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Key Features

  • Occurs in up to 10% of the elderly

  • Minor incontinence

    • Slight soilage of undergarments that tends to occur after bowel movements or with straining or coughing

    • Causes

      • Local anal problems, such as prolapsed hemorrhoids or isolated weakness of the internal anal sphincter

      • Ulcerative proctitis

      • Chronic diarrheal conditions

      • Irritable bowel syndrome

  • Major incontinence

    • Complete uncontrolled loss of stool

    • Causes

      • Significant sphincteric or neurologic damage resulting from obstetric trauma (especially forceps delivery, episiotomy, or pudendal nerve damage)

      • Rectal prolapse

      • Prior anal surgery

      • Physical trauma

      • Aging

      • Diabetes mellitus

      • Dementia

      • Cerebrovascular accident

      • Multiple sclerosis

      • Spinal cord injury

      • Cauda equina syndrome

Clinical Findings

  • Incontinence of stool, minor or major

Diagnosis

  • Confirm an intact anocutaneous reflex by stimulation of perianal skin

  • Digital examination during relaxation and squeezing to assess resting tone and external sphincter function and to exclude fecal impaction

  • Anoscopy to assess for hemorrhoids, fissures, and fistulas

  • Proctosigmoidoscopy to exclude rectal carcinoma or proctitis

  • Anal ultrasonography or pelvic MRI to assess integrity of sphincters

  • Anal manometry and surface electromyography to assess rectal sensation, resting and voluntary squeeze pressures, and innervation

Treatment

  • Minor incontinence

    • Fiber supplements

    • Bulking agents

    • Loose application of a cotton ball near the anal opening

    • Kegel perineal strengthening exercises

  • Major incontinence

    • Antidiarrheal drugs (eg, loperamide, 2 mg before meals and prophylactically before social engagements, shopping trips, etc)

    • Scheduled toilet use after glycerin suppositories or tap water enemas

  • Provide elderly more time and assistance to reach toilet

  • Prevent stool impaction and "overflow" incontinence

  • Biofeedback training with anal sphincter exercises for patients with reduced sensation or poor voluntary squeeze pressures

  • Injection of sterile gel containing dextranomer and sodium hyaluronate submucosally into the proximal anal canal

    • Indicated for patients who have not responded to conservative therapies, such as fiber supplements and antidiarrheal agents

    • Reduces incontinence episodes by bulking up of the anal wall and consequent narrowing of the anal canal

    • In clinical trials, more than one-half of treated patients reported a > 50% reduction in the number of fecal incontinence episodes

  • Sacral nerve stimulation device

    • In uncontrolled trials, improvement was seen in 83% of selected patients

    • Inserts also are available that can be placed in the anus or vagina to enhance continence

  • Surgical intervention in patients who have not responded to medical therapy, especially patients with traumatic disruption of sphincters

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