“I’ve been having accidents — I can’t always make it to the toilet — I’ve been too ashamed to tell anyone”

Faecal incontinence is deeply STIGMATISED and under-reported, often hidden for years and disclosed tentatively (here after booking about something else; NICE CG49 advises asking in higher-risk groups such as women after childbirth), so the first task is COMMUNICATION: respond with genuine empathy and without embarrassment, thank and validate the patient, normalise that it is common and often TREATABLE, and give it the time it deserves. Then ASSESS systematically: characterise it as URGE incontinence (urgency, cannot reach the toilet — often sphincter/neurological) versus PASSIVE incontinence/soiling (unaware — internal sphincter dysfunction or OVERFLOW), and assess stool CONSISTENCY (loose stool is harder to control; constipation with overflow soiling is a common, treatable cause), frequency, pad use and psychosocial impact. Screen causes and contributors: OBSTETRIC anal sphincter injury (vaginal deliveries/forceps — a key cause in women), diarrhoea or constipation with overflow, IBS/IBD, diabetes and neurological disease, rectal prolapse/haemorrhoids, anorectal surgery, medications, and cognitive/mobility/access factors. Critically, EXCLUDE the RED FLAGS that change the pathway: a CHANGE IN BOWEL HABIT, RECTAL BLEEDING or unintentional WEIGHT LOSS (consider colorectal pathology — NICE NG12: FIT for a change in bowel habit, with suspected cancer pathway referral if FIT is 10 µg Hb/g faeces or more (NICE HTG690) or a rectal mass is felt; examination including DRE), and NEUROLOGICAL features — saddle anaesthesia or new bowel/bladder incontinence with back pain/leg weakness (CAUDA EQUINA, a neurosurgical emergency). Examine face to face with consent and a chaperone offered (GMC) — the abdomen, perianal area and a digital rectal examination (resting/squeeze tone, faecal impaction/overflow, masses), and manage first-line conservatively (NICE CG49: treat constipation/overflow or diarrhoea, optimise stool consistency, loperamide for loose stool if no contraindication, bowel-retraining/scheduled toileting, supervised pelvic floor muscle training (NICE NG210), skin care and continence products), referring to continence services and/or colorectal (sphincter assessment, biofeedback, surgery) as indicated — and via the cancer pathway if red flags. The hidden agenda is the shame-laden disclosure itself and a belief that nothing can be done; receive it compassionately, assess systematically, exclude red flags, address the psychosocial/mood impact, and give realistic hope. NICE NG12/lower-GI assessment applies where there is a change in bowel habit or rectal bleeding.