INTRODUCTION
Christine Norton PhD, MA, RN
Normal bowel control
Nursing and bowel care
Nurse specialists and continence care
Definitions of faecal incontinence
The need for research

THE PHYSIOLOGY OF DEFAECATION AND CONTINENCE
Anton Emmanuel BSc, MD, MRCP
Colonic motility
Anatomy
The rectum
The internal anal sphincter
The external anal sphincter
The pelvic diaphragm (pelvic floor)
Nerve supply of the rectum and anus
Rectal compliance
Ano-rectal sampling
The dynamics of continence
The dynamics of defaecation

THE EPIDEMIOLOGY OF FAECAL INCONTINENCE
Nicholas J. Kenefick MA, MB, BChir, MRCS
Faecal incontinence in the general population
Faecal incontinence in elderly people
Faecal Incontinence after childbirth
Faecal incontinence after colorectal surgery
Faecal incontinence in childhood

CAUSES OF FAECAL INCONTINENCE
Christine Norton and Sonya Chelvanayagam MSc, RN, RMN
Anal sphincter floor damage
Obstetric trauma to the anal sphincters
Iatrogenic damage to the anal sphincters
Iatrogenic damage to the anal sphincters
Gut motility / Stool consistency
Ano-rectal pathology
Neurological disease
Consequences of degenerative neurological disease
Impaction with overflow
Environmental factors
'Lifestyle' and other factors
Idiopathic incontinence

PSYCHOSOCIAL ASPECTS OF PATIENTS WITH FAECAL INCONTINENCE
Sonya Chelvanayagam and Solveig Wilson CSS
Developing bowel control
Maintaining bowel control
Psychosocial aspects of faecal incontinence
Psychological aspects of faecal incontinence
Quality of life
Nursing assessment of psychological issues
Assessment and treatment by psychological services

NURSING ASSESSMENT OF ADULTS WITH FAECAL INCONTINENCE
Sonya Chelvanayagam and Christine Norton
The assessment interview
Examination
Rating the severity of incontinence and constipation

RECTAL BLEEDING – WHEN TO REFER
Maggie Vance MSc, RGN
Definition of rectal bleeding
Differential diagnoses of rectal bleeding
When to refer
The assessment process
Diagnostic pathway for patients with rectal bleeding
The rectal bleeding clinic – a model for practice
Rationale for service
Clinic practice
Preliminary Results

ANO-RECTAL PHYSIOLOGY INVESTIGATION TECHNIQUES
Tanya Nicholls BSc, PhD
Ano-rectal manometry
Fatigue rate measurement
Sensory testing
Rectal sensation
Recto-anal inhibitory reflex
Balloon expulsion
Anal canal and rectal mucosal sensation
Anal canal
Pudendal nerve terminal motor latency (PNTML)
Perineal descent
Rectal compliance testing
Saline Retention Test

RADIOGRAPHIC INVESTIGATIONS
Andrew Williams MSc, FRCS
Anal ultrasound
Magnetic resonance imaging (MRI)
Defaecography / Evacuation proctography
Scintigraphy and transit measurement

INVESTIGATION AND MANAGEMENT OF CHRONIC DIARRHOEA IN ADULTS
Sally Bell MB, BS, FRACP, MD
Definition and mechanisms of chronic diarrhoea
History
Examination
Differential diagnosis and investigation
Management

COMMON ANO-RECTAL CONDITIONS
Gordon Buchanan MSc, FRCS and Richard Cohen MD, FRCS
Pruritus ani
Haemorrhoids
Anal fissure
Anal fistula
Rectovaginal fistula
Pilonidal sinus
Perianal haematoma
Anal warts (condylomata acuminata)
Rectal prolapse
Solitary rectal ulcer syndrome
Polyps and neoplasia

CONSERVATIVE MANAGEMENT OF FAECAL INCONTINENCE IN ADULTS
Christine Norton and Sonya Chelvanayagam
BIOFEEDBACK
Introduction
Background
The biofeedback clinic
Elements of the package
Patient teaching
Resisting urgency – bowel habit training
A suggested mechanism – can urgency be learned?
Anal sphincter exercises
Biofeedback
Conclusions
ELECTRICAL STIMULATION FOR FAECAL INCONTINENCE
Electrical stimulation parameters
Conclusions on electrical stimulation

BOWEL CARE IN OLD AGE
Danielle Harari FRCP
Epidemiology of constipation in older people
Epidemiology of faecal incontinence in older people
The ageing bowel / pathogenesis of constipation and incontinence
Ano-rectal problems
Causes of constipation in older people
Causes of faecal incontinence in older people
Assessment and diagnosis of constipation and faecal incontinence
Complications of constipation and faecal incontinence
Treatment of constipation
Treatment of faecal incontinence

SURGICAL TREATMENT OF FAECAL INCONTINENCE
Andrew James Malouf FRACS
Local ano-rectal conditions causing incontinence
Incontinence associated with full-thickness rectal prolapse
Overlapping external anal sphincter repair
Internal anal sphincter repair
Injection augmentation of the internal anal sphincter
Post-anal repair
Total pelvic floor repair
Anal neosphincters
Antegrade continence enema (ACE) procedures and colonic conduits
Sacral nerve stimulation
Colostomy

A STOMA FOR INCONTINENCE?
Julia Williams MSc, RGN
What is a stoma?
Options for ostomists
Biodegradable appliance
The colostomy plug
Colostomy irrigation
Biofeedback training
Incontinence versus a stoma

DRUG THERAPY FOR FAECAL INCONTINENCE
Mark Cheetham MB, BS, BSc, FRCS
Constipating agents
Stool bulking agents
Evacuation aids
Novel treatments

BOWEL DYSFUNCTION: ASSESSMENT AND MANAGEMENT IN THE NEUROLOGICAL PATIENT
Paul Wiesel MD and Sally Bell FRACP, MD
Epidemiology of the neurogenic bowel
Neurophysiology of the gastrointestinal tract
Assessment of the neurogenic bowel
Further investigations of constipation and faecal incontinence
Ano-rectal physiology tests
Radiological investigations
Autonomic dysreflexia
Management of the neurogenic bowel
Bowel programmes
Assistive methods
Management of constipation and faecal incontinence in neurological disease
Management of faecal incontinence
Summary
Educational strategies for the neurogenic patient

BOWEL CONTROL AND INTELLECTUAL DISABILITY
Linda Smith MA, MSc and Paul Smith MA, MSc, PhD
Encopresis in the Field of Learning Disability
Prevalence of Encopresis in Learning Disability
Prevalence of Constipation in Learning Disability
Aetiology
Treatment

CONSTIPATION AND FAECAL INCONTINENCE IN CHILDHOOD
Graham Clayden MD, FRCP, FRCPCH and Gillian Hollins RGN
Causes of faecal incontinence in children
Chronic constipation in childhood
Pathophysiology of chronic constipation
The use and pharmacology of laxatives
Useful routines
Eating
Drinking
Liaison with the school
Exercise
Self-massage
Toileting or bowel training
Laxatives
Psychological Aspects
Team working
Other conditions

PRACTICAL MANAGEMENT OF FAECAL INCONTINENCE
Sonya Chelvanayagam and Christine Norton
Emotional support
Diet and fluids
Lifestyle modification and medication
Products for managing faecal incontinence
Anal plug
Pads and Pants
Washing and odours
Skin care

CONSTIPATION
Anton Emmanuel
Clinical sub-types of constipation
Clinical features
Primary care management
Investigation of constipation
Treatment
Biofeedback
Surgical management
Specific conditions
Idiopathic megabowel
Hirschsprung's disease

BEHAVIOURAL AND BIOFEEDBACK THERAPY FOR EVACUATION DISORDERS
Nicky Horton RGN
Aims of treatment
Patterns of presentation
The Biofeedback session
Assessment
Health education
Medication
Defaecatory muscle exercises
Teaching the exercises
Biofeedback protocols
Follow-up appointments
Psychological Issues
Discharge
Efficacy of biofeedback for evacuation disorders

MAKING TOILETS MORE ACCESSIBLE FOR INDIVIDUALS WITH A DISABILITY
Helen White RGN, RHV
Environmental issues and continence
Public and private toilets – a guide to good practice
Accessible toilets – designs and recommendations
Alternatives to the toilet
Commodes and chemical toilets
Accessories for the toilet
Toilet seats and supports
Hygiene appliances
Obtaining and supplying equipment

USEFUL ADDRESSES

INDEX