Fecal incontinence

Fecal incontinence is a condition in which an individual experiences loss of control over defecation leading to the involuntary release of feces. This condition leaves an impact on an individual’s social life and also impairing the quality of life. The factors leading to fecal incontinence include structural abnormalities of the anus and rectum, damage to the pelvic muscles, nerve injury or neuropathies, cognitive deficit, consistency of the stool, advancing age and at times may be idiopathic. Many individuals may refrain from expressing their concern regarding their condition due to the stigma associated with it.

• Fecal incontinence occurs as a result of structural and fucntional abnormalities of the anal sphincter and the surrounding muscles and nerves. It is usually multifactorial as a result of the underlying pathology.^{[1] [2]}
• The resting anal pressure is provided by the internal anal sphincter (IAS) which is then supplemented by the external anal sphincter (EAS) along with the mucosal folds and endovascular cushions of the anus.^[1]
• Malfunctioning of the external anal sphincter (EAS) may lead to the urge type or diarrhea type of fecal incontinence.^[1]
• Impairment of the anorectal sampling reflex may result in ineffective anal seal mechanism as a result of damage to the endovascular cushions.^[1]
• Damage to the pudendal nerve may impair rectal sensations which may lead to fecal impaction, enlarged rectum and overflow of the fecal matter.^[1]
• During childbirth the anal sphincter may be disrupted which may result in individual or combined damage to the pudendal nerve, external anal sphincter (EAS), internal anal sphincter (IAS).^[1]

• Fecal Incontinence may be caused due to the following: ^{[3] [4] [5]}
  • Anal sphincter dysfunction/damage
  • Rectal prolapse
  • Surgical procedures of the rectum and anus may lead to muscle or nerve injuries.
  • Anorectal surgical procedures such as hemorrhoidectomy, fistula surgery and sphincterotomy may lead to fecal incontinence. ^[4]
  • Impaired rectal sensation
  • Rectocele
  • Damage to the nerves
  • Diarrhea
  • Inflammatory bowel disease
  • Constipation
  • Hemorrhoids
  • Neurologic abnormalities such as multiple sclerosis and pudendal neuropathy
  • Decreased compliance of the rectum

• Fecal incontinence must be differentiated from other diseases such as:
  • Crohn’s disease
  • Acute diarrhea
  • Chronic diarrhea
  • Traveler’s diarrhea
  • Colorectal cancer
  • Ulcerative colitis
  • Fistulae

• The prevalence of fecal Incontinence is approximately 2000-3000 per 100,000 individuals worldwide. ^[6]
• In the US, the prevalence of fecal Incontinence is similar in women and men and increases with age, with the prevalence of 8900 per 100,000 individuals in women and 7700 per 100,00 individuals in men. ^[7]
• In the US, fecal Incontinence affects 2600 per 100,000 individuals in the age group of 20 to 29 years and in elderly people up to 15,300 per 100,000 individuals who are over the age of 70 years. ^[7]
• There is no racial predilection to fecal Incontinence.^[7]

• Common risk factors in the development of Fecal incontinence include: ^{[7] [8] [9] [10] [11]}
  • Age factor: Mostly seen in middle-age and older adult population.
  • Gender: Females are more likely to have fecal incontinence when compared to men. The major risk factor being the complications during childbirth that damage the anal sphincter and injure the pelvic floor muscles and nerves such as:
    • Episiotomy
    • Forceps delivery
    • Prolonged second stage of labor
    • Occipitoposterior presentation of the fetus
    • Pelvic floor injury resulting in significant tears and higher birth-weight of the infant
  • Nerve injury/neuropathy: Damage to the pudendal nerve/pudendal neuropathy
  • Alzheimer’s disease and Dementia: Fecal incontinence is usually seen in individuals with Alzheimer’s disease(advanced stage) and Dementia.
  • Multiple sclerosis
  • Anorectal congenital abnormalities
  • Radiation therapy of the pelvis
  • Rectal prolapse
  • Hormone therapy: In post-menopausal women, fecal incontinence may be due to hormonal therapy.

• There is insufficient evidence to recommend routine screening for fecal incontinence.
• However, a physician should rule out the symptoms in conditions which may pose as risk factors for developing fecal incontinence.

• If left untreated, patients with Fecal incontinence may progress to develop complications such as:
  • Pain and itching in the anal region leading to rashes and ulcers
  • Social withdrawal
  • Emotional distress
  • Depression
  • Insomnia
• Prognosis is generally good. After sphincteroplasty, the success rate is 64–90% initially which then declines as the years progress. By the end of 7 to 8 years after the surgery, only around half of the patients have observed better outcomes. ^{[12] [13] [14]}

• Reliable scoring systems for the assessment of fecal incontinence based on symptoms and the response received as a result of interventions are:^{[15] [16]}
  • The American Medical System Score
  • The Vaizey Score
  • The Wexner Score

• A thorough and detailed history is crucial while obtaining a history from a patient experiencing fecal incontinence. ^[4]
• The history taking should be focused mainly on obstetrical and surgical history apart from medication history and other associated medical conditions if any. ^[4]
• Symptoms should be categorized based on the onset, duration, severity and the type of incontinence. ^[4]
• Soiling of undergarments is a common symptom observed in individuals with fecal incontinence wherein stains of stool are observed on the undergarments.
• Symptoms of fecal incontinence vary acoording to the type of incontinence such as the urge fecal incontinence and passive fecal incontinence.
• Symptoms in individuals with urge fecal incontinence, the patient realizes the need to defecate but lacks control over it and may pass the stool even before reaching the restroom. ^{[17] [18]}
• Symptoms in individuals with passive fecal incontinence, the patient does not realize nor does have control over the passage of stools and hence it happens without their knowledge.^[18]

• Physical examination includes:
  • Inspection of the perianal area: To check for anocutaneous reflex (anal wink sign). Absence of this reflex indicates nerve damage.
  • Digital rectal examination: It is done to evaluate for anal pathology and assess anal sphincter resting tone.
• Procedures that may help in determining the underlying cause of fecal incontinence are:
  • Colonoscopy
  • Sigmoidoscopy
  • Anoscopy

Stool testing may be helpful in determining the underlying cause of diarrhea.

There are no ECG findings associated with fecal incontinence.

There are no x-ray findings associated with fecal incontinence.

• Ultrasound or magnetic resonance imaging may be helpful in the diagnosis of fecal incontinence. An ultrasound or magnetic resonance imaging may be helpful in determining the underlying abnormalities of the pelvic floor muscles, structural abnormalities of the anal sphincter and abnormalities of the wall of the rectum.

• Anorectal manometry may be helpful in the diagnosis of fecal incontinence. This procedure helps in determining the anal sphincter tone and also the sensation and reflexes of the rectum.
• Balloon expulsion test may be more helpful in determining defecation disorders in the elderly patients who suffer from fecal incontinence secondary to fecal impaction.

• Medical management of fecal incontinence involves medical therapy along with supportive measures that are focused at symptom control and also resolving the underlying conditions such as the stool consistency, rectal prolapse and other underlying associated medical conditions, if any.^[4]
• The first-line of management inn case of the affected patients would be the streamlining of conservative measures. Symptom control approach that includes dietary modification along with behavioral modification, usage of pads, skin care and pharmacotherapy. The patients in whom behavioral changes are suggested, should be made aware of the gastrocolic reflex.^[4]
• Dietary habits have to be assessed inorder to minimize the negative impacts of the food on stool consistency and volume.^[4]
• Inclusion of fiber rich foods or supplements may help in minimizing loose stools but, such foods should be used cautiously in patients with baseline formed stools, because the softer consistency and increased volume of the stools may result in the symptoms getting deteriorated.^[4]
• Medical therapy includes the use of drugs such as diphenoxylate/atropine, loperamide, cholestyramine, ondansetron, and/or amitriptyline. In order to reduce diarrhea and slightly increase the internal sphincter tone, diphenoxylate/atropine or loperamide are frequently used.^[19] Amitriptyline may also be used as an alternative for treating diarrhea, and it may also be used to reduce rectal urgency.^[20]
• In order to reduce episodes of incontinence in patients with fecal impaction and overflow incontinence, enema is suggested to facilitate stool elimination and reduce the stool load. ^[21]
• Supportive measures such as perianal skin care with barrier creams and restraining from over-the-counter topical creams without prescription.
• Physical therapy and biofeedback may help strengthen pelvic floor and sphincter muscles as they serve as exercises thereby helping the muscles to recordinate. ^[22]

• Surgical management involves the following procedures: ^[4]
  • Procedures to correct anatomical abnormalities
  • Repair of the anal sphincter and pelvic floor muscles ^[23]
  • Sacral nerve stimulation (SNS) by neuromodulatory procedures ^[24]
  • Creation of a new anal sphincter by transposition of the muscles and use of an artificial bowel sphincter.
  • Procedures involving increasing the anal sphincter function

• Effective measures for the primary prevention of Fecal incontinence include:
  • Avoid constipation by exercising regularly and maintaining healthy food habits by drinking plenty water and including foods rich in fiber in the diet
  • Avoiding straining or forceful defecation which may effect the anal sphincter and damage the related muscles and nerves which may lead to fecal incontinence.
  • Treating Diarrhea by managing the underlying cause such as the gastrointestinal infection.
  • In cases of fecal incontinence related to pregnancy, pelvic floor muscle training may help in prevention and reversal of the condition following the first year of delivery. ^{[25] [26]}
  • Elimination of interventions such as episiotomy, lateral sphincterotomy, and anal sphincter stretch in women may be helpful in preventing fecal incontinence. ^[27]

Case #1

• Steatorrhea
• Encopresis
• Soiling

• Consensus Conference: Treatment Options for Fecal Incontinence. Saint Vincent Oct 2002
• http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/
• http://www.spinalcord.ar.gov/Publications/FactSheets/sheets6-10/fact10.html
• NICE guidance IPG159: Stimulated graciloplasty for faecal incontinence
• NICE guidance IPG099: Sacral nerve stimulation for faecal incontinence

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