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National Collaborating Centre for Acute Care (UK). Faecal Incontinence: The Management of Faecal Incontinence in Adults. London: National Collaborating Centre for Acute Care (UK); 2007. (NICE Clinical Guidelines, No. 49.)

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Faecal Incontinence: The Management of Faecal Incontinence in Adults.

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Faecal incontinence, the involuntary loss of solid or liquid stool, has been a neglected health care problem, in the UK and around the world. In many instances it has been overshadowed by the more prevalent urinary incontinence, which itself has only recently gained widespread attention. Yet faecal incontinence is likely to affect over half a million adults in the UK and often it has very profound negative consequences for the patient. Fear of embarrassment, even at worst public humiliation, can impose major restrictions on the individual and the family. For this reason, the decision of NICE to address this hidden topic is most welcome.

Possibly past neglect of faecal incontinence has been because of the lack of a single professional healthcare group which takes a lead on this problem. Patients might be managed in primary care, or by colorectal surgeons, gastroenterologists, neurologists, care of the elderly specialists, or most often nobody. Continence nurses and physiotherapists have traditionally, with a few exceptions, focused more on urinary than faecal incontinence.

The task of producing a guideline on the management of faecal incontinence in adults has presented challenges, the greatest of which has been the almost complete absence of high quality evidence for most assessment and treatment methods. The guideline development group was therefore faced with a choice: recommending nothing in the absence of good evidence, or doing the best that we could on lesser quality evidence and expert opinion. We chose the latter as we felt that the needs of patients demanded that we at least provide a starting point. But we urge the reader to remember that little of what is contained in this guideline is based on incontrovertible evidence.

A second major challenge has been the absence of agreed and validated outcome measures for faecal incontinence. There is particularly an absence of measures based on patients’ views of what is important in outcomes. For this reason, we have included a section on patients’ views, from the very limited evidence that could be obtained. With a non life-threatening symptom such as faecal incontinence, where there is no objective gold standard for measuring symptoms, the patient’s view must be paramount.

Some of our recommendations may seem conservative: such as avoiding costly unproven investigations and surgical interventions, at least in the absence of very specific indications. This is not because we believe that faecal incontinence should not be managed in the most vigorous manner, but rather that we wish to avoid potentially harmful interventions, pending the availability of better research.

The overall message of this guideline is simple: do not ignore the symptom of faecal incontinence and assume that nothing can be done. Clinical experience suggests that the majority of patients can be at least improved, and in many instances symptoms can be resolved. Success will usually depend upon identifying the often complex interaction of factors causing symptoms for each individual, and some persistence in finding a combination of interventions that gives best control of those symptoms.

NICE guidelines are by their nature intended for the general situation, aiming to cover 80% of cases 80% of the time, rather than being totally all-inclusive of all possible eventualities. Guidelines deliberately suggest what should be done, rather than specifying service configurations and personnel to deliver care. We hope that this guideline will raise awareness, lead to structured systematic thinking about faecal incontinence and in time stimulate research that will improve quality of life for a substantial number of people.

Professor Christine Norton

Chair, Guideline Development Group

Copyright © 2007, National Collaborating Centre for Acute Care.

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Bookshelf ID: NBK50652


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