Clinical Assessment and Differential Diagnosis of Fecal Incontinence and Its Severity

  • Kathleen F. HunterEmail author
  • Tamara Dickinson
  • Veronica Haggar


Assessment and diagnosis of fecal incontinence by the advanced practice nurse involve critical thinking in the process of differential diagnosis of fecal incontinence. Fecal incontinence is a stigmatized condition that requires the advanced practice nurse to approach the patient from a perspective of cultural competence, demonstrating respect and acknowledgment of the sensitive nature of the concern. History taking starts with symptom assessment, as well as gathering a comprehensive health history. The use of a standardized symptom assessment instrument, particularly one that includes quality of life, can be helpful. The physical examination includes abdominal examination, vaginal examination in women, assessment of pelvic muscles in both women and men, and rectal examination. Arriving at the differential diagnosis must take into account the data gathered in the history and physical exam, as well as consideration of the breadth of potential causes, including red flag symptoms and signs. Laboratory investigations for specific conditions that may contribute to fecal incontinence may include tests for suspected hypo- and hyperthyroidism, diabetes, celiac disease, colorectal cancer screening, and infection. Diagnostic imaging to further evaluate fecal incontinence may be ordered by the advanced practice nurse or be accessed through referral.


Assessment History taking Rectal examination Pelvic floor Differential diagnosis 


  1. 1.
    Jarvis C. Physical examination and health assessment. Elsevier Health Sciences: St. Louis; 2016.Google Scholar
  2. 2.
    Stanhope M, Lancaster J. Public health nursing: population-centered health care in the community. 8th ed. Elsevier Mosby: Maryland Heights, MO; 2012.Google Scholar
  3. 3.
    Elstad EA, Taubenberger SP, Botelho EM, Tennstedt SL. Beyond incontinence: the stigma of other urinary symptoms. J Adv Nurs. 2010;66(11):2460–70.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    The Simon Foundation for Continence. First International Conference on Stigma in Healthcare.
  5. 5.
    Bliss DZ, Mimura T, Berghmans B, Bharucha A, Chiarioni G, Emmanuel A, et al. Assessment and conservative management of faecal incontinence and quality of life in adults. In: Abrams P, Cardozo L, Wagg A, Wein A, editors. Incontinence. 6th ed. Bristol: International Continence Society; 2017. p. 1993–2085.Google Scholar
  6. 6.
    Daines J, Baumann L, Scheibel P. Advanced health assessment and clinical diagnosis in primary care. 4th ed. St. Louis, MI: Elsevier Mosby; 2012.Google Scholar
  7. 7.
    Rhoads J, Petersen SW. Advanced health assessment and diagnostic reasoning. Burlington, MA: Jones & Bartlett Learning; 2016.Google Scholar
  8. 8.
    Nevler A. The epidemiology of anal incontinence and symptom severity scoring. Gastroenterol Rep (Oxf). 2014;2(2):79–84.CrossRefGoogle Scholar
  9. 9.
    Cotterill N, Norton C, Avery KNL, Donovan JL. A patient-centered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence. Dis Colon Rectum. 2008;51(1):82–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Cotterill N, Norton C, Avery KN, Abrams P, Donovan JL. Psychometric evaluation of a new patient-completed questionnaire for evaluating anal incontinence symptoms and impact on quality of life: the ICIQ-B. Dis Colon Rectum. 2011;54(10):1235–50.CrossRefPubMedGoogle Scholar
  11. 11.
    Sansoni J, Hawthorne G, Fleming G, Marosszeky N. The revised faecal incontinence scale: a clinical validation of a new, short measure for assessment and outcomes evaluation. Dis Colon Rectum. 2013;56(5):652–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Jorge JMN, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36(1):77–97.CrossRefPubMedGoogle Scholar
  13. 13.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Fecal incontinence quality of life scale: a quality of life instrument for patients with fecal incontinence. Dis Colon Rectum. 2000;43:9–17.CrossRefPubMedGoogle Scholar
  14. 14.
    Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut. 1999;44(1):77–80.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920–4.CrossRefPubMedGoogle Scholar
  16. 16.
    Bliss DZ, Larson SJ, Burr JK, Savik K. Reliability of a stool consistency classification system. J Wound Ostomy Cont Nurs. 2001;28(6):305–13.Google Scholar
  17. 17.
    Haylen B, Maher C, Camargo S, Dandolu V, Withagen M. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Neurourol Urodyn. 2016;35:137–68.CrossRefPubMedGoogle Scholar
  18. 18.
    Riss P, Koch M. Evaluation of pelvic organ prolapse. In: Principles and practice of urogynaecology. New Delhi: Springer India; 2015. p. 107–14.Google Scholar
  19. 19.
    Laycock J. Pelvic muscle exercises: physiotherapy for the pelvic floor. Urol Nurs. 1994;14:136–40.PubMedGoogle Scholar
  20. 20.
    American Gastroenterological Association. American Gastroenterological Association Medical position statement on constipation. Gastroenterology. 2013;144:211–7.CrossRefGoogle Scholar
  21. 21.
    Orkin BA, Sinykin SB, Lloyd PC. The digital rectal examination scoring system (DRESS). Dis Colon Rectum. 2010;53(12):1656–60.CrossRefPubMedGoogle Scholar
  22. 22.
    Cannon JA. Evaluation, diagnosis, and medical management of rectal prolapse. Clin Colon Rectal Surg. 2017;30(01):016–21.Google Scholar
  23. 23.
    Stewart DB Sr, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SR. Clinical practice guideline for the management of anal fissures. Dis Colon Rectum. 2017;60(1):7–14.CrossRefPubMedGoogle Scholar
  24. 24.
    Birnbaum E, editor. Surgical anatomy of the colon, rectum, and anus. Cham: Springer International; 2017.Google Scholar
  25. 25.
    Theys T, Kho KH. The saddle and the horse’s tail: Cauda equina syndrome. JAMA Neurol. 2014;71(7):914–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Weinstein A, Pinto-Powell R. Introductory clinical reasoning curriculum. MedEdPortal. 2016.;
  27. 27.
    Hippisley-Cox J, Coupland C. Identifying patients with suspected colorectal cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract. 2012;62(594):e29–37. CrossRefPubMedGoogle Scholar
  28. 28.
    Krishnan B, Babu S, Walker J, Walker AB, Pappachan JM. Gastrointestinal complications of diabetes mellitus. World J Diabetes. 2013;4(3):51–63.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013;108(5):656–76.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Yamada T, Inadomi J, Bhattacharya R, Dominitz J, Hwang J. Yamada’s handbook of gastroenterology. 3rd ed. Hoboken, NJ: Wiley; 2013.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Kathleen F. Hunter
    • 1
    • 2
    Email author
  • Tamara Dickinson
    • 3
  • Veronica Haggar
    • 4
  1. 1.Faculty of NursingUniversity of AlbertaEdmontonCanada
  2. 2.Glenrose Hospital Continence ClinicEdmontonCanada
  3. 3.Radiation OncologySouthwestern Medical Center, Harold C. Simmons Comprehensive Cancer CenterDallasUSA
  4. 4.Homerton University Hospital, NHS Foundation TrustLondonUK

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