History

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

• when assessing 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 with 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.