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 patient’s quality of life.
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.
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:
Fecal incontinence can be differentiated as the following three different subtypes:
Essential history to assess underlying etiology in FI include:
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:
If diarrhea is suspected as a primary reason for incontinence:
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.
Directed at improving stool consistency and reducing stool frequency
If above therapy fails, further investigation should be done with anorectal manometry with imaging (EUS/MRI).
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 pelvic floor and abdominal musculature to overcome 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.
In patients with refractory symptoms that do not respond to above measures.
Surgical approaches can be divided into four categories:
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.
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