Fecal incontinence: Difference between revisions

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{{Infobox_Disease |
__NOTOC__
  Name        = Fecal incontinence |
  ICD10      = {{ICD10|R|15||r|10}} |
  ICD9        = {{ICD9|787.6}} |
}}
{{SI}}
{{SI}}
{{CMG}}
{{CMG}}; {{AE}} {{ARK}}


{{EH}}
==Overview==
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''' is the loss of regular control of the [[bowels]]. Involuntary excretion and leaking are common occurrences for those affected.
==Pathophysiology==
 
*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.<ref name="pmid14978634">{{cite journal| author=Rao SS| title=Pathophysiology of adult fecal incontinence. | journal=Gastroenterology | year= 2004 | volume= 126 | issue= 1 Suppl 1 | pages= S14-22 | pmid=14978634 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14978634  }} </ref> <ref name="pmid25533002">{{cite journal| author=Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA et al.| title=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. | journal=Am J Gastroenterol | year= 2015 | volume= 110 | issue= 1 | pages= 127-36 | pmid=25533002 | doi=10.1038/ajg.2014.396 | pmc=4418464 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25533002  }} </ref>
Subjects relating to [[defecation]] are often socially unacceptable, thus those affected are often beset by feelings of shame and humiliation. Some refuse to seek medical help, and instead attempt to self-manage the problem. This can lead to social withdrawal and [[Solitude|isolation]], which can turn into cases of [[agoraphobia]]. Such effects may be reduced by undergoing prescribed treatment, taking prescribed medicine and making dietary changes.
*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.<ref name="pmid14978634">{{cite journal| author=Rao SS| title=Pathophysiology of adult fecal incontinence. | journal=Gastroenterology | year= 2004 | volume= 126 | issue= 1 Suppl 1 | pages= S14-22 | pmid=14978634 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14978634  }} </ref>
 
*Malfunctioning of the external anal sphincter (EAS) may lead to the urge type or diarrhea type of fecal incontinence.<ref name="pmid14978634">{{cite journal| author=Rao SS| title=Pathophysiology of adult fecal incontinence. | journal=Gastroenterology | year= 2004 | volume= 126 | issue= 1 Suppl 1 | pages= S14-22 | pmid=14978634 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14978634  }} </ref>
==Prevalence==
*Impairment of the anorectal sampling reflex may result in ineffective anal seal mechanism as a result of damage to the endovascular cushions.<ref name="pmid14978634">{{cite journal| author=Rao SS| title=Pathophysiology of adult fecal incontinence. | journal=Gastroenterology | year= 2004 | volume= 126 | issue= 1 Suppl 1 | pages= S14-22 | pmid=14978634 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14978634  }} </ref>
Fecal incontinence affects people of all ages. Fecal incontinence is more common in women than in men, and more in older adults than in younger adults. It is not, however, a normal part of aging.
*Damage to the [[pudendal nerve]] may impair rectal sensations which may lead to [[fecal impaction]], enlarged [[rectum]] and overflow of the fecal matter.<ref name="pmid14978634">{{cite journal| author=Rao SS| title=Pathophysiology of adult fecal incontinence. | journal=Gastroenterology | year= 2004 | volume= 126 | issue= 1 Suppl 1 | pages= S14-22 | pmid=14978634 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14978634  }} </ref>
*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).<ref name="pmid14978634">{{cite journal| author=Rao SS| title=Pathophysiology of adult fecal incontinence. | journal=Gastroenterology | year= 2004 | volume= 126 | issue= 1 Suppl 1 | pages= S14-22 | pmid=14978634 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14978634  }} </ref>


==Causes==
==Causes==
===Constipation===
*Fecal Incontinence may be caused due to the following: <ref name="pmid22908765">{{cite journal| author=Ness W| title=Faecal incontinence: causes, assessment and management. | journal=Nurs Stand | year= 2012 | volume= 26 | issue= 42 | pages= 52-4, 56, 58-60 | pmid=22908765 | doi=10.7748/ns2012.06.26.42.52.c9162 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22908765  }} </ref> <ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref> <ref name="pmid24976729">{{cite journal| author=Muñoz-Yagüe T, Solís-Muñoz P, Ciriza de los Ríos C, Muñoz-Garrido F, Vara J, Solís-Herruzo JA| title=Fecal incontinence in men: causes and clinical and manometric features. | journal=World J Gastroenterol | year= 2014 | volume= 20 | issue= 24 | pages= 7933-40 | pmid=24976729 | doi=10.3748/wjg.v20.i24.7933 | pmc=4069320 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24976729  }} </ref>
**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. <ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
**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


Constipation is the most common cause of fecal incontinence. Constipation causes prolonged muscle stretching and leads to weakness of the intestinal muscles. After a certain point, the rectum will no longer close tightly enough to prevent stool loss, resulting in incontinence.<ref name=medlineFI>{{cite url|title=NIH MedlinePlus - Bowel Incontinence|url=http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/003135.htm|accessdate=2008-08-08}}</ref>
==Differentiating Fecal incontinence from Other Diseases==
*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]]


===Muscle damage===
==Epidemiology and Demographics==
Fecal incontinence can be caused by injury to one or both of the ring-like muscles at the end of the rectum called the internal and external anal sphincters. During normal function, these sphincters help retain [[Human feces|stool]]. In women, damage can occur during [[childbirth]]. The risk of injury is greatest when the birth attendant uses [[Forceps in childbirth|forceps]] to help the delivery or does an [[episiotomy]]. [[Hemorrhoid]] surgery can damage the sphincters as well. A pelvic tumor that grows in or becomes attached to the [[rectum]] or [[anus]] also can cause muscle damage, as can surgery to remove the tumor. Although [[anal sex]] resulting in repeated injury to the internal anal sphincter can lead to incontinence, the threat is relatively small.<ref name=duke_analsex>{{cite url|title=Duke Student Health Center - Anal Stimulation and Intercourse |url=http://healthydevil.studentaffairs.duke.edu/health_info/Anal%20Stimulation%20and%20Intercourse.html|accessdate=2008-08-08}}</ref> One study among 14 anoreceptive homosexual men and ten non-anoreceptive heterosexual men showed that anoreceptive homosexual men have decreased anal canal resting pressure relative to non-anoreceptive heterosexual men and no associated fecal incontinence.<ref name=pmid9068471>{{cite url|title=Anal sphincter structure and function in homosexual males engaging in anoreceptive intercourse.|url=http://www.ncbi.nlm.nih.gov/pubmed/9068471 |accessdate=2008-08-08}}</ref> Another study among forty anoreceptive homosexual men and ten non-anoreceptive heterosexual men found a very significant increase in fecal incontinence (fourteen, or 35% amongst the anoreceptive men, and one, or 10% in the non-anoreceptive sample) amongst the the anoreceptive sample.<ref name=pmid8459377>{{cite url|title=Effect of anoreceptive intercourse on anorectal function.|url=http://www.ncbi.nlm.nih.gov/pubmed/8459377 |accessdate=2008-08-31}}</ref>
*The prevalence of fecal Incontinence is approximately 2000-3000 per 100,000 individuals worldwide. <ref name="pmid7629985">{{cite journal| author=Nelson R, Norton N, Cautley E, Furner S| title=Community-based prevalence of anal incontinence. | journal=JAMA | year= 1995 | volume= 274 | issue= 7 | pages= 559-61 | pmid=7629985 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7629985  }} </ref>
*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. <ref name="pmid19410574">{{cite journal| author=Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A et al.| title=Fecal incontinence in US adults: epidemiology and risk factors. | journal=Gastroenterology | year= 2009 | volume= 137 | issue= 2 | pages= 512-7, 517.e1-2 | pmid=19410574 | doi=10.1053/j.gastro.2009.04.054 | pmc=2748224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19410574  }} </ref>
*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. <ref name="pmid19410574">{{cite journal| author=Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A et al.| title=Fecal incontinence in US adults: epidemiology and risk factors. | journal=Gastroenterology | year= 2009 | volume= 137 | issue= 2 | pages= 512-7, 517.e1-2 | pmid=19410574 | doi=10.1053/j.gastro.2009.04.054 | pmc=2748224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19410574  }} </ref>
*There is no racial predilection to fecal Incontinence.<ref name="pmid19410574">{{cite journal| author=Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A et al.| title=Fecal incontinence in US adults: epidemiology and risk factors. | journal=Gastroenterology | year= 2009 | volume= 137 | issue= 2 | pages= 512-7, 517.e1-2 | pmid=19410574 | doi=10.1053/j.gastro.2009.04.054 | pmc=2748224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19410574  }} </ref>


===Nerve damage===
==Risk Factors==
Fecal incontinence can also be caused by damage to the nerves that control the anal sphincters or to the nerves that detect stool in the rectum. Damage to the nerves controlling the sphincter muscles may render the muscles unable to work effectively. If the sensory nerves are damaged, detection of stool in the rectum is disabled, and one will not feel the need to defecate until too late. Nerve damage can be caused by childbirth, long-term [[constipation]], [[stroke]], and diseases that cause [[nerve]] degeneration, such as [[diabetes]] and [[multiple sclerosis]].
*Common risk factors in the development of Fecal incontinence include: <ref name="pmid19410574">{{cite journal| author=Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A et al.| title=Fecal incontinence in US adults: epidemiology and risk factors. | journal=Gastroenterology | year= 2009 | volume= 137 | issue= 2 | pages= 512-7, 517.e1-2 | pmid=19410574 | doi=10.1053/j.gastro.2009.04.054 | pmc=2748224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19410574  }} </ref> <ref name="pmid19844202">{{cite journal| author=Rey E, Choung RS, Schleck CD, Zinsmeister AR, Locke GR, Talley NJ| title=Onset and risk factors for fecal incontinence in a US community. | journal=Am J Gastroenterol | year= 2010 | volume= 105 | issue= 2 | pages= 412-9 | pmid=19844202 | doi=10.1038/ajg.2009.594 | pmc=3189687 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19844202  }} </ref> <ref name="pmid28209529">{{cite journal| author=Staller K, Townsend MK, Khalili H, Mehta R, Grodstein F, Whitehead WE et al.| title=Menopausal Hormone Therapy Is Associated With Increased Risk of Fecal Incontinence in Women After Menopause. | journal=Gastroenterology | year= 2017 | volume= 152 | issue= 8 | pages= 1915-1921.e1 | pmid=28209529 | doi=10.1053/j.gastro.2017.02.005 | pmc=5447480 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28209529  }} </ref> <ref name="pmid27783401">{{cite journal| author=Andy UU, Vaughan CP, Burgio KL, Alli FM, Goode PS, Markland AD| title=Shared Risk Factors for Constipation, Fecal Incontinence, and Combined Symptoms in Older U.S. Adults. | journal=J Am Geriatr Soc | year= 2016 | volume= 64 | issue= 11 | pages= e183-e188 | pmid=27783401 | doi=10.1111/jgs.14521 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27783401  }} </ref> <ref name="pmid25110978">{{cite journal| author=Matthews CA| title=Risk factors for urinary, fecal, or double incontinence in women. | journal=Curr Opin Obstet Gynecol | year= 2014 | volume= 26 | issue= 5 | pages= 393-7 | pmid=25110978 | doi=10.1097/GCO.0000000000000094 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25110978  }} </ref>
**'''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.


===Loss of storage capacity===
==Screening==
Normally, the rectum stretches to hold stool until it is voluntarily released. But rectal surgery, [[radiation]] treatment, and [[inflammatory bowel disease]] can cause scarring, which may result in the walls of the rectum becoming stiff and less elastic. The rectum walls are unable to stretch as much and are unable to accommodate as much stool. Inflammatory bowel disease also can make rectal walls very irritated and thereby unable to contain stool.
*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.


===Diarrhea===
==Natural History, Complications, and Prognosis==
{{main|Diarrhea}}
*If left untreated, patients with Fecal incontinence may progress to develop complications such as:
[[Diarrhea]], or loose stool, is more difficult to control than solid stool that is formed. Where diarrhea is caused by temporary problems such as mild infections or food reactions, incontinence tends to last for a period of days. Chronic conditions, such as [[Irritable Bowel Syndrome]], or [[Crohn's disease]] can cause severe diarrhea lasting for weeks or months until successful treatment can be found.
**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. <ref name="pmid24409050">{{cite journal| author=Van Koughnett JA, Wexner SD| title=Current management of fecal incontinence: choosing amongst treatment options to optimize outcomes. | journal=World J Gastroenterol | year= 2013 | volume= 19 | issue= 48 | pages= 9216-30 | pmid=24409050 | doi=10.3748/wjg.v19.i48.9216 | pmc=3882396 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24409050  }} </ref> <ref name="pmid12068192">{{cite journal| author=Halverson AL, Hull TL| title=Long-term outcome of overlapping anal sphincter repair. | journal=Dis Colon Rectum | year= 2002 | volume= 45 | issue= 3 | pages= 345-8 | pmid=12068192 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12068192  }} </ref> <ref name="pmid8064190">{{cite journal| author=Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ, Ritchie JK, Hawley PR, Thomson JP| title=Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year follow-up functional results. | journal=Int J Colorectal Dis | year= 1994 | volume= 9 | issue= 2 | pages= 110-3 | pmid=8064190 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8064190  }} </ref>


===Pelvic floor dysfunction===
==Diagnosis==
Abnormalities of the [[pelvic floor]] can lead to fecal incontinence. Examples of some abnormalities are decreased perception of rectal sensation, decreased anal canal pressures, decreased squeeze pressure of the anal canal, impaired anal sensation, a dropping down of the rectum ([[rectal prolapse]]), protrusion of the rectum through the vagina ([[rectocele]]), and generalized weakness and sagging of the pelvic floor.
===Diagnostic Study of Choice===
*Reliable scoring systems for the assessment of fecal incontinence based on symptoms and the response received as a result of interventions are:<ref name="pmid14668583">{{cite journal| author=Baxter NN, Rothenberger DA, Lowry AC| title=Measuring fecal incontinence. | journal=Dis Colon Rectum | year= 2003 | volume= 46 | issue= 12 | pages= 1591-605 | pmid=14668583 | doi=10.1097/01.DCR.0000098906.61097.1C | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14668583  }} </ref> <ref name="pmid9862829">{{cite journal| author=Vaizey CJ, Carapeti E, Cahill JA, Kamm MA| title=Prospective comparison of faecal incontinence grading systems. | journal=Gut | year= 1999 | volume= 44 | issue= 1 | pages= 77-80 | pmid=9862829 | doi= | pmc=1760067 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9862829  }} </ref>
**The American Medical System Score
**The Vaizey Score
**The Wexner Score


===Other causes===
===History and Symptoms===
Fecal incontinence can have other causes including one or a combination of the following:
*A thorough and detailed history is crucial while obtaining a history from a patient experiencing fecal incontinence. <ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
* [[excretion|Excretory problems]]
*The history taking should be focused mainly on [[Obstetrics|obstetrical]] and surgical history apart from medication history and other associated medical conditions if any. <ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
* [[Fecal impaction]]
*Symptoms should be categorized based on the onset, duration, severity and the type of incontinence. <ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
* Diseases, drugs, and indigestible dietary fats that interfere with the [[intestine]]al absorption. Respective examples include [[cystic fibrosis]], [[orlistat]], and [[olestra]].
*Soiling of undergarments is a common symptom observed in individuals with fecal incontinence wherein stains of stool are observed on the undergarments.
* [[Lateral internal sphincterotomy]] (Surgical procedure for helping [[Anal fissure]]s heal)
*Symptoms of fecal incontinence vary acoording to the type of incontinence such as the urge fecal incontinence and passive fecal incontinence.
* Seizure
*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. <ref name="pmid26544817">{{cite journal| author=van Meegdenburg MM, Heineman E, Broens PM| title=Pudendal Neuropathy Alone Results in Urge Incontinence Rather Than in Complete Fecal Incontinence. | journal=Dis Colon Rectum | year= 2015 | volume= 58 | issue= 12 | pages= 1186-93 | pmid=26544817 | doi=10.1097/DCR.0000000000000497 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26544817  }} </ref> <ref name="pmid25351694">{{cite journal| author=Buhmann H, Nocito A| title=[Update on fecal incontinence]. | journal=Praxis (Bern 1994) | year= 2014 | volume= 103 | issue= 22 | pages= 1313-21 | pmid=25351694 | doi=10.1024/1661-8157/a001831 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25351694  }} </ref>
*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.<ref name="pmid25351694">{{cite journal| author=Buhmann H, Nocito A| title=[Update on fecal incontinence]. | journal=Praxis (Bern 1994) | year= 2014 | volume= 103 | issue= 22 | pages= 1313-21 | pmid=25351694 | doi=10.1024/1661-8157/a001831 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25351694  }} </ref>


==Diagnosis==
===Physical Examination===
===Severity scales===
*Physical examination includes:
The [[Cleveland Clinic]] Incontinence Score is widely used because it is practical and easy to use and interpret. The score takes into account the frequency of incontinence and the use of pads and lifestyle alteration. A Fecal Incontinence Severity Index<ref name="pmid10613469">{{cite journal
**'''Inspection of the perianal area:''' To check for anocutaneous reflex (anal wink sign). Absence of this reflex indicates nerve damage.
| author = Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC
**'''Digital rectal examination:''' It is done to evaluate for anal pathology and assess [[Anus|anal sphincter]] resting tone.
| title = Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index.
*Procedures that may help in determining the underlying cause of fecal incontinence are:
| journal = Dis. Colon Rectum
**[[Colonoscopy]]
| volume = 42
**[[Sigmoidoscopy]]
| issue = 12
**[[Anoscopy]]
| pages = 1525–32
| year = 1999
| pmid = 10613469
| doi =
| issn =
}}</ref> is based on a type-by-frequency matrix with four types of leakage (gas, mucus, liquid stool, solid stool) and five frequencies (one to three times per month, once per week, twice per week, once per day, twice or more per day).


Other tests include: AMS, Pescatori, Williams score, Kirwan, Miller score, Parks criteria, and the Vaizey scale.
===Laboratory Findings===
Stool testing may be helpful in determining the underlying cause of [[diarrhea]].


===Tests===
===Electrocardiogram===
[[Anal manometry]] checks the tightness of the anal sphincter and its ability to respond to signals, as well as the sensitivity and function of the rectum. [[Anorectal ultrasonography]] evaluates the structure of the anal sphincters. [[Proctography]], also known as defecography, shows how much stool the rectum can hold, how well the rectum holds it, and how well the rectum can evacuate the stool. [[Proctosigmoidoscopy]] allows doctors to look inside the rectum for signs of disease or other problems that could cause fecal incontinence, such as inflammation, tumors, or scar tissue. [[Anal electromyography]] tests for nerve damage, which is often associated with obstetric injury.
There are no ECG findings associated with fecal incontinence.
===X-ray===
There are no x-ray findings associated with fecal incontinence.
===Ultrasound/MRI===
*[[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|pelvic floor muscles]], structural abnormalities of the anal sphincter and abnormalities of the wall of the [[rectum]].
===Other Diagnostic Studies===
*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]].


==Treatment==
==Treatment==
Treatment depends on the cause and severity of fecal incontinence; it may include dietary changes, medication, bowel training, or surgery. More than one treatment may be necessary because some forms of fecal incontinence can be rather complicated. Most physicians that specialize in [[gastroenterology]], rehabilitative medicine, neurotrauma, and pediatric surgery have experience with bowel management programs. "Social continence" may be achievable for some people using a bowel management program that cleans out the colon daily.
===Medical Therapy===
 
*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.<ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
There are several devices and medications available to combat fecal incontinence. One method of relatively easy treatment is the use of diapers. Both cloth and disposable diapers are available for fecal incontinence. Pull-up type diapers are not recommended for fecal incontinence. Thicker-type diapers are generally seen as the best method of treating fecal incontinence, since these diapers are thicker and have inner linings to help control fecal matter better.
*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.<ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
 
*Dietary habits have to be assessed inorder to minimize the negative impacts of the food on stool consistency and volume.<ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
===Dietary changes===
*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.<ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
Food affects the consistency of stool and how quickly it passes through the digestive system. One way to help control fecal incontinence in some persons is to eat foods that add bulk to stool, decreasing the water content of the feces and making it firmer.  Also, avoidance of foods and drinks such as those containing caffeine, which relax the internal anal sphincter muscle. Another approach is to eat foods low in fiber to decrease the work of the anal sphincters. Fruit can act as a natural laxative and should be eaten sparingly. Foods to be avoided also include those that typically cause diarrhea, such as [[Curing (food preservation)|cured]] or [[Smoking (food)|smoked]] [[meat]]; [[spice|spicy]] foods; [[alcohol]]; [[dairy products]]; fatty and greasy foods; and artificial [[sweeteners]].
*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.<ref name="pmid7105952">{{cite journal| author=Read M, Read NW, Barber DC, Duthie HL| title=Effects of loperamide on anal sphincter function in patients complaining of chronic diarrhea with fecal incontinence and urgency. | journal=Dig Dis Sci | year= 1982 | volume= 27 | issue= 9 | pages= 807-14 | pmid=7105952 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7105952  }} </ref> Amitriptyline may also be used as an alternative for treating diarrhea, and it may also be used to reduce rectal urgency.<ref name="pmid11156450">{{cite journal| author=Santoro GA, Eitan BZ, Pryde A, Bartolo DC| title=Open study of low-dose amitriptyline in the treatment of patients with idiopathic fecal incontinence. | journal=Dis Colon Rectum | year= 2000 | volume= 43 | issue= 12 | pages= 1676-81; discussion 1681-2 | pmid=11156450 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11156450  }} </ref>
 
*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. <ref name="pmid10791451">{{cite journal| author=Chassagne P, Jego A, Gloc P, Capet C, Trivalle C, Doucet J et al.| title=Does treatment of constipation improve faecal incontinence in institutionalized elderly patients? | journal=Age Ageing | year= 2000 | volume= 29 | issue= 2 | pages= 159-64 | pmid=10791451 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10791451 }} </ref>
===Medication===
*Supportive measures such as perianal skin care with barrier creams and restraining from over-the-counter topical creams without prescription.
Medication consists primarily of [[antipropulsive]] drugs.
*Physical therapy and biofeedback may help strengthen pelvic floor and sphincter muscles as they serve as exercises thereby helping the muscles to recordinate. <ref name="pmid19966605">{{cite journal| author=Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead WE| title=Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. | journal=Dis Colon Rectum | year= 2009 | volume= 52 | issue= 10 | pages= 1730-7 | pmid=19966605 | doi=10.1007/DCR.0b013e3181b55455 | pmc=3855426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19966605  }} </ref>


===Surgery===
===Surgery===
[[surgery|Surgical]] procedures used to treat otherwise intractable [[fecal incontinence]] include:
*Surgical management involves the following procedures: <ref name="pmid26268955">{{cite journal| author=Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L| title=Fecal Incontinence: Etiology, Diagnosis, and Management. | journal=J Gastrointest Surg | year= 2015 | volume= 19 | issue= 10 | pages= 1910-21 | pmid=26268955 | doi=10.1007/s11605-015-2905-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26268955  }} </ref>
 
**Procedures to correct anatomical abnormalities
*[[Colostomy]]
**Repair of the anal sphincter and pelvic floor muscles <ref name="pmid10796816">{{cite journal| author=Bachoo P, Brazzelli M, Grant A| title=Surgery for faecal incontinence in adults. | journal=Cochrane Database Syst Rev | year= 2000 | volume= | issue= 2 | pages= CD001757 | pmid=10796816 | doi=10.1002/14651858.CD001757 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10796816  }} </ref>
 
**Sacral nerve stimulation (SNS) by neuromodulatory procedures <ref name="pmid7475602">{{cite journal| author=Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP| title=Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence. | journal=Lancet | year= 1995 | volume= 346 | issue= 8983 | pages= 1124-7 | pmid=7475602 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7475602  }} </ref>
*Stimulated graciloplasty creates a new [[anal sphincter]], using [[gracilis muscle]] from the [[thigh]] and a temporary electric device to retrain the muscle for its new function.
**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
*Artificial anal sphincter (also known as "artificial bowel sphincter" and "neosphincter").<ref name="pmid17062108">{{cite journal
| author = Schrag HJ, Ruthmann O, Doll A, Goldschmidtböing F, Woias P, Hopt UT
| title = Development of a novel, remote-controlled artificial bowel sphincter through microsystems technology.
| journal = Artif Organs
| volume = 30
| issue = 11
| pages = 855–62
| year = 2006
| pmid = 17062108
| doi = 10.1111/j.1525-1594.2006.00312.x
| url = http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0160-564X&date=2006&volume=30&issue=11&spage=855
}}</ref> The usual surgical approach is through the [[perineum]] but because in many cases of fecal incontinence the perineum is damaged, for women an alternative approach is through the [[vagina]].<ref name="pmid17665251">{{cite journal
| author = Michot F, Tuech JJ, Lefebure B, Bridoux V, Denis P
| title = A new implantation procedure of artificial sphincter for anal incontinence: the transvaginal approach.
| journal = Dis. Colon Rectum
| volume = 50
| issue = 9
| pages = 1401–4
| year = 2007
| pmid = 17665251
| doi = 10.1007/s10350-007-0314-6
}}</ref>
 
*Temperature-controlled radiofrequency energy (SECCA)<ref name="pmid17556904">{{cite journal
| author = Felt-Bersma RJ, Szojda MM, Mulder CJ
| title = Temperature-controlled radiofrequency energy (SECCA) to the anal canal for the treatment of faecal incontinence offers moderate improvement.
| journal = Eur J Gastroenterol Hepatol
| volume = 19
| issue = 7
| pages = 575–80
| year = 2007
| pmid = 17556904
| doi = 10.1097/MEG.0b013e32811ec010
| url = http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00042737-200707000-00010
}}</ref>
 
*Antegrade continent enema stoma. This procedure is often necessary in addition to others when fecal incontinence is complicated by [[neuropathy]] and/or an incomplete internal anal sphincter.
 
*Sacral nerve stimulation, the newest of these surgical procedures, involves implanting an electric device that may enable control of the anal sphincter and restore a patient's continence.[http://www.pelviperineology.org/pelvic_floor/sacral_neuromodulation_in_treatment_fecal_incontinence.html]
 
Graciloplasty and artificial anal sphincter both significantly improve continence, with artificial anal sphincter being superior,<ref name="pmid16896900">{{cite journal
| author = Ruthmann O, Fischer A, Hopt UT, Schrag HJ
| title = [Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence]
| language = German
| journal = Chirurg
| volume = 77
| issue = 10
| pages = 926–38
| year = 2006
| pmid = 16896900
| doi = 10.1007/s00104-006-1217-0
}}</ref> however both methods have high rates of complications.<ref name="pmid16896900">{{cite journal
| author = Ruthmann O, Fischer A, Hopt UT, Schrag HJ
| title = [Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence]
| language = German
| journal = Chirurg
| volume = 77
| issue = 10
| pages = 926–38
| year = 2006
| pmid = 16896900
| doi = 10.1007/s00104-006-1217-0
}}</ref><ref name="pmid16554983">{{cite journal
| author = Belyaev O, Müller C, Uhl W
| title = Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature.
| journal = Surg. Today
| volume = 36
| issue = 4
| pages = 295–303
| year = 2006
| pmid = 16554983
| doi = 10.1007/s00595-005-3159-4
}}</ref>


===Kegel Exercises===
===Primary Prevention===
*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. <ref name="pmid18268289">{{cite journal| author=Landefeld CS, Bowers BJ, Feld AD, Hartmann KE, Hoffman E, Ingber MJ et al.| title=National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. | journal=Ann Intern Med | year= 2008 | volume= 148 | issue= 6 | pages= 449-58 | pmid=18268289 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18268289  }} </ref> <ref name="pmid23076935">{{cite journal| author=Boyle R, Hay-Smith EJ, Cody JD, Mørkved S| title=Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 10 | issue=  | pages= CD007471 | pmid=23076935 | doi=10.1002/14651858.CD007471.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23076935  }} </ref>
**Elimination of interventions such as episiotomy, lateral sphincterotomy, and anal sphincter stretch in women may be helpful in preventing fecal incontinence. <ref name="pmid20025031">{{cite journal| author=Norton C, Whitehead WE, Bliss DZ, Harari D, Lang J, Conservative Management of Fecal Incontinence in Adults Committee of the International Consultation on Incontinence| title=Management of fecal incontinence in adults. | journal=Neurourol Urodyn | year= 2010 | volume= 29 | issue= 1 | pages= 199-206 | pmid=20025031 | doi=10.1002/nau.20803 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20025031  }} </ref>
==Case Studies==


[[Kegel exercise|Appropriate exercise]] of the sphincter muscles can help restore muscle tone, and reduce or even eliminate anal incontinence<ref>{{cite web|url=http://www.continence-foundation.org.uk/publications/pdfs/Sphincter%20Exercises%209.PDF|title=The Continence Foundation - Sphincter Exercises to Aid Bowel Control|accessdate=2008-05-14}}</ref>.
[[Fecal incontinence case study one|Case #1]]


==See also==
==Related Chapters==
* [[Steatorrhea]]
* [[Steatorrhea]]
* [[Encopresis]]
* [[Encopresis]]
* [[Soiling]]
* [[Soiling]]


==References==
==External Links==
{{reflist|2}}
 
==External links==
*[http://www.colorep.it/Rivista%20CEC/consensus_conference.htm Consensus Conference: Treatment Options for Fecal Incontinence. Saint Vincent Oct 2002]
*[http://www.colorep.it/Rivista%20CEC/consensus_conference.htm Consensus Conference: Treatment Options for Fecal Incontinence. Saint Vincent Oct 2002]
*[http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/ http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/]
*http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/
*[http://www.spinalcord.ar.gov/Publications/FactSheets/sheets6-10/fact10.html http://www.spinalcord.ar.gov/Publications/FactSheets/sheets6-10/fact10.html]
*http://www.spinalcord.ar.gov/Publications/FactSheets/sheets6-10/fact10.html
*[[National Institute for Health and Clinical Excellence|NICE]] guidance IPG159:  [http://www.nice.org.uk/page.redirect?o=IP_19 Stimulated graciloplasty for faecal incontinence]
*[[National Institute for Health and Clinical Excellence|NICE]] guidance IPG159:  [http://www.nice.org.uk/page.redirect?o=IP_19 Stimulated graciloplasty for faecal incontinence]
*[[National Institute for Health and Clinical Excellence|NICE]] guidance IPG099: [http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11079 Sacral nerve stimulation for faecal incontinence]
*[[National Institute for Health and Clinical Excellence|NICE]] guidance IPG099: [http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11079 Sacral nerve stimulation for faecal incontinence]
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Latest revision as of 21:44, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Reddy Kothagadi M.B.B.S[2]

Overview

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.

Pathophysiology

  • 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]

Causes

Differentiating Fecal incontinence from Other Diseases

Epidemiology and Demographics

  • 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]

Risk Factors

  • 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.

Screening

  • 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.

Natural History, Complications, and Prognosis

  • 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]

Diagnosis

Diagnostic Study of Choice

  • 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

History and Symptoms

  • 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

  • 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:

Laboratory Findings

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

Electrocardiogram

There are no ECG findings associated with fecal incontinence.

X-ray

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

Ultrasound/MRI

  • 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.

Other Diagnostic Studies

  • 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.

Treatment

Medical Therapy

  • 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]

Surgery

  • 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

Primary Prevention

  • 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 Studies

Case #1

Related Chapters

External Links

Template:Antidiarrheals, intestinal anti-inflammatory/anti-infective agents Template:WH Template:WS

cs:Fekální inkontinence de:Stuhlinkontinenz it:Incontinenza fecale nl:Ontlastingincontinentie sk:Fekálna inkontinencia fi:Ulosteinkontinenssi

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Rao SS (2004). "Pathophysiology of adult fecal incontinence". Gastroenterology. 126 (1 Suppl 1): S14–22. PMID 14978634.
  2. ↑ Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA; et al. (2015). "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. 110 (1): 127–36. doi:10.1038/ajg.2014.396. PMC 4418464. PMID 25533002.
  3. ↑ Ness W (2012). "Faecal incontinence: causes, assessment and management". Nurs Stand. 26 (42): 52–4, 56, 58–60. doi:10.7748/ns2012.06.26.42.52.c9162. PMID 22908765.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L (2015). "Fecal Incontinence: Etiology, Diagnosis, and Management". J Gastrointest Surg. 19 (10): 1910–21. doi:10.1007/s11605-015-2905-1. PMID 26268955.
  5. ↑ Muñoz-Yagüe T, Solís-Muñoz P, Ciriza de los Ríos C, Muñoz-Garrido F, Vara J, Solís-Herruzo JA (2014). "Fecal incontinence in men: causes and clinical and manometric features". World J Gastroenterol. 20 (24): 7933–40. doi:10.3748/wjg.v20.i24.7933. PMC 4069320. PMID 24976729.
  6. ↑ Nelson R, Norton N, Cautley E, Furner S (1995). "Community-based prevalence of anal incontinence". JAMA. 274 (7): 559–61. PMID 7629985.
  7. ↑ 7.0 7.1 7.2 7.3 Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A; et al. (2009). "Fecal incontinence in US adults: epidemiology and risk factors". Gastroenterology. 137 (2): 512–7, 517.e1–2. doi:10.1053/j.gastro.2009.04.054. PMC 2748224. PMID 19410574.
  8. ↑ Rey E, Choung RS, Schleck CD, Zinsmeister AR, Locke GR, Talley NJ (2010). "Onset and risk factors for fecal incontinence in a US community". Am J Gastroenterol. 105 (2): 412–9. doi:10.1038/ajg.2009.594. PMC 3189687. PMID 19844202.
  9. ↑ Staller K, Townsend MK, Khalili H, Mehta R, Grodstein F, Whitehead WE; et al. (2017). "Menopausal Hormone Therapy Is Associated With Increased Risk of Fecal Incontinence in Women After Menopause". Gastroenterology. 152 (8): 1915–1921.e1. doi:10.1053/j.gastro.2017.02.005. PMC 5447480. PMID 28209529.
  10. ↑ Andy UU, Vaughan CP, Burgio KL, Alli FM, Goode PS, Markland AD (2016). "Shared Risk Factors for Constipation, Fecal Incontinence, and Combined Symptoms in Older U.S. Adults". J Am Geriatr Soc. 64 (11): e183–e188. doi:10.1111/jgs.14521. PMID 27783401.
  11. ↑ Matthews CA (2014). "Risk factors for urinary, fecal, or double incontinence in women". Curr Opin Obstet Gynecol. 26 (5): 393–7. doi:10.1097/GCO.0000000000000094. PMID 25110978.
  12. ↑ Van Koughnett JA, Wexner SD (2013). "Current management of fecal incontinence: choosing amongst treatment options to optimize outcomes". World J Gastroenterol. 19 (48): 9216–30. doi:10.3748/wjg.v19.i48.9216. PMC 3882396. PMID 24409050.
  13. ↑ Halverson AL, Hull TL (2002). "Long-term outcome of overlapping anal sphincter repair". Dis Colon Rectum. 45 (3): 345–8. PMID 12068192.
  14. ↑ Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ, Ritchie JK, Hawley PR, Thomson JP (1994). "Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year follow-up functional results". Int J Colorectal Dis. 9 (2): 110–3. PMID 8064190.
  15. ↑ Baxter NN, Rothenberger DA, Lowry AC (2003). "Measuring fecal incontinence". Dis Colon Rectum. 46 (12): 1591–605. doi:10.1097/01.DCR.0000098906.61097.1C. PMID 14668583.
  16. ↑ Vaizey CJ, Carapeti E, Cahill JA, Kamm MA (1999). "Prospective comparison of faecal incontinence grading systems". Gut. 44 (1): 77–80. PMC 1760067. PMID 9862829.
  17. ↑ van Meegdenburg MM, Heineman E, Broens PM (2015). "Pudendal Neuropathy Alone Results in Urge Incontinence Rather Than in Complete Fecal Incontinence". Dis Colon Rectum. 58 (12): 1186–93. doi:10.1097/DCR.0000000000000497. PMID 26544817.
  18. ↑ 18.0 18.1 Buhmann H, Nocito A (2014). "[Update on fecal incontinence]". Praxis (Bern 1994). 103 (22): 1313–21. doi:10.1024/1661-8157/a001831. PMID 25351694.
  19. ↑ Read M, Read NW, Barber DC, Duthie HL (1982). "Effects of loperamide on anal sphincter function in patients complaining of chronic diarrhea with fecal incontinence and urgency". Dig Dis Sci. 27 (9): 807–14. PMID 7105952.
  20. ↑ Santoro GA, Eitan BZ, Pryde A, Bartolo DC (2000). "Open study of low-dose amitriptyline in the treatment of patients with idiopathic fecal incontinence". Dis Colon Rectum. 43 (12): 1676–81, discussion 1681-2. PMID 11156450.
  21. ↑ Chassagne P, Jego A, Gloc P, Capet C, Trivalle C, Doucet J; et al. (2000). "Does treatment of constipation improve faecal incontinence in institutionalized elderly patients?". Age Ageing. 29 (2): 159–64. PMID 10791451.
  22. ↑ Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead WE (2009). "Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence". Dis Colon Rectum. 52 (10): 1730–7. doi:10.1007/DCR.0b013e3181b55455. PMC 3855426. PMID 19966605.
  23. ↑ Bachoo P, Brazzelli M, Grant A (2000). "Surgery for faecal incontinence in adults". Cochrane Database Syst Rev (2): CD001757. doi:10.1002/14651858.CD001757. PMID 10796816.
  24. ↑ Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP (1995). "Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence". Lancet. 346 (8983): 1124–7. PMID 7475602.
  25. ↑ Landefeld CS, Bowers BJ, Feld AD, Hartmann KE, Hoffman E, Ingber MJ; et al. (2008). "National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults". Ann Intern Med. 148 (6): 449–58. PMID 18268289.
  26. ↑ Boyle R, Hay-Smith EJ, Cody JD, Mørkved S (2012). "Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women". Cochrane Database Syst Rev. 10: CD007471. doi:10.1002/14651858.CD007471.pub2. PMID 23076935.
  27. ↑ Norton C, Whitehead WE, Bliss DZ, Harari D, Lang J, Conservative Management of Fecal Incontinence in Adults Committee of the International Consultation on Incontinence (2010). "Management of fecal incontinence in adults". Neurourol Urodyn. 29 (1): 199–206. doi:10.1002/nau.20803. PMID 20025031.
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