history

Last reviewed 01/2018

Important distinguishing features in the history are:

  • impaction usually has a history of regular bowel opening, not complete constipation
  • impaction is also accompanied by fullness and seepage, but it is important to rule out rectal carcinoma
  • urinary incontinence also suggests impaction
  • soiling without the patient's awareness is indicative of neuropathy
  • recent symptoms suggest recent and changing pathology

NICE suggest a specific proforma when enquiring regarding faecal incontinence (1):

  • when assess faecal incontinence healthcare professionals should:
    • be aware that faecal incontinence is a symptom, often with multiple contributory factors for an individual
    • avoid making simplistic assumptions that causation is related to a single primary diagnosis
  • History of bowel habit:
    • Questions to ask patients
      • What is your normal bowel habit?
        • Has it changed recently? If so how? Has there been any bleeding from the back passage? Or loss of mucus?
      • What is the usual consistency of your stools (bowel motions)? (Refer to stool chart such as the Bristol Stool Chart to assist the patient/carer to describe)
        • Do the stools vary in consistency?
        • Do you have to strain to empty your bowels?
          • If so, for how long?
      • Are you able to tell the difference between when you are about to pass wind or stool?
      • Do you pass much wind?
        • Can you control this wind?
      • Are you able to delay emptying your bowels?
        • If so for how long?
      • Do you experience any abdominal pain or bloating before passing a bowel motion?
        • Does that relieve the sensation?
      • Do you have a feeling of incomplete emptying after an attempted bowel evacuation?
        • Do you ever have to assist the passage of stool with your finger?
      • Are you able to clean yourself after passing stools?
        • Do you have to clean yourself several times after passing stools?
      • Do you ever leak stools without being aware of it?
      • When faecal incontinence is reported, ask the following:
        • How often does it happen?
        • When has it happened?
        • Is there any pattern to this or any factor that provokes it?
        • How much leaks?
        • What is the consistency of the leakage?
        • Can it be wiped away easily?
        • Do you get the sensation of the need to empty your bowels before you leak?
        • Is that sensation an urgent need to empty your bowels? (Passive soiling)
        • Does soiling occur after a bowel motion has been passed? (post-defecation soiling)
        • Do you wear pads (or something else) in your underwear? If so, are they effective in preventing soiling of clothes/surroundings/furnishing?
      • Previous medical history
        • Assess the patient for possible contributory factors:
          • Constipation/diarrhoea
          • Acute severe illness
          • Terminal illness
          • Severe cognitive impairment
      • Assess the patient for limited mobility and toilet access:
        • Does the patient have adequate toilet facilities (for example, is there limited availability, access problems, lack of privacy, unclean, unsafe?)
        • Does the patient need assistance for toileting? If so, is there delayed assistance when there is an urgent call to stool?
        • Is the patient able to communicate when there is a need to defecate?
        • Are there any physical or environmental difficulties with toilet access, for example, unmarked doors, steps, non-slip shiny floors, potentially confusing floor patterns. carpets. excessive distance?
      • Is there a history of a neurological disorder(s)?
        • If yes - how long has it been present? Is it expected to improve?
        • Is it permanent?
      • Does the patient have an obstetric history and/or history of weak pelvic floor (as appropriate)
        • Parity
        • Difficult delivery
        • Large birth weight
      • Is there a history of perianal trauma or surgery?
      • Is there a history of urinary incontinence?
      • Is there a history of rectal prolapse?
      • Is there a history of other comorbidities such as diabetes
      • Perform a medication review
        • Is the patient taking any of the drugs that may exacerbate faecal incontinence
          • e.g. drugs that may cause profuse loose stools include
            • Laxatives
            • Metformin
            • Orlistat
            • Selective serotonin reuptake inhibitors
            • Magnesium-containing antacids
            • Digoxin
      • Consequences of faecal incontinence
        • Do you experience itching or soreness around the back passage? When is this present?
      • Impact of symptoms on lifestyle/quality of life
        • Do the patient’s bowel symptoms affect the following?
          • General lifestyle
          • Family life
          • Leisure and social activity
          • Work
          • Sexual activity
          • Emotions
          • Self-image
          • Relationships, particularly any changes in close relationships
          • Ability to travel
          • Ability to manage within place of residence, for example does the patient require any structural changes to be made to their residence?

Reference:

  1. NICE (2007).Faecal incontinence: the management of faecal incontinence in adults.