Fecal incontinence

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Diagnosis

Severity scales

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 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.

Tests

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.

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.

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.

Dietary changes

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 cured or smoked meat; spicy foods; alcohol; dairy products; fatty and greasy foods; and artificial sweeteners.

Medication

Medication consists primarily of antipropulsive drugs.

Surgery

Surgical procedures used to treat otherwise intractable fecal incontinence include:

• Colostomy

• 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.

• Artificial anal sphincter (also known as "artificial bowel sphincter" and "neosphincter"). 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.

• Temperature-controlled radiofrequency energy (SECCA)

• 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.[2]

Graciloplasty and artificial anal sphincter both significantly improve continence, with artificial anal sphincter being superior, however both methods have high rates of complications.

Kegel Exercises

Appropriate exercise of the sphincter muscles can help restore muscle tone, and reduce or even eliminate anal incontinence.

See also

• Steatorrhea
• Encopresis
• Soiling

External links

• 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