the person consciously bears down by tensing abdominal muscles. Pelvic floor muscles then relax, enabling feces to enter the lower rectum, where their presence stimulates an involuntary, propulsive rectosigmoid contraction until the rectum is emptied. Passage of the last bit of feces releases the stretch on the external anal sphincter, reflexively closing it.

Figure 1.

Figure 2.

Fecal incontinence has been defined as the "in voluntary loss of liquid or solid stool that is a social or hygienic problem."7 It can be caused by impaired sensory or motor function, poor coordination of defecation processes, cognitive or physical disability, or loose or liquid stool consistency, and may result from

In some cases, fecal incontinence is multifactorial or idiopathic (see Table 18, 9).

Table 1. ETIOLOGIES OF FECAL INCONTINENCE

Leaked stool most commonly has a loose or liquid consistency. Leakage is often episodic, with many people experiencing leaks at a frequency of several times per month or more. The amount of leakage may be small, soiling only the area between the buttocks, an absorbent pad, or underwear.10,11 Although soiling of outer clothing may not be a common occurrence,10 findings from a recent qualitative study,3 as well as reports of patients in our own clinical practices and our research, indicate that the negative impact and embarrassment related to this type of bowel "accident" are lasting and cause ongoing anxiety about the possibility of a future occurrence.

PREVALENCE IN VARIOUS SETTINGS

More than 40% of nursing home residents have fecal incontinence,8,12,13 and a substantial number of residents have "double incontinence"-that is, both urinary and fecal incontinence. After reviewing the medical records of 59,558 residents of 555 nursing homes in 31 states, investigators reported that 7.7% of residents had urinary incontinence only, 12.4% had fecal incontinence only, and 39.7% had double incontinence.12 Another nursing home study found that a large majority (78.6%) of the 1,918 residents had double incontinence.13

Among community-dwelling adults, it's estimated that 10% to 15% have fecal incontinence.8,14-16 Prevalence has been investigated in diverse community-dwelling populations (frail women, patients visiting the offices of generalist physicians or gastroenterologists, or elderly patients seeking care at health clinics) through surveys conducted in several different ways or settings (by telephone, by mail, or in a health care clinic or physician's office). Although the prevalence of fecal incontinence increases with age and disability, the condition is by no means confined to older or disabled people,17 nor is it limited to one sex. Most large community surveys and a systematic review have found a similar prevalence in women and men.8,17,18 As many as 50% of community-dwelling people who have fecal incontinence also have urinary incontinence.10,19

According to a study conducted by one of us (DZB), approximately one-third of hospitalized adult patients at one Veterans Affairs Medical Center had fecal incontinence.20 In hospitalized patients, severe illness is one risk factor for fecal incontinence; others are having a loose or liquid stool, regardless of etiology, and advanced age.

IMPACT ON QUALITY OF LIFE

Qualitative research reveals that fecal incontinence can have a significant impact on numerous dimensions of quality of life. One validated quality-of-life instrument has been used to quantify how the condition alters four aspects of quality of life: lifestyle, coping behavior, depression or self-perception, and embarrassment.21 Both men and women who had fecal incontinence and completed the 29-item scale scored significantly lower (indicating a poorer quality of life) in all four categories, compared with a control group of patients who had other gastrointestinal problems. Most research into the effects of fecal incontinence on quality of life, however, has focused on women with the condition.

Women with fecal incontinence experience anxiety about possible embarrassment from visible soiling or fecal odor and have a wide variety of related concerns, including types and colors of clothing to wear, proximity to a toilet while in public, and the need to wait in line for a toilet in a public restroom.3,22,23 Women with fecal incontinence feel the burden of harboring a secret and fear discovery. Fecal incontinence creates feelings of depression, tearfulness, and stress. It's associated with a poor self-image, often manifested as feeling "dirty" from leakage or like a "baby" for needing to wear diapers.3,22 It can also interfere with the frequency of and desire for sex as well as with intimacy.22 Women expressed lasting anger at physicians over complications of procedures or surgery that resulted in fecal incontinence.23

When going out in public, women with fecal incontinence describe engaging in an array of preparatory or preventive routines, such as packing self-made kits of cleansing and absorbent products in their purses, determining the location of public restrooms upon arrival at an unfamiliar place, and arranging appointments around their bowel patterns.3,23 The difficulties they've reported included changing discretely, dealing effectively with soiled garments in public restrooms, and supervising small children in public places when needing to rush to a toilet.

Given the numerous possible causes of fecal incontinence and the complexity of contributing factors, a detailed, often multidisciplinary, assessment is essential for all patients presenting with this condition. The aims are to determine symptoms, identify reversible causes or any "alarm signals" that indicate a need for fast-track referral, and construct the most logical care plan for the specific individual. Nurses need to be cognizant of the embarrassing nature of the condition and the reticence of many patients to discuss it. Patients may delay many years before seeking help.17 For this reason, it's necessary to pursue active case finding through empathetic inquiry when patients belong to high-risk groups, such as the frail elderly, patients with neurologic disorders, people with diarrhea from any cause, those who've had a recent change in bowel habits (such as looser or more frequent stools), and postpartum women. Finding a vocabulary that's acceptable to patients trying to communicate about an embarrassing condition and that's understood by both nurses and patients can be challenging.2,24 Because urinary and fecal incontinence often coexist, it's important to ask patients about urinary symptoms as well.

Symptom pattern and history provide important clues to causation. Urgency accompanied by fecal incontinence ("urge fecal incontinence") often indicates a loose stool or weakness of the external (voluntary) anal sphincter. Patients with this problem typically experience a strong urge to defecate and the inability to defer for more than a few minutes. By contrast, passive soiling without sensation often results from dysfunction of the smooth muscle internal anal sphincter, rectal impaction with "overflow" leakage, or neurologic impairment with blunted sensation. If the patient has difficulty remembering the pattern or severity of the incontinence, a daily chart or diary can help clarify matters.25

Rectal bleeding can be a sign of colorectal cancer and always warrants further investigation, especially in a patient over age 50 with a history of altered bowel habits or unexplained weight loss. Although colorectal cancer is not specifically related to fecal incontinence, the two may coexist. Colorectal cancer is the second most common cause of cancer-related death.26 Caught early, it can often be cured. Diagnosed in its late stages, it's associated with a high mortality rate. It's crucial, therefore, to refer patients with rectal bleeding and bowel changes for a diagnostic evaluation by a gastroenterologist or colorectal surgeon. Other conditions that warrant immediate medical referral are profuse diarrhea, rectal prolapse, third-degree (constantly prolapsing, for example) hemorrhoids, and acute anal sphincter injury (as can occur immediately after childbirth).

Diet and fluid intake may influence stool consistency and bowel patterns. Mobility, dexterity, and cognitive function will determine the patient's ability to access the toilet when needed. If the patient is dependent, caregivers who are available and supportive are crucial to maintaining the patient's well-being. Comorbidities, such as neurologic dysfunction or diabetes, may contribute to fecal incontinence. A huge range of drugs may cause loose stools or constipation, so be sure to review patients' drug regimens. Weight loss drugs and fat substitutes, for example, have been found to increase fecal incontinence.27

Because causes are often complex, great care should be taken to avoid "diagnostic overshadowing," the tendency to attribute all symptoms to a primary diagnosis. A woman with multiple sclerosis, for example, may also have sustained damage to her anal sphincter during childbirth, a fact that could be overlooked if her symptoms are assumed to be entirely neurologic in origin. Symptom management may also be required after some surgical procedures (such as hemorrhoidectomy) that may reduce, without eliminating, fecal incontinence.

The International Consultation on Incontinence (ICI), an international assembly of clinical practitioners and researchers working in the area of fecal incontinence, has developed and refined an evidence-based algorithm for management of the condition (see Figure 3).28 In addition to revealing risk factors for fecal incontinence, a thorough assessment can guide symptom management, which includes educational, behavioral, pharmacologic, and containment strategies.29 If such conservative strategies fail to restore continence, diagnostic testing (through anal ultrasound or magnetic resonance imaging) and other therapies, including surgery, may be indicated.7,30

Figure 3.

EDUCATION

A single nurse-conducted education session was found to improve bowel function after stroke.31 In one randomized controlled trial, four to five nurse-led education and advice sessions, conducted at a specialty colorectal clinic over a period of three to six months, reduced fecal incontinence in more than half of the patients who completed treatment.32 The sessions focused on topics such as bowel patterns, diet and fluid intake, titration of antidiarrheal medications, and bowel training techniques. The 29 patients who completed the education and advice sessions achieved a reduction in the frequency of fecal incontinence comparable to rate reductions among the patients who completed a similar education and advice program with the addition of either anal sphincter exercises or one of two types of biofeedback training methods.

Because people with fecal incontinence often restrict their diet and social activities to avoid public disclosure and humiliation, there may be a need for diet counseling. Approximately three times as many women as men employ such practices as a means of managing fecal incontinence.5 Women restrict the type, as well as the amount, of food they eat, sometimes skipping meals before going out or while in public, even if others are eating.6,22 Favorite foods that are considered troublesome are often consumed only at home as a reward for prolonged restriction.6

Diet modifications are usually determined by trial and error and may be borrowed from those used for other gastrointestinal conditions, such as irritable bowel syndrome and lactose intolerance. Foods thought to worsen incontinence include nuts, caffeinated drinks, chocolate, greasy or spicy foods, dairy products, and various raw fruits and vegetables. By contrast, foods such as yogurt and high-fiber bread are believed to be therapeutic. Patients acknowledge varying success in adjusting their diets to limit foods that exacerbate fecal incontinence and consuming more foods that attenuate the condition.6

A supplement of soluble dietary fiber has been shown to reduce the leakage of loose or liquid stools.33-35 Soluble fiber is believed to be beneficial in this regard because it reduces free stool water, firming stool consistency. Whether certain types of soluble fiber are more effective in managing fecal incontinence than others is currently under investigation.16 Other issues still to be determined include the ideal amount of dietary fiber to be used in a supplement and the comparative benefit of eating high-fiber foods, which usually contain a mixture of fiber types, versus taking a fiber supplement, which would normally provide a single type of fiber. Clinical experience suggests that patients' response to fiber varies widely, without any clear predictors of response.

Distress from amending eating patterns or restricting social activities needs further examination. One study found few differences in the nutritional composition of diets consumed by people with fecal incontinence and those of age- and sex-matched controls.36 If, however, patients who are at risk for malnutrition, such as the frail elderly, are altering their intake to manage fecal incontinence, they should be monitored for nutritional deficiencies through a daily diet record and nutritional assessment.

RECTAL EMPTYING

Rectal loading with overflow incontinence is most common in residents of long-term care institutions who suffer from impaction or constipation. The accumulation of feces and gas in the rectum distends the intestinal lumen, thereby relaxing the internal anal sphincter and allowing for passive, intermittent leakage. Liquid stool from higher in the intestine can seep past the fecal bolus, increasing soiling. Preventing impaction or constipation by emptying the rectum regularly with enemas, suppositories, or laxatives (bulk forming, stimulant, or osmotic) has been found to reduce fecal incontinence in patients with this problem.31, 37-39 The use of such agents after stroke, however, hasn't been adequately studied.31

In addition to monitoring the effectiveness of rectal evacuation, nurses need to evaluate patients undergoing treatment for fluid and electrolyte imbalances, thirst, and abdominal discomfort, instituting appropriate treatment as warranted. Rectal emptying can be combined with a toileting program that promotes regular defecation after awakening and after meals (to capitalize on the gastrocolic response). At such times, a full rectum and sitting in the correct position are most likely to stimulate the conditioned response of emptying the bowel.40

Other methods of emptying the rectum include abdominal massage (applying firm pressure in the direction of stool movement around the colon to promote movement of bowel contents)41 and digital stimulation (inserting a gloved, lubricated finger through the anus into the rectum to trigger anal relaxation and a rectal contraction), but the effectiveness of these techniques has yet to be established in controlled studies. Abdominal massage and rectal irrigation (using up to one liter of tap water instilled by rectal catheter) are used in bowel management programs for patients with incontinence secondary to neurologic disease or in jury.42-44 Digital stimulation is appropriate only with certain types of motor neurologic function (in other words, when spinal reflexes are intact). Patients with a flaccid bowel (indicating lower motor neuron dysfunction) may need to resort to manual evacuation.45

BOWEL TRAINING

Complications of fecal incontinence are unpredictable and therefore difficult to manage. Perineal dermatitis is a common adverse consequence. Its manifestations include skin redness, skin loss, and in the more severe cases, secondary fungal infection. For acutely ill patients with fecal incontinence, bowel catheters or an anal pouch can be used to reduce perineal skin damage by diverting liquid stool into a collection bag. Technologic advances in the design of bowel catheters and the balloons used to keep them in place have made their use much safer than in years past.7,46 Skin care regimens that include a pH balanced cleanser and moisture barrier reduce the risk of incontinence-associated dermatitis.13,47 It's important to take steps to prevent perineal skin damage even when a bowel catheter is used because fecal seepage may occur around the catheter.

Although absorbent pads and briefs may provide a feeling of security for incontinent community dwellers, these products do little to protect the skin from irritation. Few elderly men will wear standard absorbent products,4 and most such products have been designed for absorbing urine, not feces. A small surgical dressing, however, designed specifically to absorb small amounts of leaked stool when placed between the buttocks, has been found to be more acceptable by men with fecal incontinence.48

The anal plug is an alternative to absorbent briefs that has been evaluated in research studies but isn't currently available for use in the United States. This device is inserted into the rectum to prevent fecal leakage. Various designs and materials have been tested in both children and adults.49 Although the anal plug has been found to prevent fecal leakage, its use over extended periods has been limited by practical considerations such as discomfort, pain, and involuntary expulsion. Improved designs and materials have increased tolerance in some people, but responsevaries widely and is difficult to predict.50-52 Nurses are encouraged to participate in the development and evaluation of a comfortable and effective anal plug.

MEDICATION

Antimotility, or antidiarrheal, medications are commonly used to manage diarrhea-related fecal incontinence. Based on current evidence, loperamide (Imodium) is the drug of first choice.53,54 It reduces the frequency of bowel movements, firms stools, and increases pressure in the anal canal. The drug can be initiated in doses as small as 1 mg per day and titrated upward as needed to a maximum dosage of 16 mg per day. In our experience, not all patients with fecal incontinence take antidiarrheal medication regularly, although such a regimen is recommended. Reasons for nonadherence include forgetfulness, inconvenience, a fear of constipation, or an inability to afford the drug. Patients who use varying amounts of antidiarrheal medication on an as-needed basis may also derive some benefit. Nurses should assess patterns of medication use and evaluate the feasibility of instituting a more regular dosing regimen, as well as its likely effectiveness.

DIAGNOSTIC TESTING AND FOLLOW-UP

Pelvic floor muscle training, as used for urinary incontinence, hasn't been widely studied as a treatment for fecal incontinence. Biofeedback, which involves a pressure-sensitive probe inserted into the anus to show the patient aspects of anorectal function in order to guide these exercises and modify anal sphincter function and anorectal sensation, is often used in specialty centers. Evidence of an additional benefit over conservative measures, however, is lacking.28,55 Intra-anal electrical stimulation may be used to enhance anal sphincter strength and sensation, but here too, there's little evidence of its effectiveness.7,56,57

SURGERY

When assessment and physical examination reveal defects for which surgery is indicated, patients should be referred to a surgeon. Such conditions would include a complete rectal prolapse, in which the intestine protrudes through the anus, preventing complete closure of the anal sphincter(s); surgical repair would be required not only to cure the incontinence but also to prevent intestinal necrosis. Patients with a disrupted anal sphincter also may benefit from surgical repair, although perfect continence is seldom maintained over the long term.58,59 Surgical implantation of a sacral nerve stimulator is a promising recent option, but long-term results aren't yet available. When all else has failed and fecal incontinence severely limits the quality of a patient's life, some patients find a stoma an acceptable and life-enhancing option.60 The nurse should undertake postoperative follow-up on the extent of incontinence resolution and the need for continued symptom management.

REFERENCES

1. Leigh RJ, Turnberg LA. Faecal incontinence: the unvoiced symptom. Lancet 1982;1(8285):1349-51. [Context Link]

2. Patel K, et al. Health literacy and emotional responses related to fecal incontinence. J Wound Ostomy Continence Nurs 2010;37(1):73-9. [Context Link]

3. Peden-McAlpine C, et al. The experience of community-living women managing fecal incontinence. West J Nurs Res 2008;30(7):817-35. [Context Link]

4. Bliss DZ, Jung H-JG. Non-nutritive dietary supplements: dietary fiber. In: Rolandelli RH, et al., editors. Clinical nutrition: enteral and tube feeding. Philadelphia: Elsevier Saunders; 2005. p. 155-71. [Context Link]

5. Bliss DZ, et al. Managing fecal incontinence: self-care practices of older adults. J Gerontol Nurs 2005;31(7):35-44. [Context Link]

6. Hansen JL, et al. Diet strategies used by women to manage fecal incontinence. J Wound Ostomy Continence Nurs 2006;33(1):52-61. [Context Link]

7. Norton C. Building the evidence base-the Zassi Bowel Management System. Br J Nurs 2009;18(6):S38, S40-S42. [Context Link]

8. Shamliyan T, et al. Prevention of urinary and fecal incontinence in adults. Evid Rep Technol Assess (Full Rep) 2007(161):1-379. [Context Link]

9. Bartolo DC, Paterson HM. Anal incontinence. Best Pract Res Clin Gastroenterol 2009;23(4):505-15. [Context Link]

10. Bliss DZ, et al. Severity of fecal incontinence in community-living elderly in a health maintenance organization. Res Nurs Health 2004;27(3):162-73. [Context Link]

11. Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol 1996;91(1):33-6. [Context Link]

12. Bliss DZ, et al. Prevalence and correlates of perineal dermatitis in nursing home residents. Nurs Res 2006;55(4):243-51. [Context Link]

13. Bliss DZ, et al. An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention. J Wound Ostomy Continence Nurs 2007;34(2):143-52. [Context Link]

14. Goode PS, et al. Prevalence and correlates of fecal incontinence in community-dwelling older adults. J Am Geriatr Soc 2005; 53(4):629-35. [Context Link]

15. Macmillan AK, et al. The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature. Dis Colon Rectum 2004;47(8):1341-9. [Context Link]

16. Whitebird RR, et al. Community-based recruitment and enrollment for a clinical trial on the sensitive issue of fecal incontinence: the Fiber study. Res Nurs Health 2006;29(3): 233-43. [Context Link]

17. Perry S, et al. Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut 2002;50(4):480-4. [Context Link]

18. Whitehead WE, et al. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 2009;137(2): 512-7, 517 e1-2. [Context Link]

19. Roberts RO, et al. Prevalence of combined fecal and urinary incontinence: a community-based study. J Am Geriatr Soc 1999;47(7):837-41. [Context Link]

20. Bliss DZ, et al. Fecal incontinence in hospitalized patients who are acutely ill. Nurs Res 2000;49(2):101-8. [Context Link]

21. Rockwood TH, et al. Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 2000;43(1):9-16. [Context Link]

22. Chelvanayagam S, Norton C. Quality of life with faecal continence problems. Nurs Times 2000;96(31 Suppl):15-7. [Context Link]

23. Collings S, Norton C. Women's experiences of faecal incontinence: a study. Br J Community Nurs 2004;9(12):520-3. [Context Link]

24. Cotterill N, et al. A patient-centered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence. Dis Colon Rectum 2008;51(1):82-7. [Context Link]

25. Fisher K, et al. Comparison of recall and daily self-report of fecal incontinence severity. J Wound Ostomy Continence Nurs 2008;35(5):515-20. [Context Link]

26. Ahlquist DA, et al. Stool DNA and occult blood testing for screen detection of colorectal neoplasia. Ann Intern Med 2008;149(7):441-50, W81. [Context Link]

27. Heck AM, et al. Additive gastrointestinal effects with concomitant use of olestra and orlistat. Ann Pharmacother 2002;36(6):1003-5. [Context Link]

28. Norton C, et al. Conservative and pharmacological management of faecal incontinence in adults. In: Abrams P, et al., editors. Incontinence: Fourth International Consultation on Incontinence, Paris, July 5-8, 2008. London: Health Publications, Ltd.; 2009. p. 1321-86. [Context Link]

29. Norton C, Chelvanayagam S. A nursing assessment tool for adults with fecal incontinence. J Wound Ostomy Continence Nurs 2000;27(5):279-91. [Context Link]

30. Madoff RD, et al. Surgery for faecal incontinence. In: Abrams P, et al., editors. Incontinence: Fourth International Consultation on Incontinence, Paris, July 5-8, 2008. London: Health Publications, Ltd.; 2009. p. 1387-418. [Context Link]

31. Harari D, et al. Treatment of constipation and fecal incontinence in stroke patients: randomized controlled trial. Stroke 2004;35(11):2549-55. [Context Link]

32. Norton C, et al. Randomized controlled trial of biofeed back for fecal incontinence. Gastroenterology 2003;125(5): 1320-9. [Context Link]

33. Bliss DZ, et al. Supplementation with dietary fiber improves fecal incontinence. Nurs Res 2001;50(4):203-13. [Context Link]

34. Eherer AJ, et al. Effect of psyllium, calcium polycarbophil, and wheat bran on secretory diarrhea induced by phenolphthalein. Gastroenterology 1993;104(4):1007-12. [Context Link]

35. Wenzl HH, et al. Determinants of decreased fecal consistency in patients with diarrhea. Gastroenterology 1995; 108(6):1729-38. [Context Link]

36. Bliss DZ, et al. Comparison of the nutritional composition of diets of persons with fecal incontinence and that of age- and gender-matched controls. J Wound Ostomy Continence Nurs 2000;27(2):90-7. [Context Link]

37. Chassagne P, et al. Does treatment of constipation improve faecal incontinence in institutionalized elderly patients? Age Ageing 2000;29(2):159-64. [Context Link]

38. Chassagne P, et al. Fecal incontinence in the institutionalized elderly: incidence, risk factors, and prognosis. Am J Med 1999;106(2):185-90. [Context Link]

39. Tobin GW, Brocklehurst JC. Faecal incontinence in residential homes for the elderly: prevalence, aetiology and management. Age Ageing 1986;15(1):41-6. [Context Link]

40. Stokes G. Psychological approaches to bowel care in older people with dementia. In: Potter J, et al., editors. Bowel care in older people: research and practice. London: Clinical Effectiveness and Evaluation Unit, Royal College of Physicians; 2002. p. 97-110. [Context Link]

41. Resende TL, et al. A pilot study on the effect of exercise and abdominal massage on bowel habit in continuing care patients. Clinical rehabilitation 1993;7(3):204-9. [Context Link]

42. Christensen P, et al. A randomized, controlled trial of transanal irrigation versus conservative bowel management in spinal cord-injured patients. Gastroenterology 2006;131(3): 738-47. [Context Link]

43. Coggrave M. Transanal irrigation for bowel management. Nurs Times 2007;103(26):47-8. [Context Link]

44. Sentovich SM, et al. Patterns of male fecal incontinence. Dis Colon Rectum 1995;38(3):281-5. [Context Link]

45. Coggrave M. Effective bowel management for patients after spinal cord injury. Nurs Times 2004;100(20):48-51. [Context Link]

46. Beitz JM. Fecal incontinence in acutely and critically ill patients: options in management. Ostomy Wound Manage 2006;52(12):56-66. [Context Link]

47. Gray M, et al. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs 2007;34(1):45-54. [Context Link]

48. Bliss DZ, Savik K. Use of an absorbent dressing specifically for fecal incontinence. J Wound Ostomy Continence Nurs 2008;35(2):221-8. [Context Link]

49. Deutekom M, Dobben A. Plugs for containing faecal incontinence. Cochrane Database Syst Rev 2005(3):CD005086. [Context Link]

50. Bond C, et al. Anal plugs for the management of fecal incontinence in children and adults: a randomized control trial. J Clin Gastroenterol 2007;41(1):45-53. [Context Link]

51. Doherty W. Managing faecal incontinence or leakage: the Peristeen Anal Plug. Br J Nurs 2004;13(21):1293-7. [Context Link]

52. Van Winckel M, et al. Is an anal plug useful in the treatment of fecal incontinence in children with spina bifida or anal atresia? J Urol 2006;176(1):342-4. [Context Link]

53. Cooper ZR, Rose S. Fecal incontinence: a clinical approach. Mt Sinai J Med 2000;67(2):96-105. [Context Link]

54. Sun WM, et al. Effects of loperamide oxide on gastrointestinal transit time and anorectal function in patients with chronic diarrhoea and faecal incontinence. Scand J Gastroenterol 1997;32(1):34-8. [Context Link]

55. Norton C, et al. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2006(3):CD002111. [Context Link]

56. Hosker G, et al. Electrical stimulation for faecal incontinence in adults. Cochrane Database Syst Rev 2007(3): CD001310. [Context Link]

57. Mahony RT, et al. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004;191(3):885-90. [Context Link]

58. Madoff RD, et al. Faecal incontinence in adults. Lancet 2004;364(9434):621-32. [Context Link]

59. Malouf AJ, et al. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet 2000; 355(9200):260-5. [Context Link]

60. Norton C, et al. Patients' views of a colostomy for fecal incontinence. Dis Colon Rectum 2005;48(5):1062-9. [Context Link]

For 34 additional continuing nursing education articles on research topics, go to http://www.nursingcenter.com/ce.