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Getting Ready for Certification

Getting Ready for Continence Certification

Bowel Management

Thompson, Donna L.

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Journal of Wound, Ostomy and Continence Nursing: November/December 2019 - Volume 46 - Issue 6 - p 550-552
doi: 10.1097/WON.0000000000000584
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Fecal incontinence is a life-altering condition that affects up to 15% of community-dwelling adults.1 Rates in the nursing home population range from 40% to 55%, and prevalence increases with age.2 National professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Colon and Rectal Surgeons recommend conservative management strategies as initial treatment of fecal incontinence.3,4 Conservative treatments include body-worn absorptive products,5 skin care, dietary modification, fiber supplementation, pelvic floor rehabilitation, antidiarrheal medication for loose stools, and rectal devices such as anal plugs or vaginal bowel control devices.3,4,6 Conservative management strategies are what the CWOCN Society considers its primary practice focus7 and are the focus of the WOCNCB Continence Certification Examination. Fortunately, up to 25% of patients with fecal incontinence can become continent after implementing conservative management strategies.6

Adequate preparation and careful analysis of certification-type questions help increase success with taking the certification exam. When preparing for continence certification, it is important to review the examination outline and prepare a structured review based on the 6 content categories listed in the Box. A helpful test-taking strategy is to carefully analyze the examination question stem to identify information critical to the correct answer. For example, a question may request the test taker to choose where best to refer a patient for further evaluation. This type of question tends to be difficult and requires analysis of multiple facts included in the stem. Identify those facts and link them together. Then read each answer option and choose the option that best matches the linked facts in the stem. The advanced practice sample question included in this article is an example of such a question. The WOCNCB Web site ( has a number of testing preparation resources available, and additional practice questions from previous “Getting Ready for Certification” columns are archived on the journal Web site.


WOCNCB Continence Exam Outline for Bowel Dysfunction: Task 7a

1. Bharucha AE, Dunivan D, Goode PS, et al Epidemiology, pathophysiology, and classification of fecal incontinence. State of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol. 2015;110(1):127–136.

2. Saga S, Vinsnes AG, Morkved S, Norton C, Seim A. Prevalence and correlates of fecal incontinence among nursing home residents: a population-based cross-sectional study. BMC Geriatr. 2013;13:87.

3. ACOG Practice Bulletin No. 210. Fecal incontinence. Obstet Gynecol. 2019;133e:260–273.

4. Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty JR. The American Society of Colon and Rectal Surgeons clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. 2015;58:623–636.

5. Gray M, Kent D, Ermer-Seltun J, McNichol L. Assessment, selection, use, and evaluation of body-worn absorbent products for adults with incontinence: a WOCN Society consensus conference. J Wound Ostomy Continence Nurs. 2018;45(3):243–264. doi:10.1097/WON.0000000000000431.

6. Whitehead WE, Rao SS, Lowry A, et al Treatment of fecal incontinence: state of the science summary from the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Am J Gastroenterol. 2015;110(1):138–146.

7. Berke C, Conley MJ, Netsch D, et al Role of the wound, ostomy and continence nurse in continence care: 2018 update. J Wound Ostomy Continence Nurs. 2019;46(3):221–225. doi:10.1097/WON.0000000000000529.


1. What is an important component of a bowel habit training program for a patient with constipation?

  1. Encourage vigorous pushing throughout toilet time.
  2. Exercise the anal sphincter using strong squeezes.
  3. Schedule toilet time 30 minutes after the morning meal.
  4. Use a raised toilet seat so that hips are higher than knees.

Content outline: Task 7e 030705

Cognitive level: Application


Rationale: An important component of bowel habit training is to utilize normal colonic activity. Colonic contractions, the gastrocolic response, are strongest after meals and tend to be more frequent and stronger in the morning. Teaching a patient to attempt defecation in the morning after the morning meal will optimize the chances of a successful bowel movement. Contracting the anal sphincter during an attempt to defecate will suppress peristaltic activity and increase compliance of the rectum with subsequent decrease in sensation of fecal urgency. Vigorous pushing during attempts to defecate are not to be encouraged due to long-term effects on the pelvic floor and anal sphincter. Elevating the hips resulting in dangling feet does not optimize normal anatomy during defecation. The anorectal angle will increase from 90° to 135° when in the squatting or forward sitting position with feet on the floor or on a small stool.

1. Callan LL, Willson M. Fecal incontinence pathology, assessment and management. In: Doughty DB, Moore KN, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:297–327.

2. Chang J, McLemore E, Tejirian T. Anal health care basics. Perm J. 2016;20(4):15–222.

3. Ermer-Sultun J. Physiology of normal defecation. In: Doughty DB, Moore KN, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:250–267.

4. Norton C, Emmanuel A, Stevens N, et al Habit training versus habit training with direct visual biofeedback in adults with chronic constipation: study protocol for a randomized controlled trial. Trials. 2017;18(1):139.

2. What product would be the best choice to manage a critically-ill patient's frequent incontinence of liquid stool due to enteral feedings?

  1. Anal plug
  2. Containment brief
  3. External fecal pouch
  4. Small fecal pad

Content outline: Task 7d 030704

Cognitive level: Application


Rationale: Healthy skin pH is mildly acidic, ranging from 4.5 to 6.0. Increased pH due to a higher amount of digestive enzymes found in liquid stools along with frequent fecal incontinence can elevate any patient's risk for moisture-associated skin damage. Containment of liquid stool would be best achieved with an external fecal pouch. A containment brief would most likely contain the stool but would carry the risk of skin damage and require diligent application of skin protection products. An anal plug, of which there are 2 different products currently available in the United States, is most effective for fecal incontinence in independent patients who can remove the plug in the presence of fecal urge. The plugs can become dislodged especially with increased peristalsis and will leak in the presence of liquid stools. A small fecal pad is primarily used for very small-volume fecal soiling and will not contain diarrheal stool. These small pads are strategically placed in between the buttocks to absorb small amounts of stool.

1. Anderson PH, Bucher AB, Saeed I, Lee PC, Davis JA, Maibach HI. Faecal enzymes: in vivo human skin irritation. Contact Dermatitis. 1994;30(3):152–158. Accessed August 12, 2019.

2. Callan LL, Willson M. Fecal incontinence pathology, assessment and management. In: Doughty DB, Moore KN, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:297–327.

3. Willison MM, Angyus M, Beals D, et al Executive summary: a quick reference guide for managing fecal incontinence. J Wound Ostomy Continence Nurs. 2014;41(1):61–69.

3. What dietary recommendation will help a patient with fecal incontinence due to chronic loose stools?

  1. Drink at least 1 cup of coffee or tea in the morning.
  2. Encourage hydration with carbonated diet beverages.
  3. Fiber supplementation with psyllium.
  4. Increase fiber intake with beans found in chili.

Content outline: Task 7c 030703

Cognitive level: Application


Rationale: The first step in conservative treatment of fecal incontinence is to normalize stool consistency. The consistency of stool described in this question stem is unformed and thus can increase fecal incontinence episodes. Bulk forming fiber such as psyllium is not completely broken down by colonic bacteria and thus increases the size of stool and absorbs water content in the stool forming a gel. Bliss and colleagues1 found that dietary supplementation with psyllium was more effective in reducing fecal incontinence episodes than other types of fiber. The beans in chili are a good source of fiber, but unfortunately the spiciness of chili can increase gastrointestinal motility, increasing risk for diarrheal-type stools. Hydration is always good when stools are liquid, but carbonation can also increase gastrointestinal motility. Caffeine stimulates bowel motility and would increase motility and frequency of unformed stools, thus is not an appropriate option.

1. Bliss DZ, Savik K, Jung HG, Whitebird R, Lowry A. Dietary fiber supplementation for fecal incontinence: a randomized clinical trial. Res Nurs Health. 2014;37(5):367–378.

2. Callan LL, Willson M. Fecal incontinence pathology, assessment and management. In: Doughty DB, Moore KN, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:297–327.


4. A 55-year-old woman reports a chronic problem with infrequent bowel movements that are large, hard, and difficult to pass. She complains that fiber, hydration, and laxatives have not been consistently effective, and she will occasionally notice smeared stool on her underwear. Screening colonoscopies have been normal. The physical examination is normal, and she denies rectal bleeding, weight loss, or symptoms of anemia. What would be the next level of evaluation the advanced practice continence nurse should initiate?

  1. A colorectal surgeon for obstruction and surgery.
  2. A dietitian for lactose intolerance and diet counseling.
  3. A gastroenterologist for slow-transit constipation and colon transit study.
  4. An urogynecologist for dyssnergia and anorectal manometry.

Content outline: Task 7a 030701

Cognitive level: Analysis


Rationale: The patient in this case exhibits symptoms consistent with idiopathic constipation. She has infrequent stools that are large, hard, and difficult to pass, with no history of secondary causes such as neurologic disease, diabetes, or obstructing lesions. She has tried conservative management that has not been consistently successful. The next decision is referral to a specialist for further evaluation. Based upon the available history and physical examination information, the best choice would be a referral to a gastroenterologist for a colonic transit study to determine if the patient has delayed transit. A colonic transit study would determine if she had colonic hypomotility versus normal colonic transit. Normal transit constipation would be more responsive to hydration, fiber supplementation, and lifestyle modifications. A referral to a pelvic floor specialist such as an urogynecologist would be appropriate if functional obstruction of defecation is suspected. The question stem does not indicate symptoms specific to dyssynergic defecation, which is caused by inappropriate contraction of the puborectalis and external anal sphincter muscles during defecation, causing straining and sensation of incomplete emptying. Referral to a dietitian is not an appropriate choice due to this patient not showing symptoms consistent with lactose intolerance, which is characterized by diarrheal stools and not constipation. A dietitian is an excellent resource for dietary counseling once the diagnosis is established. Colonoscopies have been normal, and a review of the question stem reveals that this patient does not have obvious “red flag” symptoms of a rectal lesion or tumor. A referral to a colorectal surgeon would not be an appropriate choice.


1. Hayat U, Dugum M, Garg S. Chronic constipation: update on management. Cleve Clin J Med. 2017;84(5):397–407.
2. Steele SE, Han CJ, Heitkemper M. Motility disorders. In: Doughty DB, Moore KN, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:268–296.
    © 2019 by the Wound, Ostomy and Continence Nurses Society.