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Incontinence, Fecal
Kalyanakrishnan Ramakrishnan, MD
image BASICS
Continuous or recurrent involuntary passage of fecal material for >1 month in individual at least 4 years of age
  • Involves recurrent, involuntary loss of solid/liquid stool
  • Requires careful rectal exam to assess rectal tone, voluntary squeeze, and rule out overflow incontinence from fecal impaction
  • Endorectal ultrasound (EUS) is the simplest, most reliable and least invasive method to detect anatomic anal sphincter defects.
  • The goal of treatment is to restore continence and/or improve quality of life.
DESCRIPTION
Major incontinence is the involuntary evacuation of feces. Minor incontinence (fecal soilage) includes incontinence to flatus and occasional seepage of liquid stool.
Geriatric Considerations
  • The prevalence of fecal incontinence increases with age. It is an important cause of nursing home placement among the elderly.
  • Idiopathic fecal incontinence is more common in older women.
EPIDEMIOLOGY
Incidence
Patients will not report fecal incontinence unless specifically queried (“silent affliction”). The number of patients affected is likely significantly underestimated.
Prevalence
  • In younger persons: women > men
  • 8% of adults
  • 15% of adults age >70 years
  • 56-66% of hospitalized older patients and >50% of nursing home residents
  • 50-70% of patients who have urinary incontinence also suffer from fecal incontinence.
Pregnancy Considerations
Obstetric injury to the pelvic floor may result in either temporary incontinence or persistent incontinence.
Geriatric Considerations
  • Fecal impaction and overflow diarrhea leading to fecal incontinence is common in older patients.
  • Surgical history—particularly anal surgery, including hemorrhoidectomy, anal fissure repair (sphincterotomy), anal dilatation, or prior pelvic floor surgeries
ETIOLOGY AND PATHOPHYSIOLOGY
  • Continence requires complex orchestration of pelvic musculature, nerves, and reflex arcs.
  • Stool volume and consistency, colonic transit time, anorectal sensation, rectal compliance, anorectal reflexes, external and internal sphincter muscle tone, puborectalis muscle function, and mental capacity each play a role in maintaining fecal continence.
  • Disease processes or structural defects impacting any of these factors may contribute to fecal incontinence.
  • Diabetes is the most common metabolic disorder leading to fecal incontinence through pudendal nerve neuropathy.
  • Congenital: spina bifida and myelomeningocele with spinal cord damage
  • Trauma: anal sphincter damage from vaginal delivery or surgical procedures
  • Medical: diabetes, stroke, spinal cord trauma, degenerative disorders of the nervous system, inflammatory conditions, rectal neoplasia
RISK FACTORS
  • Functional status—older age, female sex, obesity, limited physical activity contribute to poor functional status
  • Neuropsychiatric conditions (dementia, depression)
  • Multiple sclerosis, spinal cord injury, stroke, diabetic neuropathy
  • Prostatectomy, radiation
  • Trauma: Risk factors for perineal trauma at the time of vaginal delivery include occipitoposterior presentation, prolonged second stage of labor, assisted vaginal delivery (forceps or vacuum-assist), and episiotomy.
  • Diarrhea, inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), menopause, smoking, constipation
  • Potential association with child abuse and sexual abuse
  • Congenital abnormalities, such as imperforate anus/rectal prolapse
  • Fecal impaction
GENERAL PREVENTION
  • Behavioral and lifestyle changes: Obesity, limited physical activity/exercise, poor diet, and smoking are modifiable risk factors.
  • Postmeal bowel regimen—defecate regularly after meals to maximize effect of gastrocolic reflex.
  • Pelvic floor muscle training during and after pregnancy and pelvic surgery
  • Increase fiber intake (>30 g/day)
COMMONLY ASSOCIATED CONDITIONS
  • Age >70 years
  • Urinary incontinence/pelvic organ prolapse
  • Chronic medical conditions—diabetes mellitus, dementia, stroke, spinal cord compression, depression, immobility, chronic obstructive pulmonary disease, IBS, and IBD
  • Perineal trauma (obstetric)
  • Anorectal surgery
  • History of pelvic/rectal irradiation
image DIAGNOSIS
Diagnosis is based on history and physical findings.
PHYSICAL EXAM
  • Inspect the perineum for chemical dermatitis, hemorrhoids, fistula, surgical scars, skin tags, rectal prolapse, soiling, and ballooning of the perineum (sarcopenia of pelvic musculature).
  • A patulous anal orifice may indicate myopathy or a neurologic disorder.
  • Evaluate the external sphincter response to perineal skin stimulation (anal wink). Absence suggests neuropathy.
  • Ask the patient to bear down, preferably in standing position, to assess for rectal prolapse.
  • Digital rectal exam to assess anal canal pressure sphincter tone, rectal bleeding, hemorrhoids, neoplasm, fecal consistency, and diarrhea/distal fecal impaction.
  • General neurologic examination, including perianal sensation (1)[C]
  • Evaluate mental status.
DIFFERENTIAL DIAGNOSIS
  • Anorectal disorders
    • Inflammatory/infectious disorders
    • Neoplasms, radiation proctitis, ischemic colitis, fistulas
    • Prolapsed internal hemorrhoids; rectal prolapse
    • Trauma: obstetric, surgical, radiation, accidental, sexual
  • Neurologic disorders
    • Stroke, dementia, neoplasms, spinal cord injury, and/or diseases causing altered level of consciousness
    • Pudendal neuropathy, neurosyphilis, multiple sclerosis, diabetes mellitus
  • Miscellaneous causes
    • Infectious diarrhea, fecal impaction and overflow, IBS, laxative abuse, IBD, short bowel syndrome, myopathies, senescence and frailty, collagen vascular disease, psychological and behavioral problems
DIAGNOSTIC TESTS & INTERPRETATION
The approach to fecal incontinence in older patients should be individualized, minimally invasive, and practically feasible. History and physical exam are generally sufficient for diagnosis. If uncertainty remains, consider the following:
  • EUS is the most reliable and least invasive test for defining anatomic defects in the external and internal anal sphincters, rectal wall, and the puborectalis muscle (1)[B]. EUS can predict therapeutic response to sphincteroplasty.
  • Plain abdominal x-ray (impaction, constipation)
  • Sigmoidoscopy/anoscopy/colonoscopy (colitis, neoplasm)
Initial Tests (lab, imaging)
  • If history of travel, antibiotics, tube feedings, or signs and symptoms of sepsis, consider stool studies:
    • Culture
    • Ova and parasites
    • Clostridium difficile toxin assay
  • Thyroid-stimulating hormone (TSH), electrolytes, and BUN in elderly patients
  • EUS may demonstrate structural abnormalities of the anal sphincters, rectal wall, or puborectalis muscle.
  • EUS may detect a sphincter injury in over 1/3 of primiparous vaginal deliveries and nearly half of multipararous vaginal deliveries.
Follow-Up Tests & Special Considerations
  • Defecography can measure the anorectal angle, evaluate pelvic descent, and detect occult/overt rectal prolapse (2)[C].
  • MRI defecography (dynamic MRI) can further define pelvic floor anatomy.
  • P.549

  • Anorectal manometry: Measures parameters such as maximal resting anal pressure, amplitude and duration of squeeze pressure, the rectoanal inhibitory reflex, threshold of conscious rectal sensation, rectal compliance, and anorectal pressures during straining.
  • Pudendal nerve terminal motor latency (PNTML): This technique is operator-dependent and has poor correlation with clinical and histologic findings.
  • Electromyography: can assess neurogenic/myopathic damage
image TREATMENT
GENERAL MEASURES
  • In ambulatory patients, scheduled (or prompted) defecation is effective, particularly in patients with overflow incontinence.
  • Kegel exercises to strengthen pelvic floor
  • If bed-bound, scheduled osmotic or stimulant laxatives for constipation
  • Enemas, laxatives, and suppositories may help promote more complete bowel emptying in impacted patients while minimizing postdefecation leakage.
  • Scheduled toileting and use of stool deodorants (Periwash, Derifil, Devrom).
MEDICATION
Limited evidence that antidiarrheals (loperamide, codeine) and drugs enhancing sphincter tone (phenylephrine gel, sodium valproate) are of benefit (3)[B]. Cholestyramine, colestipol useful in diarrhea following malabsorption or cholecystectomy; alosetron in diarrhea due to IBS, amitriptyline in idiopathic fecal incontinence
First Line
Specific treatment of underlying disorder (e.g., infectious diarrhea/IBD) may improve fecal continence.
Second Line
  • Increasing dietary fiber in milder forms of fecal incontinence reduces symptoms (1)[B]. Stool-bulking agents include high-fiber diet, psyllium products, or methylcellulose.
  • Antidiarrheal agents, such as adsorbents or opium derivatives, may reduce fecal incontinence (1)[C].
  • Disimpact patients with fecal impaction and overflow incontinence and treat with a bowel regimen to prevent recurrence.
ADDITIONAL THERAPIES
  • Biofeedback: initial treatment modality in motivated patients with some voluntary sphincter control (1)[C]; teaches patients to recognize rectal distension and contract the external anal sphincter while keeping intra-abdominal pressure low
  • Biofeedback plus electrical stimulation is more effective than either alone.
  • Patients with systemic neurologic disorders, anal deformities, or frequent episodes of incontinence respond poorly.
SURGERY/OTHER PROCEDURES
  • Surgery should be considered only when nonsurgical approaches have failed.
  • Sphincter repair should be offered for highly symptomatic patients with well-defined defect of external anal sphincter (1)[A].
  • Injectable therapy (tissue-bulking agent injected into the anorectal submucosa or the intersphincteric space) appears safe and effective for patients with internal anal sphincter dysfunction (4)[B].
  • Artificial anal sphincter implantation/dynamic graciloplasty (where gracilis muscle transposed into anus as modified sphincter) may be considered in patients with severe fecal incontinence and irreparable sphincter damage (5)[B].
  • Stoma (colostomy/ileostomy) creation may be appropriate in patients with disabling fecal incontinence when other available therapeutic options have failed or if preferred by patient (1)[B].
  • Anal plugs are available to minimize fecal leakage in patients who do not benefit from other treatment modalities, especially immobilized, institutionalized, or neurologically disabled patients; often poorly tolerated (6)[C].
  • Sacral nerve stimulation (neuromodulation) via implantation of SC electrodes delivering lowamplitude electrical stimulation to sphincter muscles improves overall rectal tone, especially in patients with a coexistent sphincter defect (7)[B].
  • SECCA PROCEDURE (radiofrequency anal sphincter remodeling)—temperature-controlled radiofrequency energy delivered to the anorectal junction distal to the dentate line causing tissue damage, scarring, and anal canal narrowing. Minimally invasive, ambulatory procedure useful in mild-to-moderate fecal incontinence (8)[C].
  • Magnetic anal sphincter (MAS) devices—series of interlinked titanium beads (14 to 20) with internal magnetic cores placed to form a flexible ring that encircles the external anal sphincter 3 to 5 cm from the anal verge. During expulsion of feces, the beads separate allowing evacuation. After evacuation, the beads approximate and close the canal (9)[B]. Useful in moderate and severe incontinence
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
If secondary to fecal impaction, manual evacuation of fecal mass (after lubrication with lidocaine jelly)
Nursing
  • Avoid catharsis.
  • No hot water, soap, or hydrogen peroxide enemas.
Discharge Criteria
Outpatient care
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Periodic rectal exam
Patient Monitoring
Consider impaction if there is <1 bowel movement every other day with fecal incontinence.
DIET
  • High fiber (20 to 30 g/day) and at least 1.5 L fluid daily
  • Avoid precipitants (caffeine).
PATIENT EDUCATION
Kegel/sphincter training exercises are necessary but not sufficient for treating fecal incontinence.
PROGNOSIS
  • Reimpaction likely if bowel regimen discontinued
  • 50% failure rate over 5 years following overlapping sphincteroplasty
REFERENCES
1. Tjandra JJ, Dykes SL, Kumar RR, et al. Practice parameters for the treatment of fecal incontinence. Dis Colon Rectum. 2007;50(10):1497-1507.
2. Vitton V, Vignally P, Barthet M, et al. Dynamic anal endosonography and MRI defecography in diagnosis of pelvic floor disorders: comparison with conventional defecography. Dis Colon Rectum. 2011;54(11):1398-1404.
3. Omar MI, Alexander CE. Drug treatment for faecal incontinence in adults. Cochrane Database Syst Rev. 2013;(6):CD002116.
4. Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence in adults. Cochrane Database Syst Rev. 2013;(2):CD007959.
5. Chapman AE, Geerdes B, Hewett P, et al. Systematic review of dynamic graciloplasty in the treatment of faecal incontinence. Br J Surg. 2002;89(2):138-153.
6. Deutekom M, Dobben AC. Plugs for containing faecal incontinence. Cochrane Database Syst Rev. 2012;(4):CD005086.
7. Ratto C, Litta F, Parello A, et al. Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review. Colorectal Dis. 2012;14(6):e297-e304.
8. Frascio M, Mandolfino F, Imperatore M, et al. The SECCA procedure for faecal incontinence: a review. Colorectal Dis. 2014:16(3):167-172.
9. Lehur PA, McNevin S, Buntzen S, et al. Magnetic anal sphincter augmentation for the treatment of fecal incontinence: a preliminary report from a feasibility study. Dis Colon Rectum. 2010; 53(12):1604-1610.
Additional Reading
&NA;
  • Rao SSC. Current and emerging treatment options for fecal incontinence. J Clin Gastroenterol. 2014;48(9):752-764.
  • Rao SSC. Fecal incontinence. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, PA: Saunders/Elsevier; 2010:247-258.
Codes
&NA;
ICD10
  • R15.9 Full incontinence of feces
  • R15.2 Fecal urgency
  • R15.0 Incomplete defecation
Clinical Pearls
&NA;
  • New onset fecal incontinence may indicate spinal cord compression if accompanied by other neurologic signs or symptoms.
  • Differentiate true incontinence from pseudoincontinence (overflow or functional incontinence).
  • Scheduled defecation after meals, bulking agents, and scheduled enemas minimize impaction and are helpful in mild/moderate fecal incontinence.