Faecal incontinence and constipation — Rapid

Synopsis

Distinguish true faecal incontinence from overflow and functional toileting failure, identify obstruction, neurological and cancer danger, and restore predictable bowel emptying with cause-specific, dignified and practical care.

Constipation includes hard or infrequent stool, straining, incomplete emptying or obstructed defaecation; daily stool does not exclude retention.
Faecal incontinence is involuntary loss of solid or liquid stool; classify urge, passive, seepage, overflow and functional patterns.
First-line assessment uses a bowel and food-fluid history, Bristol stool form, medicine review, abdominal and perianal examination and digital rectal examination when appropriate.
Always exclude faecal loading before prescribing loperamide for apparent diarrhoea or incontinence in a frail older adult.
Review opioids, anticholinergics, iron, calcium, verapamil, diuretics, laxatives, metformin and antibiotics, balancing changes against the original indication.
First-line constipation care combines accessible fluids, regular unhurried toileting after meals, movement, adequate fibre when safe and a titrated laxative regimen.
Treat impaction before maintenance; oral macrogol is commonly used when obstruction is excluded, with rectal treatment selected from stool location and tolerance.
For faecal incontinence, optimise stool consistency and bowel emptying before pelvic-floor training, biofeedback, irrigation or surgical referral.
NICE recommends loperamide as the preferred initial antidiarrhoeal for faecal incontinence with loose stool when contraindications and loading are excluded, starting low and titrating.
A community bowel plan must specify target stool, medicine dose, toileting timing, assistance, skin care, escalation and who reviews it.

Key red flags

Colicky pain, vomiting, marked distension and absent flatus requires urgent bowel-obstruction assessment before laxative escalation.

New retention or faecal incontinence with saddle change or bilateral leg weakness requires emergency spinal imaging.

Weight loss, iron-deficiency anaemia, rectal bleeding, mass or persistent change in bowel habit requires colorectal cancer investigation.

Fever, tachycardia, severe tenderness or bloody diarrhoea raises colitis, ischaemia or perforation concern and requires acute care.

Overflow diarrhoea around a large rectal load can cause dehydration, delirium and urinary retention despite apparently loose stool.

Perianal injury, unexplained bruising, fear of carers or deliberate withholding of toileting support raises safeguarding concern.

Obstructive or neurological danger

Vomiting, absent flatus, peritonism or new saddle and leg signs requires emergency assessment.

Investigation priorities

Bowel diary and Bristol stool formFirst step

Define consistency, timing, leakage and treatment response.

Management branches

First-line bowel assessmentSeparate loading, diarrhoea and access failure

Constipation or faecal leakage is reported.

Describe stool, emptying, warning, leakage, diet, fluids, medicines, neurology and red flags and assess abdomen, perineum and rectum.
Treat obstruction, spinal, inflammatory and cancer danger before routine bowel medicines.
Agree a target stool and a practical food, fluid, movement, toileting, medicine and skin plan with a review date.

Key medicines

Macrogol 3350 with electrolytesFor constipation, use one sachet orally one to three times daily according to response. For confirmed faecal impaction in adults, dissolve eight sachets in one litre of water and consume within six hours daily for up to three days, only after obstruction is excluded.Review swallowing, fluid and electrolyte tolerance, heart or kidney disease and worsening pain or vomiting; individual products differ and obstruction is a contraindication.

LoperamideFor faecal incontinence with loose stool, NICE advises starting at 0.5 to 1 mg orally daily and titrating to the desired stool consistency, with a maximum total dose of 16 mg daily.Avoid in hard or infrequent stool, acute bloody diarrhoea, active inflammatory colitis, ileus or suspected loading; excessive doses cause constipation, overflow and potentially serious cardiac toxicity.

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