Basics
Description
Involuntary loss of solid or liquid feces or mucus
Epidemiology
Prevalence
- Estimated prevalence in non-institutionalized US adults 8.3%, and 15.3% in people aged ≥70
- Prevalence of fecal incontinence or combined urinary/fecal incontinence in the elderly institutionalized population is about 50%.
- Approximately 60-70% of incontinent patients are women.
Risk Factors
- Obstetrical trauma to sphincter muscle or pudendal nerves
- Prior anorectal surgery with iatrogenic injury to sphincter muscle
- Advancing age
- Diarrhea in women with >21 stools/week
- Multiple chronic illnesses
- Urinary incontinence
- Diabetic neuropathy
Pathophysiology
- Anatomical: Sphincter disruption secondary to obstetrical trauma, anal surgery, or trauma
- Neurological: Pudendal nerve injury or neuropathy, diminished rectal sensation with altered rectoanal reflexes secondary to acquired or congenital central and peripheral nervous system dysfunction
- Congenital: Malformations impacting sphincter, nerves, rectal compliance
- Functional: Diminished rectal compliance secondary to inflammatory bowel disease or radiation, fecal impaction, malabsorption
Etiology
- Congenital anorectal and neurological anomalies
- Functional
- Inflammatory bowel disease
- Irritable bowel syndrome
- Short-gut syndrome
- Radiation enteritis/proctitis
- Laxative abuse
- Malabsorption
- Hypersecretory rectal tumors
- Fecal impaction
- Physical disabilities
- Anal fistula
- Encopresis
- Neurological conditions
- Dementia, stroke, infection, trauma
- Pudendal neuropathy due to stretch nerve injury (vaginal delivery)
- Diabetes mellitus
- Pelvic floor denervation
- Multiple sclerosis
- Anatomical
- Accidental injury, pelvic fracture
- Anorectal surgery
- Obstetrical injury
Associated Conditions
- Urinary incontinence
- Rectovaginal fistula
- Pelvic organ prolapse
Diagnosis
History
- Onset of incontinence and history of antecedent anorectal or gynecological surgery
- Detailed obstetrical history
- Degree of incontinence and progression of symptoms
- Presence or absence of passage of stool and of sensation/urgency of need to defecate
- Sensation of incomplete evacuation
- Stool consistency
- Quality of life questionnaire
- Bowel diary for at least 2 weeks; incontinence score
- Detailed urologic history
- History of lower back pain, lower extremity sensory loss
Physical Exam
- Inspection: Look for patulous anus, perineal body (intact, scarred, or thinned)
- Digital exam: Examine for defects, diminished resting/squeeze tone, palpable masses, stool impaction in rectal vault
- Test sensation: Is the "anal wink" reflex intact
- Examine for evidence of prior obstetrical trauma and anorectal surgery
- Bimanual exam to examine for associated rectovaginal fistula
- Examine for associated rectocele
- Examine for prolapse with Valsalva maneuver
Tests
Lab
- Stool cultures if diarrhea present
- Metabolic
- Thyroid function tests
- Serum glucose
Imaging
- Endoanal ultrasound is the gold standard to assess sphincter atrophy, defects.
- Better than MRI for internal sphincter defects
- MRI with endoanal coil
- Assesses sphincter atrophy by measuring sphincter volume, which is more difficult with endoanal ultrasound
- Can be combined with dynamic pelvic MRI to assess the pelvic floor
- Defecogram
- Allows for radiographic evaluation of the dynamics of pelvic floor and anorectum during defecation
- Can assess for concomitant pelvic organ prolapse, internal rectal intussusception
Surgery
- Flexible sigmoidoscopy or colonoscopy
- Pudendal nerve terminal motor latency
- Lack of consensus about accuracy and predictive value
- Sensory function testing
- Anorectal manometry
- Quantifies pressures along sphincter
- Resting tone correlates with internal sphincter function
- Squeeze tone correlates with external sphincter function
- Real-time measurement during various simulated situations
Treatment
Medication
First Line
Stool bulking agents: Fiber supplements to increase dietary fiber intake to 30 g/day
Second Line
- Antidiarrheals
- Adsorbents to decrease fluid content in the stool
- Opium derivatives to decrease colonic motility
- Loperamide (Imodium): Decreases frequency of incontinence, increases basal sphincter tone, decreases intestinal motility and secretion (1)[A]
- Tricyclic agents
- Decrease amplitude and frequency of rectal motor complexes and prolong colonic transit time. Stools are more formed and firmer when passed.
- Ideal in patient with reduced resting pressure and poor rectal capacity
- Amitriptyline has been used (2)[A].
- Patients whose symptoms do not adversely affect their quality of life and are controlled by dietary and medical measures can be followed on a regular basis by their primary care physician who can review food and bowel diaries and adjust treatment as needed.
- If lifestyle is impaired or there is progression of symptoms, referral should be made to colorectal surgery for surgical evaluation.
Additional Treatment
Issues for Referral
- Gastroenterology for colonoscopy/evaluation for colonic dysmotility and diarrhea
- Urogynecology for evaluation of concomitant urinary complaints such as incontinence
- Referral to colorectal surgery for surgical evaluation and possible sphincter repair if significant lifestyle impairment or progression of symptoms
Complementary and Alternative Medicine
Physical therapy
- Biofeedback (3)[A]:
- Most beneficial in patients with intact rectal sensation and ability to contract external anal sphincter (EAS) voluntarily
- First line if medical therapy fails
- Response rates: 38-100%
- Goal to improve contraction of EAS in response to rectal distension
- Success independent of patient age, initial severity of symptoms, type of technique
Surgery
- Sphincter repair
- Anterior sphincteroplasty (4)[A]:
- Localized sphincter defect repaired with either direct apposition or overlapping sphincteroplasty
- SECCA procedure (5)[B]:
- Radiofrequency energy used to create discreet submucosal thermal lesions circumferentially which results in remodeling of anal canal
- Useful with multifocal injury not amenable to sphincteroplasty
- Artificial bowel sphincter (4)[B]:
- Inflatable cuff with reservoir that can be deflated for passage of stool and gas
- Useful when multifocal injury present or pudendal neuropathy present
- Substantial functional improvement, but high repeat operation rate and complications
- Dynamic stimulated gracilis neosphincter (4)[B]:
- Transposition of gracilis muscle to form neosphincter with electronic stimulation from implanted device
- Patient deactivates pulse generator to effect defecation
- Good success, but significant morbidity and mortality
- Sacral nerve stimulation (6)[B]:
- Stimulation of sacral nerve afferent and efferent fibers by implantable device
- Direct effect on sphincter tone and modulation of rectoanal reflex arc
- Temporary device is tried first; if response obtained, proceed to implanted device
- Rectal irrigation (7)[B]:
- Infusing tepid water into the rectum, facilitates removal of fecal matter
- Allows self-management
- Antegrade continence enemas (ACE) (4)[B]:
- Uses appendix to create catheterizable channel through which antegrade enemas are given
- Ensures regular colonic emptying
- Anal plug (8)[B]:
- Device inserted into anal canal to block loss of stool
- May help, but often difficult to tolerate
Ongoing Care
Diet
- Dietary modification
- Limit foods that encourage loose/frequent bowel movements, such as alcohol, caffeine, prunes, and fruit juices
- Test for food intolerance to gluten and lactose
- Fiber supplements: Firmer, bulkier stool
Prognosis
- Variable prognosis depending on underlying etiology and method of treatment
- Improved continence with overlapping sphincteroplasty: 70-90%
- Relapse incidence of incontinence 6-10 years following successful sphincteroplasty: 50-60%
Complications
Cesarean section recommended for subsequent deliveries in women of child-bearing age after sphincter repair.
References
1Sun WM, Read NW, Verlinden M. Effects of loperamide oxide on gastrointestinal transit time and anorectal function in patients with chronic diarrhoea and faecal incontinence. Scan J Gastroenterol. 1997;32(1):34-38. [View Abstract]2Santoro GA, Eitan BZ, Pryde A. Open study of low-dose amitriptyline in the treatment of patients with idiopathic fecal incontinence. Dis Colon Rectum. 2000;43(12):1676-1681. [View Abstract]3Norton C, Cody JD, Hosker G. Biofeedback and/or sphincter exercises for the treatment of incontinence in adults. Cochrane Database Syst Rev. 2006;3:CD002111. [View Abstract]4Maslekar S, Gardiner A, Maklin C. Investigation and treatment of faecal incontinence. Postgrad Med J. 2006;82(968):363-371. [View Abstract]5Takahashi-Monroy T, Morales M, Garcia-Osogobio S. SECCA procedure for the treatment of fecal incontinence: Results of five year follow up. Dis Colon Rectum. 2008;51(3):355-359. [View Abstract]6Mowatt G, Glazener C, Jarrett M. Sacral nerve stimulation for fecal incontinence and constipation in adults: A short version Cochrane review. Neurourol Urodyn. 2008;27(3):155-161. [View Abstract]7Crawshaw AP, Pigott L, Potter MA. A retrospective evaluation of rectal irrigation in the treatment of disorders of faecal continence. Colorectal Dis. 2004;6(3):185-190. [View Abstract]8Deutekom M, Dobben A. Plugs for containing faecal incontinence. Cochrane Database Syst Rev. 2005;3:CD005086. [View Abstract]
Additional Reading
1Akbari HM, Bernstein MR., Zbar A, Pescatori M, Wexner S Complex anorectal disorders: investigation and management. Berlin: Springer-Verlag, 2005.2Corman ML., Corman ML Colon and rectal surgery, 5th ed. Philadelphia: Lippincott, Williams and Wilkins, 2005.3Hinninghofen H, Enck P. Fecal incontinence: Evaluation and treatment. Gastroenterol Clin. 2003;32:685-706. [View Abstract]4Rothholtz N, Wexner SD. Surgical treatment of constipation and fecal incontinence. Gastroenterol Clin. 2001;30:131-166.5Song AH, Advincula AP, Fenner DE. Common gastrointestinal problems in women and pregnancy. Clin Fam Prac 2204.;6:3.6Whitehead WE, Borrud L, Goode PS. Fecal incontinence in US adults: Epidemiology and risk factors. Gastroenterology. 2009;137(2):512-517. [View Abstract]
Codes
ICD9
- 569.49 Other specified disorders of rectum and anus
- 619.1 Digestive-genital tract fistula, female
- 787.60 Full incontinence of feces
- 787.61 Incomplete defecation
- 307.7 Encopresis
ICD10
- K62.7 Radiation proctitis
- N82.3 Fistula of vagina to large intestine
- R15.9 Full incontinence of feces
- R15.0 Incomplete defecation
- F98.1 Encopresis not due to a substance or known physiol condition
SNOMED
- 386707000 idiopathic fecal incontinence (finding)
- 440421009 fecal incontinence due to anorectal disorder (finding)
- 236081008 congenital fecal incontinence (finding)
- 235760009 radiation proctitis (disorder)
- 65619001 rectovaginal fistula (disorder)
- 302690004 encopresis (finding)
Clinical Pearls
- May affect up to 8% of the general population.
- Obstetrical trauma is the most common cause of fecal incontinence in women.
- Fecal incontinence is associated with significant social and mental health disability, stigmatization, and impaired quality of life.
- Many patients are home-bound due to fear of embarrassing public incontinence events.
- Many patients with incontinence do not seek medical attention.