What’s causing Jim’s faecal incontinence?

I met Jim and his family when he was in a intermediate care unit. He’d had a stroke several years ago. He had a pacemaker in. He had cellulitis on his legs and a lot of health problems as a result of his stroke. He had dysphasia, so he couldn’t communicate properly. He was confined to a wheelchair and essentially he was incontinent of urine and faeces as well. At home he’d been managing his urinary continence himself by using a urine bottle but he was so frail and weak at this point that he wasn’t able to do that, so the staff got in touch with me to see if I could come up with any other solutions.

His condition did improve once he was in intermediate care and had physiotherapy and so on, but his main urinary problem was a bit of urgency and when someone has urgency of urine and it’s a new symptom I always think bowel and he seemed to have had a history of constipation as well, so I thought perhaps that might be part of the problem and so I asked the unit to keep me 24 hours worth of pads to look at and they had various amounts of urine in them but almost every single one had some faecal smearing on it, which would be an indication that he’s either constipated or he’s not emptying his bowels properly.

I looked at his fluid intake and output charts and unfortunately even the ones from hospital, the ones from intermediate care, all had gaps in them, so it wasn’t really going to tell me very much. I looked at his medication charts and he was prescribed laxatives but wasn’t always getting them and the reason being that he was a bit loose in the bowel department from time to time but also there were some recordings on the bowel charts that showed a tight one on the Bristol Stool Scale which would indicate constipation. So actually there wasn’t a lot of evidence there to support a good assessment.

I decided the best thing that I could do was to have a meeting with him and have a chat through to see if I could help to make a bit more sense of it all. He was not really able to make a lot of sense because of his dysphasia but his daughter was able to translate for him, she was really, really good. The gist of what he was saying was that he was happy with things as they were. He didn’t want to use a urine bottle. I discussed the potential of using a urisheath which might have been a bit challenging because he’d been in a wheelchair for a long time and so the penis tends to retract quite a lot.

However, he wasn’t prepared to even consider that and really he was wanting to be left alone, but I discussed with him that perhaps we should have a meeting with his home care supervisor, the staff in the unit and his family and social workers so that we could have a chat about what treatment would be best and how we could support him. If there was anything that he would actually agree to. I held the meeting and it became clear that there had been problems with his bowels all along and that he hadn’t actually sat on the toilet for three years. The reason for that was, well he was incontinent so there wasn’t any point.

So I did a bit of teaching in the meeting and I explained how the body works, how the bowel works, how the you eat food and sort of 20-30 minutes later generally you’re ready to have a bowel movement. And I felt - well I told them that I felt if he could sit on the toilet that he could potentially become fecally continent. The immediate reaction from the home care supervisor was that they don’t have time to do that and the social worker didn’t seem to think that there was going to be any more funding for it.

However, his daughter was very, very interested in this and said that she would give it a go and the staff in the intermediate care unit said, yes, that they would try and get him on the toilet as well and see if they could make a difference, but as so often happens, suddenly someone’s ready for discharge home and he was away before anything really could be done.

However, I got in touch with his daughter and they had a toileting sling at home and she started to get him on the toilet after breakfast and also I had suggested that rather than giving him his laxatives intermittently that they gave them as prescribed and then we could adjust the dosage as required and the combination of that and his daughter getting him on the toilet seemed to work and he was having daily bowel movements after his breakfast.

For Jim, the over- whelming impact was his relationship with his granddaughter - so he had a granddaughter who was 12 and she was the apple of his eye, he just absolutely loved her, but she didn’t like cuddling him too much because he quite often was a bit smelly and he said that he gets loads of cuddles from his grand- daughter now because granddad’s not smelly anymore and for him that was a huge impact.

From my perspective it was good in a lot of other ways, but the impact on Jim was so good and his mood improved so much after that as well that he started using a urine bottle again - we got him an adapter so it was easier to use but he became completely independent with his urine during the day. Still used a pad at night and his bowels were good as long as he got on the toilet at the right time.