Being incontinent of feces is a chronic health condition that can have debilitating effects on functional, psychological, and social well-being. Fecal incontinence (FI) remains a prominent problem in nursing homes, affecting 20-40% of residents (Chassagne et al., 1999;Nelson, Furner, & Jesudason, 1998;Tobin & Brocklehurst, 1986). The prevalence of FI in the general population has been estimated to be 2%, and in community-living elderly it can be as high as 17% (Kok et al., 1992;Nelson, Norton, Cautley, & Furner, 1995;Perry et al., 2002;Roberts et al., 1999). Women who give childbirth vaginally are another group thought to be at risk for FI (Gordon et al., 1999; Sultan, Kamm, Hudson, Thomas, & Batram, 1996). Reported differences in the prevalence of FI between men and women living in the community are inconsistent (Bliss, Fischer, Savik, Avery, & Mark, 2004;Johanson & Lafferty, 1996).

The etiology of FI can be categorized as follows: (a) neuro-sensory-motor dysfunction of the anal sphincter or pelvic floor, often seen in anorectal trauma or systemic diseases such as multiple sclerosis or diabetes; (b) abnormal colonic transit; (c) loose or liquid stool consistency; (d) decreased intestinal capacity with overflow, such as around a tumor or impacted feces; and (e) idiopathy (Rudolf & Galanduik, 2002). Multiple physiological factors may contribute to FI. Fecal incontinence of any etiology can be influenced by functional impairments in mobility and cognition. The precise mechanisms underlying FI are poorly understood. Technologies such as endoanal ultrasound have advanced the ability to subcategorize some potential mechanisms such as subclinical disruptions in the internal versus external anal sphincters (Kamm, 1998); however, dependency on expensive equipment requiring a high skill level for their implementation and interpretation of their results limits feasibility and translation into routine practice.

Surgical procedures can cure or significantly reduce FI in a small number of conditions (e.g., rectal prolapse). The artificial anal sphincter holds promise for the most severe form of FI, but its infection and complication rates are yet too high for widespread use (Parker et al., 2003). Symptom management is an important part of therapy as an adjunct after surgery (e.g., sphincteroplasty), for persons who elect nonsurgical treatment or have diseases for which there is no cure (e.g., multiple sclerosis), for those with a mild severity of FI for whom conservative therapy is recommended, or for those whom the risk of surgery outweighs potential benefit. Symptom management is holistic and can be therapeutic as well as palliative. It usually involves modification of some aspect of behavior and encompasses dietary, muscle exercise/training, pharmacological, and counseling approaches and defecation pattern adjustment. Reports of varying success rates of some of these approaches are influenced by differing protocols and uncontrolled investigations. The patient-clinician relationship may be an intervening factor. At present there are no consistent, physiological predictors of a successful response to symptom management strategies (Carty, Moran, Johnson, 1994;Sangwan et al., 1995).

In 1982, Leigh and Turnberg referred to FI as the "unvoiced symptom" reflecting the reluctance of patients or physicians to discuss FI, lack of knowledge about many aspects of the problem, and public taboo and shame associated with being incontinent. Johanson and Lafferty (1996) referred to FI as the "silent affliction" and similar findings can still be found in recent publications (Gordon et al., 1999). Although the work of authors of this manuscript and others has been instrumental in raising awareness about the impact of FI on incontinent patients and increasing the evidence base about FI management, there is a need for continued and additional nursing research. In this manuscript, we report on recommendations for future nursing research about FI that were presented and refined at the International Nursing Summit on Incontinence in October, 2003. The research areas that are identified reflect the authors' expertise and insights formulated during the summit and the consensus priorities of those attending the summit.

Physiological Mechanisms Underlying FI: Implications for Prevention and Management

Maintenance of continence is a complex process involving neurological and muscular coordination, voluntary control and involuntary reflexes, behavioral habits, emotions, and cultural attitudes. A poorly defined area of research is the interplay among physiological, psychological, and cultural components of learned bowel habits and their effect on retraining in adults. There is a gap in knowledge about the relationship between the cognitive dysfunction of dementia and the interpretation of the need for bowel control (Stokes, 2002).

There are many unanswered questions about the physiological mechanisms underlying FI. Answers to questions about normal bowel health and the influence of disease states and injuries such as those proposed in the following sections will advance the field, guide efforts to prevent the onset of FI, and refine management practices. What changes in the morphology and function of the internal and external anal sphincters and the pelvic floor musculature in the postpartum period, menopause, aging, and comorbid chronic health problems precipitate FI? Due to the inaccessibility and slow motility of the colon, can colonic motility and transit be more easily measured, perhaps in "real time," to quantify their influence in the episodic and unpredictable problem of FI? Is there a set of measures defining a "physiological threshold" that predicts the margin for retaining continence? Are there characteristic vulnerabilities of the continence system that are associated with different types of injuries or levels of severity of FI? Fecal incontinence and urinary incontinence (UI) both occur in 6% to 10% of older, community-living people (Roberts et al., 1999). Does visceral sensitivity, which is thought to influence gastrointestinal symptoms in irritable bowel syndrome (Bueno, Fioramonti, Delvaux, & Frexinos, 1997), play a role in defecation urgency? Is there a pelvic floor defect that is common to UI and FI? Are there health practices that are protective against developing FI, and is there a critical period of time when these practices should be initiated?

Approximately 8% to 22% of patients with diabetes have FI (Valdovinos, Camilleri, & Zimmerman, 1993). In patients with diabetes or other systemic diseases characterized by neurological impairments, it is unknown whether there are genetic or structural factors that differentiate those who are asymptomatic from those who develop FI. Can FI be prevented in a progressive systemic disease? What is the mechanism underlying impaired rectal sensation to distension, often seen in these patients, and is it amenable to treatment? Bowel care for FI and constipation in patients with central neurological disease remains empirically based. The conclusion from a recent Cochrane systematic review of this topic was that no treatment recommendations could be supported (Coggrave, Wiesel, Norton, & Brazzelli, 2003). The best approaches to manage the neurogenic bowel (e.g., from spinal cord injury) to prevent FI are undetermined.

The conditions of childbirth that contribute to FI include overt and subclinical sphincter trauma, multiparity, large infant birth weights, and use of forceps and suction (MacArthur, Bick, & Keighley, 1997;Ryhammer, Laurberg, & Hermann, 1996;Sultan et al., 1993). The type of damage (e.g., muscle avulsion versus nerve stretch versus crush injury) that ensues from each of these conditions remains unclear. The natural history of muscle and nerve recuperation after such injuries is unknown. Is there a nerve regenerative process that can be stimulated to enhance recovery of function?

Defining and Assessing the Problem

Since investigators around the world and in different professional disciplines conduct research on FI and other bowel problems, there is an imminent need for international consensus on terminology used in research as well as practice. Without a common vocabulary, it is impossible to replicate methods, compare and interpret results, and evaluate conclusions across studies. The relative lack of past research and few active researchers in the field may be an advantage here. A start toward a common language has been made in the gastroenterology (Whitehead et al., 1999) and continence (Norton et al., 2002) communities. It is essential for nurses to define and integrate terms commonly used in continence nursing into this shared language. For example, standard terms and definitions of stool characteristics, difficulty or ease of defecation, gastrointestinal sensations, and nursing interventions need to be established and validated. Following common terminology, consensus on the minimum data set to include on a bowel diary or other assessment tool is needed. Such data sets could then serve as a rich, economical, and common resource for consortia of researchers.

FI Management

Individual Goals of Management

There is little known about which outcomes of bowel control (if complete continence is not possible) are important goals for the aging adult with FI or their caregivers. A bowel symptom questionnaire has been developed for older people (O'Keefe, Talley, Tangalos, & Zinsmeister, 1992), but its utility as an outcome measure for FI research and practice has not been reported. A start has been made in defining symptoms and quality of life issues of adults with FI (Bugg, Kiff, & Hosker, 2001;Rockwood et al., 1999;Rockwood et al., 2000) but an examination of their relevance to an older or frail population is needed.

Bowel Habit Training and Toileting Programs

Unlike the literature on UI, there have been virtually no reports of bowel retraining or toileting programs for FI (Norton & Chelvanayagam, 2004). There is no report of urge resistance training or deferment of defecation for people with urgency, the most common precursor to episodes of FI. Investigators of one study designed to address UI using a prompted voiding program made an incidental finding that, although actual episodes of FI were not reduced, bowel frequency increased and so did the proportion of stools passed continently in the toilet (Ouslander, Simmons, Schnelle, Uman, & Fingold, 1996). They concluded, unsurprisingly, that increasing opportunities to use the toilet increases bowel frequency and continence.

Information about normal bowel physiology and function (such as the gastrocolic response), normal defecation patterns in the general population, and the frequency of FI episodes (Bliss et al., 2004;Johanson & Lafferty, 1996) can support the initial design of toileting programs for adults with FI. The timing of toileting by caregivers for persons with both UI and FI requires additional consideration so that there is efficiency of effort and resources (Schnelle et al., 1995;Schnelle, Simmons, & Cretin, 2001). These programs should be systematically evaluated and modified as response patterns to this intervention emerge. Tobin and Brocklehurst (1986) reported a resolution of FI in 86% of nursing home residents in whom a laxative and bowel emptying regimen was administered. The investigators also found that staff administered the prescribed regimen in only 66% of residents, suggesting a lack of knowledge about the regimen, resistance to change, apathy, or a perception of inadequate time and resources. Schnelle et al. (1995, 2001) has quantified some of the shortfalls in implementing successful UI protocols in nursing homes and called for system-wide changes. A staffing ratio of five nursing home residents to one aide was needed to implement a multistep intervention (involving a toileting prompt, arm exercises, and offer of fluid) that reduced the frequency of FI by 4% (Schnelle et al., 2002). Few nursing homes are able to achieve this level of staffing. Ensuring the necessary resources and support to caregivers and nursing staff to implement successful interventions that reduce or prevent FI will require not only educational and adherence-promoting measures but also health policy and financing commitments (Krissovich, 1998).

Pelvic Floor Muscle Exercises and Biofeedback

Only one study has ever addressed the role of muscle exercises and biofeedback in an older population (Whitehead, Burgio, & Engel, 1985). Seventy-seven percent of elders who failed to show an improvement in FI frequency using sphincter exercises alone had a 75% decrease after biofeedback training. There is good evidence from clinical series that biofeedback and exercises may be effective in the general adult population, but evidence from randomized controlled studies is scarce for all age groups (Norton, Hosker, & Brazzelli, 2004). In one recent randomized controlled trial, there was no adjunctive benefit of using biofeedback over digital guidance for pelvic floor retraining (Solomon, Pager, Rex, Roberts, & Janning, 2003). In another, similar bowel continence outcomes were achieved with or without pelvic floor muscle exercises (PFMEs), leading the investigators to conclude that other elements of nursing management such as support and simple advice, rather than the exercises or biofeedback, may be the operant for change (Norton, Chelvanayagam, Wilson-Barnett, Redfern, & Kamm, 2003). The role of electrical stimulation of the external sphincter muscle on continence enhancement is unanswered in all age groups (Hosker, Norton, & Brazzelli).

There are numerous opportunities for research centering on the effects of PFME and biofeedback training for FI and conscious control of defecation and continence. Some fundamental questions are unanswered and include the following: To what extent do PFMEs help older people with FI? Which symptoms improve and how long will benefit last? What is the optimum PFME protocol? Does use of biofeedback equipment or electrical stimulation enhance the training and effect of PFMEs in the elderly? Should follow-up "booster" training for PFMEs be provided, and at what intervals? Would simple patient teaching that explains the recto-anal inhibitory reflex and its role in continence enable patients to counteract falls in anal pressure and resist the urge to defecate for long enough to prevent incontinence, in a "knack" analogous to that found effective for urinary stress incontinence (Miller, Ashton-Miller, & Delancey, 1998)? Are there criteria that can better predict success from PFMEs so we target resources needed for intensive training regimens to subgroups of patients who will most likely benefit?

Including a cost analysis of behavioral therapies for FI management in future research studies is recommended. Cost-benefit data would enable healthcare providers to determine the therapies they can offer with quality within their resources. These data might promote more timely translation of efficacious interventions into practice.

Dietary Strategies for FI

Anecdotal reports that persons with FI modify their diets and are open to dietary approaches for managing FI have recently been supported by research using surveys and qualitative interviews (Bliss, Fischer, & Savik, 2001;Bliss, McLaughlin, et al., 2000; Peden-McAlpine & Bliss, 2002;Norton & Chelvanayagam, 2000). Dietary self-care strategies include skipping meals, avoiding certain foods or food types, reducing portion size, planning meal times around outings in public, and using foods therapeutically.

Bliss, Jung, et al. (2001) reported that a dietary fiber supplement reduced FI and firmed stool consistency. A loose or liquid consistency of stool exacerbates FI (Bliss, Johnson, Savik, Clabots, & Gerding, 2000;Bliss, Jung, et al., 2001) and lowers the effectiveness of behavioral management strategies such as PFMEs and biofeedback (Sangwan et al., 1995;Soffer & Hull, 2000). Therefore, firming stool consistency is a priority objective of clinical management of FI. There are several theories about the mechanism of action of dietary fiber on colon function and stool characteristics that direct research approaches on FI management. These include water holding by a matrix of unfermented fiber and stool; gel formation by soluble fiber and water; facilitation of colonic function and water absorption by short chain fatty acids which are products of fermentation of fiber by colonic bacteria; and regulation of colonic transit (Bliss, Jung, et al., 2001;Marlett, Kajs, Fischer, 2000;Scheppach, 1994;Wenzl, Fine, Schiller, & Fordtran, 1995). Whether the fermentation properties of dietary fiber are foundational to these effects is currently being studied and will provide information about possible underlying mechanisms. Once the characteristics of an optimal type of fiber supplement have been determined, there will be the possibility of examining the contribution of dietary fiber in managing FI in a controlled way. The best use of dietary fiber-as an initial therapeutic approach, as an adjunct in raising the effectiveness of other strategies such as biofeedback or medication use, or as a general measure in promoting the health and function of colonic tissue and bacterial ecology-needs to be elucidated.

Some individuals are vulnerable to cycling between constipation and FI. Chassagne and colleagues (1999) successfully reduced FI by treating constipation using laxatives and enemas in nursing home residents. Dietary approaches may substitute or supplant certain medications such as laxatives in special populations. In long-term institutionalized residents, laxative use has been found to be ineffective in preventing FI and has even been associated with higher rates of FI (Brocklehurst, Dickinson, & Windsor, 1999). The evidence supporting colorectal emptying with oral laxatives as a means to prevent FI is inconsistent and sparse (Petticrew, Watt, & Sheldon, 1997). Comparing the effectiveness of dietary fiber and other nonpharmacological interventions such as abdominal massage (Resende, Brocklehurst, & O'Neill, 1993), adequate hydration, and digital stimulation or evacuation with medication use is an appropriate and timely topic for nursing research. Fecal impaction, a cause of incontinence, is one of 22 quality indicators monitored by the Centers for Medicaid and Medicare Services (CMS). The occurrence of fecal impaction is considered a sentinel event that can trigger an audit by CMS and carry severe penalties, especially if it occurs with other sentinel events (Berg et al., 2002). The importance placed by CMS on managing fecal impaction is an opportunity to leverage research funding to determine the effectiveness and cost of nursing practices, such as those described above, to reduce the incidence of fecal impaction and associated incontinence in nursing home residents.

Other areas for research include determining the effect of eating patterns (e.g., timing of eating and portion size) on FI and defecation urgency. Although the nutritional profile of the diet of persons with FI did not differ from that of age-and gender-matched controls with normal bowel function (Bliss, McLaughlin, et al., 2000), the possibility that individual foods or food types could aggravate or alleviate the severity of FI requires followup. Strategies to promote long-term adherence to diet supplements or other changes in diet patterns that reduce FI will be needed.

Trajectory of FI and Its Management Across the Healthcare System

Incontinence (urinary and fecal) is cited as the leading cause of institutionalizing aging adults (Nuotio, Tammela, Luukkaala, & Jylha, 2003). Little is known about the trajectory of incontinence severity, management, and response to therapy as adults move through various levels and settings of the healthcare system (Potter, Norton, & Cottenden, 2002). These findings may identify modifiable factors and points of patient contact that may improve FI outcomes. Research is also needed to identify the types of support needed by informal caregivers and assisted living staff who care for incontinent adults that would prevent institutionalization. Alternatives to institutionalization such as a home-based incontinence program directed by advanced practice nurses warrant evaluation.

Lessening the Psychological Burden of FI

Defecation is a complex event with meanings and social ramifications far more extensive than a purely biological function (Norton, 2004). Qualitative inquiry about living with UI and studies of the attitudes of healthcare workers and perceived barriers toward care of nursing home residents with UI (Mather & Bakas, 2002;Mitteness, 1987;Palmer, 1995) can be replicated in persons with FI to provide a fuller understanding of the impact of FI. Such explorations must be free of presumptions that might bias the analysis; for example, that the issues related to FI would be virtually identical to those of UI. As regional populations and healthcare staff become increasingly diverse, the typical parameters of bowel patterns, cultural meanings attributed to them, and the influence of culture on caregiving across age, sex, racial, and ethnic groups in community and institutionalized settings require investigation.

It is known that FI is associated with high levels of anxiety and depression in older people (Edwards & Jones, 2001), but the direction of causality has not been explored, nor has the psychological effect of resolving or reducing FI. Defecation urgency has been associated with reluctance of going on public outings, feelings of panic (Norton & Chelvanayagam, 2000), and increased severity of FI (Bliss et al., 2004). Persons with FI are aware of the public stigma of having FI, and hence many engage in extensive planning and rituals of preparedness prior to social outings as well as "secret-keeping" about their condition (Peden-McAlpine &Bliss, 2002). Testing of interventions directed at lessening urgency, anxiety, and fear related to FI is sorely needed. It is recommended that physiological and psychological interventions be tested in a combined or staged manner. Reconciling barriers and strategies for FI management is essential for implementing continence care, particularly when caregivers are involved. For example, negative perceptions about the appropriateness of toileting aging adults can deter this practice even though it may be effective (Lekan-Rutledge, Palmer, & Belyea, 1998).

Other Directions of Research

Among the recommendations for future research on FI are several topics addressed more fully in other presentations focused on UI in this special issue. These include measures during premenopause that will prevent the occurrence of FI. For frail elderly, the effect of the design and location of nursing home bathrooms, toilets, and commodes in promoting easy defecation, privacy, and continence of feces needs to be studied. Evidenced-based approaches for preventing FI in the elderly with dementia are needed. Perineal skin problems, such as dermatitis, are among the main and earliest consequences of FI. Developing, disseminating, and monitoring the use of cost-effective skin care protocols and products to prevent and treat incontinence-related dermatitis is a priority. There is a need to examine disposable absorbent products or reusable cloth garments for their ability to absorb, contain, and deodorize incontinent feces and prevent skin alterations. Other considerations are their fit and comfort, bulk appearance, variations for daytime versus nighttime use, discretion for carrying an extra supply in a purse or bag, easy removal for disposal in public, and cost.

Summary

The directions for nursing research on FI are summarized in Table 1. These recommendations were developed with the intent to outline an agenda for nursing investigation, encourage funding of studies in this area, stimulate new collaborations among researchers nationally and internationally, and attract novice investigators into the field. Opportunities for synergy between FI and UI research through collaborative efforts of investigators in those fields were identified. As recognition of the magnitude and impact of FI has increased, there is a compelling need for additional research to improve patient outcomes and support the prevention and management efforts of nurses.

TABLE 1. Directions for Nursing Research on Fecal Incontinence in Aging Adults

References