Fecal Incontinence


Article Author:
Rushikesh Shah


Article Editor:
Juan Villanueva Herrero


Editors In Chief:
William Gossman


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/4/2019 1:01:40 PM

Introduction

Fecal incontinence (FI) is the involuntary passage of fecal matter through anus or inability to control the discharge of bowel contents. Its severity can range from an involuntary passage of flatus to complete evacuation of fecal matter. Depending on the severity of disease, it has a significant impact on a patient’s quality of life [1].

Etiology

Causes include: 

  • Central nervous system (CNS)
  • Autonomic nervous system (ANS)
  • Inflammatory bowel disease (IBD)
  • Irritable bowel syndrome (IBS)
  • Diabetes mellitus (DM)
  • Multiple sclerosis (MS)
  • Cerebrovascular accident (CVA)

Epidemiology

The prevalence of FI is difficult to estimate because often, this condition is underreported due to social stigma. The overall reported prevalence of FI ranges from 2% to 21% with a median of 7.7%. There is significant variation depending on age. Prevalence of FI is reported as 7% in women younger than 30 years which rises to 22% in their seventh decades. In geriatric patients, prevalence is reported as high as 25% to 35% of nursing home residents and 10% to 25% of hospitalized patients. In fact, FI is the second leading cause of nursing home placement in the geriatric population. [2][3]

Pathophysiology

It is vital to understand the physiology of continence to understand the pathophysiology of incontinence. The anatomical structures which help to maintain control of bowel function are the following:

  • Rectum as a stool reservoir and can hold up to 300 ml volume without any increase in pressure. Beyond this limit, an urge to defecate occurs. The rectum is connected with the anus which is a 3 cm to 4 cm hollow muscular tube which at rest lies at 90-degree angle from the rectum. During defecation, this angle becomes obtuse, about 110 to 130 degrees allowing for the passage of stool.
  • Internal anal sphincter which is innervated by an enteric nervous system is responsible for 80% to 85% of anal canal resting tone. The anorectal inhibitory reflex allows for the internal sphincter to relax allowing anal sensory receptors to sense rectal contents. This helps to differentiate solid or liquid stool from gas.
  • External anal sphincter, innervated by pudendal nerve, contracts and maintains continence during a sudden increase in intraabdominal pressure such as during coughing or lifting.
  • Puborectalis muscle forms a sling around the anorectal junction and maintains the anorectal angle which maintains the anatomical barrier against discharge of stool.

History and Physical

History

Fecal incontinence can be differentiated as the following three different subtypes:

  • Passive incontinence: Passive discharge of fecal material without any awareness; indicates neurological disease, impaired anorectal reflexes or sphincter dysfunction
  • Urge Incontinence: Inability to retain stool despite active attempts with preserved sensation; indicates sphincter dysfunction or inability of the rectum to hold stool
  • Fecal seepage: Undesired leakage of stool often after a bowel movement with normal continence.

Essential history to assess underlying etiology in FI include:

  • Nature of incontinence (gas, stool consistency), history of urgency
  • Onset, duration, timing
  • Effect of FI on quality of life
  • H/O constipation
  • Medication which can cause constipation or diarrhea
  • Medical history (IBD, DM, thyroid problems, spinal problem, neurological diseases, urinary incontinence)
  • Obstetric history in female (use of forceps, perineal tears, number of deliveries).

Physical Examination

A detailed neurological exam should be performed to evaluate for neurological disease. A detailed rectal exam is a key in the evaluation of FI; it can be best divided into following steps, but the accuracy of rectal exam and evaluation of various structures depend to a large extent on examiner’s experience:

  • Inspection: Examine for hemorrhoids, the presence of the fecal matter, scars, skin excoriation. Also, assess for prolapse and excess perineal descent (more than 3 cm).
  • Anal wink reflex: Can be done by gently stroking perianal skin by cotton bud which will cause brisk contraction of the external anal sphincter. The absence of this reflex indicates loss of spinal arc and possibly underlying neurological disease.
  • During the digital rectal exam, a resting rectal tone should be assessed to evaluate internal anal sphincter. After this patient should be asked to bear down during which function of puborectalis (to straighten the anorectal angle) as well as pelvic floor muscles can be assessed. The final step is to ask the patient to squeeze during which increased pressure due to contraction of the external anal sphincter is felt.  

Evaluation

Diagnostic testing is guided by whether incontinence is related to stool consistency [4][5].

If diarrhea is suspected as a primary reason for incontinence:

  • Stool studies for infection, osmolality, fat content and pancreatic insufficiency
  • Evaluation of diabetes and thyroid disorder
  • Evaluate for bacterial overgrowth and lactose/fructose intolerance
  • Colonoscopy to evaluate mucosal disease (IBD/Colitis), mass, ulcer, and stricture.

If incontinence is without any diarrhea then more specific testing should be pursued. The most valuable tests for the evaluation of FI are anorectal manometry and endoscopic ultrasound. Defecography is usually reserved for refractory symptoms or before operative planning intervention.

  • Endoscopic Ultrasound (EUS)
  • Magnetic Resonance Imaging (MRI)
  • Electromyography (EMG

Treatment / Management

Supportive Measures [6][7][8]

  • Supportive measures to improve patient’s generalized well-being and nutritional status
  • Hygiene maintenance: avoid perianal skin soiling with regular cleaning, zinc oxide application, incontinence pads.
  • Avoid food which can provoke diarrhea (high lactose/ fructose diet)
  • Patient with mild cognitive impairment might benefit from regular defecation program.

Medical Management

Directed at improving stool consistency and reducing stool frequency

  • Bulking agents (methylcellulose) to improve stool consistency
  • Loperamide (Imodium) 4 mg three times a day to reduce stool frequency, improve urgency, increase colonic transit time and increases anal sphincter resting tone
  • Diphenoxylate (Lomotil) also results in clinical improvement, but objective tests do not improve
  • Treatment of other underlying disorders if suspected such as bile salt malabsorption, IBS, and IBD
  • In post-menopausal women, estrogen replacement therapy might be beneficial
  • In cases of combined urinary and fecal incontinence, amitriptyline might be helpful.

If the above therapy fails, further investigation should be done with anorectal manometry with imaging (EUS/MRI).

Biofeedback Therapy

Indicated for patients with impaired external sphincter tone and loss of sensation to rectal distention if detected during manometry. Biofeedback therapy is based on the concept of cognitive retraining of the pelvic floor and abdominal musculature to overcome the above defects. Studies report a wide range of success rate ranging from 38 % to 100%. This wide variation is due to small-scale studies with methodological limitation with a different definition of outcomes.

Surgery

In patients with refractory symptoms that do not respond to the above measures.

Surgical approaches can be divided into four categories:

  • For patients with the simple structural abnormality of sphincters, such as due to obstetric trauma, overlapping sphincter repair might be sufficient. The success rate is 70% to 80%.
  • For patients with the anatomically intact but weak sphincter, post anal approach for augmentation of anorectal angle is performed. The success rate is 20% to 58%.
  • For patients with severe structural damage to the anal sphincter, construction of neosphincter is performed using either autologous skeletal muscle (gracilis or gluteus) or artificial bowel sphincter. The success rate is 38% to 90%.
  • Rectal augmentation (side to side ileorectal pouch or ileo-rectoplasty) is considered in patients with the reservoir or rectal sensorimotor dysfunction.

Pearls and Other Issues

 

 

 

 

 

 

Enhancing Healthcare Team Outcomes

Fecal incontinence has multiple causes and is best managed by a multidisciplinary team that includes a pediatric surgeon, colorectal surgeon, dietitian, internist, a pediatrician, and a mental health worker. The treatment depends on the cause; the majority of non-congenital causes can be managed with conservative treatment and a change in diet but most congenital disorders require corrective surgery. The outcomes do depend on the cause, but in a significant number of people, recurrence is common and the quality of life is poor [9][10].


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Fecal Incontinence - Questions

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What percentage of five-year-old patients with fecal incontinence have never been continent of stool?



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A five-year-old patient has secondary fecal incontinence. He had very rare episodes before starting kindergarten but refused to use the school bathroom to defecate. He only has two bowel movements at home each week. What is the least likely cause of this patient's fecal incontinence?



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Which of the following should not be used for the treatment of overflow fecal incontinence?



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Select the correct statement about fecal incontinence in patients over 65 years.



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A 64-year-old male presents with a complaint of fecal incontinence that started about 6 months ago. He states he works at a wholesale store and often time at work, he feels the urge to defecate, and it’s hard for him to make it to the bathroom. He experiences soiling of his underpants at least twice a week with fecal material and has started using adult diapers. Colonoscopy 2 years ago was unremarkable. His only past history includes a history of prostate cancer treated with radiation. He was deemed to be in remission. Otherwise, denies any constipation or medical co-morbidities. Rectal exam shows normal resting and squeezing tone. What is the best initial management strategy?



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A 58-year-old female comes in with a 6-month history of incontinence which has adversely affected her quality of life. Conservative measures such as dietary modification and antidiarrheal medication have failed so far. You proceed with anorectal manometry which shows no sensation of fullness in rectum even when the rectal balloon was fully inflated. Sphincter tone and functions are preserved, and rest of the exam findings are unremarkable. What is the next step in management?



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A 32-year-old female comes to your office for new-onset occasional fecal incontinence which happens 2 to 3 times per week with the passage of a small amount of liquid stool. This is most common when she has hard coughing spell which she attributes to her asthma. She has had two vaginal deliveries and no other medical co-morbidities. You proceed with a rectal exam. Exam shows normal resting tone, normal perineal descent but when you ask the patient to squeeze to hold stool in, no pressure difference is felt. Which mechanism of normal physiological continence is most likely affected?



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Fecal Incontinence - References

References

Grossi U,De Simone V,Parello A,Litta F,Donisi L,Di Tanna GL,Goglia M,Ratto C, Gatekeeper Improves Voluntary Contractility in Patients With Fecal Incontinence. Surgical innovation. 2018 Dec 14;     [PubMed]
Arbuckle JL,Parden AM,Hoover K,Griffin RL,Richter HE, Prevalence and Awareness of Pelvic Floor Disorders in Adolescent Females Seeking Gynecologic Care. Journal of pediatric and adolescent gynecology. 2018 Dec 5;     [PubMed]
Thubert T,Cardaillac C,Fritel X,Winer N,Dochez V, [Definition, epidemiology and risk factors of obstetric anal sphincter injuries: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. Gynecologie, obstetrique, fertilite     [PubMed]
Kitaguchi D,Nishizawa Y,Sasaki T,Tsukada Y,Ito M, Clinical benefit of high resolution anorectal manometry for the evaluation of anal function after intersphincteric resection. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2018 Dec 8;     [PubMed]
Vande Velde S,Van Renterghem K,Van Winkel M,De Bruyne R,Van Biervliet S, Constipation and fecal incontinence in children with cerebral palsy. Overview of literature and flowchart for a stepwise approach. Acta gastro-enterologica Belgica. 2018 Jul-Sep;     [PubMed]
van der Schans EM,Paulides TJC,Wijffels NA,Consten ECJ, Management of patients with rectal prolapse: the 2017 Dutch guidelines. Techniques in coloproctology. 2018 Aug;     [PubMed]
Pratt T,Mishra K, Evaluation and management of defecatory dysfunction in women. Current opinion in obstetrics     [PubMed]
Bouchoucha M,Devroede G,Rompteaux P,Bejou B,Sabate JM,Benamouzig R, Clinical and psychological correlates of soiling in adult patients with functional gastrointestinal disorders. International journal of colorectal disease. 2018 Jul 10;     [PubMed]
Cauley CE,Savitt LR,Weinstein M,Wakamatsu MM,Kunitake H,Ricciardi R,Staller K,Bordeianou L, A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation. Diseases of the colon and rectum. 2019 Jan;     [PubMed]
Wagg A,Gove D,Leichsenring K,Ostaszkiewicz J, Development of quality outcome indicators to improve the quality of urinary and faecal continence care. International urogynecology journal. 2018 Oct 16;     [PubMed]

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