Case Study: Faecal Incontinence

Jill was referred by a Urologist to WMHP for management of Urgency Urinary Incontinence, but during subjective assessment disclosed that Faecal Incontinence was actually her most bothersome symptom.  This case study highlights the absolutely devastating effect Faecal Incontinence can have on a person’s quality of life, and how a structured treatment program can cure this highly bothersome condition. 
 
 
 

Subjective Assessment

  • History of presenting complaint:
    • Jill, a 65-year-old multiparous female, was referred from her urologist for management of Urgency Urinary Incontinence, but during subjective assessment disclosed that Faecal and Flatal Incontinence was actually her most bothersome symptom. Jill had never disclosed this before.
    • Jill reported Faecal Incontinence associated with rectal urgency, with “no warning at all”, which occurred when she was out walking, or if she had been out for a coffee or a meal that “didn’t agree with her”.
    • This started around 10 years ago, and was progressively worsening, occurring a few times per fortnight at its worst. Jill had become so embarrassed to the point of avoiding any walking, social meals, travel, shopping, or outings to the beach. She had essentially become housebound.
    • Since restricting her activity and social level, her Faecal Incontinence episodes reduced to only occasionally, but she continued to experience regular Flatal Incontinence.
    • Jill was opening her bowels 1-2 times per day with loose unformed stool (type 5-6 on the Bristol Stool Scale), better if she stuck to a low FODMAP diet. 
  • Bladder function: Jill’s Urologist had started her on Betmiga and her urgency incontinence had completely resolved, however she still reported Stress Urinary Incontinence with coughing, sneezing and laughing.
  • Sexual function: occasional intercourse with husband, no problems reported.
  • Gynaecological history: G2P2 high forceps delivery at first birth, large babies, post-menopausal, on HRT.  Hysterectomy and a posterior vaginal repair.
  • Social history: married with 2 adult children, predominately housebound, avoiding many activities due to fear of incontinence.
  • Exercise: avoiding all exercise due to fear of Faecal Incontinence.
  • Jill’s goals: to no longer feel embarrassed or ashamed, to not worry when out walking with friends or travelling overseas with her husband, and to go out to a restaurant without fear of smelling. 

Objective Assessment

  • Observation: Observation: presence of haemorrhoids, patulous / gaping anus at rest.
  • Per rectum examination: circumferential defect of the anus right anterior region, low resting tone of the external anal sphincter (EAS), normal resting tone of the internal anal sphincter and levator ani, able to elicit a weak puborectalis squeeze and hold for 3 seconds, unable to contract EAS.
  • Per vaginum examination: no prolapse, low resting tone, weak pelvic floor muscle squeeze, able to hold for 5 seconds.
  • Bowel diary: 1 week diary showed opening frequency of 1-3 times per day, medium to large amount each evacuation of a Bristol type 5-6 with straining to initiate 70% of the time.
  • Outcome measures; Patient global impression (PGI) – Severity of 4 (severe), bother of 10/10. 

Impression:

It is likely that Jill’s Faecal Incontinence is caused by poor function of the EAS and pelvic floor muscles, and poor stool consistency.   Her obstetric history of forceps delivery and large babies likely led to damage of the pelvic floor muscles and external anal sphincter, which then became more apparent with the hormonal changes of menopause and age-related changes.  Her understandable anxiety about her symptoms is likely to be further exacerbating them due to the brain-gut connection. Jill’s symptoms are having a huge impact on her quality of life, with fear-avoidance behaviours and isolation evident. 
 
Unfortunately, Jill had never discussed her Faecal Incontinence with any of her healthcare providers, and only volunteered this information when specifically asked if she had any difficulty controlling her bowels.  This highlights the importance of screening for Faecal Incontinence or Bowel Dysfunction in any patient presenting with pelvic dysfunction, as the social taboo surrounding Faecal Incontinence remains strong. (See our ‘Pelvic Floor Bother Questionnaire’ in our Useful Resources For Referrers.)
 

Treatment program:

  • Pelvic floor muscle training program: with an emphasis on external anal sphincter and puborectalis strength and functional activation.
  • Stool manipulation: education regarding how to avoid episodes of loose stools, and dietary advice for stool bulking.
  • Bowel routine advice: a morning bowel routine was created for Jill, to enable her to have good bowel opening after breakfast, so she could confidently leave the house.
  • Biofeedback with rectal balloon therapy: rectal balloon therapy was used for urgency training, to teach Jill how to control episodes of faecal urgency, and give her the confidence that she was able to do this.
  • Defecation dynamics: Jill was taught to empty her bowels without straining.

Outcome

Jill attended 6 physiotherapy appointments over a 6 month period.  After 6 weeks of treatment, with excellent compliance to her pelvic floor muscle training program, Jill no longer had Flatal Incontinence, and faecal urgency had reduced, she now had ~5 minutes to get to the toilet following onset of urge. However, she was still very anxious about leaving the house due to fear of Faecal Incontinence. 

After 6 months of diligent compliance to her treatment program Jill’s pelvic floor muscle function had improved resting tone, a moderate strength and improved endurance. Her bowel diary and self-report demonstrated no episodes of Faecal Incontinence, Flatal Incontinence, Faecal Urgency, or Urinary Incontinence. Her PGI-S has improved to 2 (mild) and her bother had reduced to 2/10.  Jill was ecstatic that she was now able to go out walking with friends and felt confident to go out to meals, as long as it was a restaurant she was familiar with. She had even been on an overseas cruise in Europe.