Colorectal Cancer -

Colorectal Cancer -

Clinical evaluation of faecal incontinence and constipation By courtesy of Christine Norton PhD MA RN Nurse Consultant (Bowel Control) & Professor of Gastrointestinal Nursing St Marks Hospital & Kings College London, United Kingdom

Assessment the evidence No evidence-based assessment protocols Informed opinion: history and physical examination most important Clinicians often fail to examine Physical environment and carers may be most important factor for immobile people What tests are needed? Comprehensive history

(Norton & Chelvanayagam, 2000) Diary & symptom questionnaire

Physical examination If bowel investigation needed: colonoscopy Anorectal physiology tests? Anal ultrasound? If indicated: proctogram, bloods What goes wrong? Anal sphincter (childbirth, injury, iatrogenic damage, degeneration) Internal anal sphincter - passive soiling

External anal sphincter - urge incontinence Gut motility (infection, inflammation, radiation, hypermotility, emotions) Stool consistency (diet, motility, anxiety) Local pathology (prolapse, piles, fistula) Neurological damage (motor or sensory) Lifestyle, toilets, drugs,immobility History

Pre-morbid and current bowel symptoms Timing of onset, is it worsening? Faecal incontinence: Urgency = loose stool or EAS problems Passive loss = IAS problems or incomplete evacuation Constipation: Slow transit or evacuation difficulty (or both)?

History Co-morbidities and general health Diet (amount, type and pattern) Fluids (amount, type and pattern) Toileting abilities, mobility, carers and toilet

facilities Medications Lifestyle & psychosocial support Depression and anxiety Stool form can give clues as to pathology Loose stool more difficult to control Hard stool suggests

evacuation difficulty Must ask about bleeding (bowel cancer second commonest cancer in UK) - refer to rectal bleeding clinic Do not assume bleeding is piles One week diary gives

a baseline Tick in shaded column when open bowels in toilet Tick in white column for incontinence or pad change More complex diaries may be needed for special groups

Physical examination Abdomen (masses, bladder) Anal inspection (soiling, prolapse, scarring, haemorrhoids, gaping) Digital anal (resting tone and squeeze) Digital rectal (loading, masses) Examine for prolapse on toilet Vaginal (rectocele)

Observing the perianal area Rectal or vaginal prolapse

Haemorrhoids or skin tags Wounds, lesions, discharge Gaping anus Skin condition Bleeding Stool, infestation and foreign bodies Rectal Prolapse

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