Hypothesis / aims of study
Fecal incontinence (FI) is an unintentional loss of fecal contents for at least one month in adult individuals. While functional constipation (FC) is based on six criteria according to ROMA IV: straining to defecate, hard or lumpy stools, incomplete evacuation, the sensation of anorectal obstruction or blockage, manual maneuvers to facilitate defecations, and less than three defecations per week. Both bowel disorders are neglected mainly and underreported due to embarrassment in reporting symptoms, even though they are debilitating physical and psychosocial conditions with a devastating impact on quality of life. The most common way to evaluate these dysfunctions is the evacuation diaries. In addition to facilitating the detailed assessment of intestinal symptoms and the frequency of episodes in real-time, it supports the diagnosis.
Furthermore, it provides a more practical direction of interventions by the nurse, as they are "closer to real life" and less susceptible to memory biases. However, the evacuation diaries do not assess FC and FI coexisting symptoms. In this context, nurses in a pelvic floor dysfunction clinic in Brazil developed an evacuation diary associated with the Bristol Stool Form Scale, Rome criteria, and Wexner score. Scales in the patient's daily filling minimize memory bias and neglect of individual or coexisting symptoms of each dysfunction.
The aim is to develop an evacuation diary that assesses coexisting symptoms of FC and FI closer to the patient's reality by incorporating scales widely used to assess these symptoms.
Study design, materials and methods
It is a methodological study that applies methods of obtaining the organization to develop and evaluate instruments, searching for new meanings and interpretations of phenomena. Through this methodological approach, we aimed to associate the Bristol Stool Form Scale, Rome criteria, and Wexner score in an evacuation diary.
The bowel diary is widely used to diagnose and treat bowel disorders and is often used to assess critical outcomes in clinical trials. Unlike subjective questionnaires, a prospective bowel diary is an objective assessment in which patients record bowel symptom characteristics and frequency of FI episodes in real-time. Its development took place in two stages.
Initially, a search was carried out for the scales widely used in Brazil and the world to assess FC and FI, with the Bristol Stool Form Scale, Rome Criteria, and Wexner score being the most evident.
The Bristol StoolForm Scale, developed and validated by Kenneth W. Heaton and S. J. Lewis, descriptively assesses the form of fecal content using graphical methods that represent seven types of stool, according to descriptions of their form and consistency. It allows a self-assessment of the stools, stimulating self-knowledge about the evacuation dysfunction.
The Rome Criteria functional gastrointestinal disorders are classified into six broad domains for adults. For the construction of the evacuation diary, items related to the diagnosis of FC (C3) were incorporated, which is part of the functional intestinal disorders (category C), which is based on six criteria: effort when evacuating, complicated or fragmented stools, the feeling of incomplete evacuation, the sensation of anorectal obstruction or blockage, manual maneuvers to facilitate bowel movements and less than three bowel movements per week. People with two or more criteria in the last six months are considered to have FC.
The Wexner score was developed as a simple and easy-to-understand tool to examine the frequency of 3 types of FI (solid, liquid, and gaseous) and their consequences (use of pads and changes in lifestyle). The instrument developed by Jorge and Wexner is the most widely used instrument for assessing FI and has the closest correlation with patients' subjective perception of FI.
In the second phase, an attempt was made to incorporate the items for evaluating the symptoms of FC, FI, and type of stool based on the scales raised in the diary. For this phase, usability concepts were used: the user's ability to interact with and accept a tool. Goals include visibility; compatibility with reality; user freedom; recognition at the expense of memorization, and minimalist design and documentation aesthetics. Some usability studies show that these goals mentioned above are methods that enable reliable and efficient diagnoses.
Results
The diary was built in the horizontal format of A4 size in a table with eight columns and three blocks of lines where each block represents a specific symptom for CF or IF.
In the columns, the symptoms of intestinal dysfunctions and days of evacuation were displayed. In the column referring to the symptoms, the lines below form the first block with the symptoms of CF according to ROME IV. According to Bristol, the second block of stool assessment and the third block refers to the symptoms of FI, according to Wexner. The other columns contain the days of the week with the option to include the date and time of the evacuation.
According to the principle of compatibility with reality; user freedom; recognition at the expense of memorization, the symptom assessment questions were adapted to a simple language consistent with the patient's reality. To improve the visualization and completion of the diary, pursuing the design goal and minimalist aesthetics of the documentation, each block of lines was given different colors to correspond to the different symptoms and alterations. For example, the block referring to the symptoms of CF is green, the block with the symptoms of FI is blue, and the block with the type and shape of the stools is pink, which makes it attractive and intuitive. In addition, each week, the diary was printed on a sheet to allow complete visualization of the patient's bowel habits during this period. This facilitates interpretation by the specialist and stimulates the patient's self-knowledge since the disposition of symptoms, colors, and lines indicate the number of bowel movements and date.
Interpretation of results
These provisions assist in decreasing the neglect of coexisting FC and FI symptoms. In a letter to the editor published in 2022, the authors reported that it was surprising that the recently released guideline for the diagnosis and treatment of FI by Assmann et al. with Forty-five practical recommendations, together with a treatment algorithm to summarise them., did not contain coexisting FC as a possible cause of incontinence, showing how much the coexistence of these symptoms has been overlooked. This negligence also occurs when analyzing the Rome IV criteria for FC. FI is not considered one of the criteria, although it is something recurrent in pediatric and geriatric populations and growth in adult populations. Proof of this was a recent study with more than 4,000 adults referred for investigation at an outpatient clinic specialized in intestinal disorders, where 61.4% of patients with FI reported significant coexisting symptoms of FC. However, such coexistence was only recognized by the referring physician in 13.6% of the patients. That is, coexisting symptoms were overlooked in 86.4%. In another study, 69.3% of 946 patients referred for investigation of FI had underlying symptoms of FC.