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In those with impaired or reduced anal tone, in particular multiparous women or those with a history of surgery to the anus, anal ultrasound is a useful and minimally invasive technique to assess the structure and function of the anal sphincter complex and correlates well with both surgical and electromyographic findings.⁵¹ Magnetic resonance imaging (MRI) has been shown to give superior spatial resolution and better contrast for lesion identification versus ultrasound⁵² but is more expensive, and availability may be limited. Defecography is a technique where a viscous barium contrast (usually, barium liquid mixed with mashed potato, oatmeal, or flour) is injected into the rectum and then defecated into a commode with X‐ray or MRI recording; it is of limited value except in the diagnosis of rectal introsusception. The advent of laparoscopic ventral rectopexy has given a useful treatment option for rectal intussusception, leading a resurgence in interest in the imaging technique.⁵³ Neurophysiological testing using electromyography, pudendal terminal motor latency, or somatosensory evoked potentials are of limited value in faecal incontinence and are not generally recommended.⁵⁴

Management of faecal incontinence

      The management of faecal incontinence should be guided by the underlying causes identified during the assessment and informed by the individual patient’s cognitive and functional abilities, willingness to participate in therapy, and realistic goal setting. Involving the patient and their caregivers is essential in treatment planning.

      Conservative Measures

      The initial management of faecal incontinence is to identify and treat any underlying or contributing causes. Deprescribing and discontinuing culprit drugs is often an effective first step.

      Normalizing the stool consistency, aiming for a type 4 or 5 on the Bristol stool form scale, can be highly effective in the treatment of faecal incontinence caused by either loose stool or constipation. Supplementation of dietary fibre with bran, increasing the intake of soft fruit and fruit juices, or using agents such as psyllium husk (Fybogel™, Metamucil™, and others) can treat both constipation and loose stool but should be introduced slowly and increased. Rapid increases in dietary fibre are associated with flatulence and abdominal discomfort. Involving a dietitian can be helpful in those with inadequate nutritional intake, and consideration should be given to the availability and affordability of changes to diet. For those with hard type 1 or 2 stool, stool softeners such as polyethylene glycol 3350 (PEG, Movicol™, Resoralax™, and others) are effective and the dose is highly adjustable. A common error made by patients is to wait until they are very constipated, then take a large dose of stool softener (leading to diarrhoea), and then stop the softener altogether or even take antidiarrhoeal agents. Individuals should be counselled to take a small dose regularly, increasing weekly until they have regular, soft, and controllable bowel movements that are easy to pass. If they overshoot and get loose stool, they should be advised to reduce the dose rather than stop. Docusate is ineffective and should not be prescribed.⁵⁵

      Stimulant laxatives, including sennosides, bisacodyl, and others, are of value in those who are constipated with soft stool but lack the propulsive force required to evacuate fully, a situation often seen in neurological disease. Rectal preparations, either enemata or suppositories, are useful in constipation not amenable to oral treatment, and 5HT⁴ antagonists such as prucalopride can also be tried,⁵⁶ although the results can be somewhat too effective.

      For those with loose stool, agents to induce constipation, including loperamide and codeine, can be helpful. As with stool softeners, starting at a low dose and increasing until the desired consistency is achieved is recommended. Loperamide is available as a liquid preparation, allowing precise dose adjustment. Occasionally, a ‘block and replace’ approach is necessary, deliberately inducing constipation and then using either oral or rectal stimulant laxatives to produce a predictable bowel movement. If bile salt malabsorption is suspected, a trial of cholestyramine can be both diagnostic and therapeutic.

      In people living with dementia, clearly signed facilities with regular reminders and assistance to toilet are recommended. Utilizing the gastrocolic reflex can be helpful. The gastrocolic reflex induces the urge to defecate some 30–60 minutes after eating, and as such encouraging toileting after breakfast can be a way help achieve successful toileting. Unfortunately, in institutional settings with common mealtimes, this can be a way TO help challenging to arrange given staffing levels.

      Pelvic floor training and biofeedback

      Pelvic floor muscle therapy, both self‐directed and with the assistance of a physiotherapist, aims to strengthen the pelvic floor muscles and therefore increase anal tone. In a typical protocol, the patient may be instructed to squeeze for 10 seconds while continuing to breathe deeply so that the abdominal wall muscles do not also contract. Ten to 20 such 10–second squeezes are separated by 20‐second periods of pelvic floor relaxation. Patients are instructed to squeeze 10–20 times in a block and to repeat this block of exercises three to five times a day, with both ‘quick’ squeezes lasting one second and ‘slow” squeezes held for up to 10 seconds. The patient may be taught how to perform this exercise using only verbal or written instructions, or the therapist may give them verbal feedback on their performance during a digital rectal examination.⁵⁷ Pelvic floor exercise has been shown to be effective for urinary incontinence in women with cognitive impairment⁵⁸ but has not been studied for faecal incontinence in this group.

Biofeedback is classically described as a learning

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