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In a 2018 survey, 4.7% of US adults reported fecal incontinence within the prior 30 days. There are five general requirements for bowel continence: (1) solid or semisolid stool (even healthy young adults have difficulty maintaining continence with liquid rectal contents); (2) a distensible rectal reservoir (as sigmoid contents empty into the rectum, the vault must expand to accommodate); (3) a sensation of rectal fullness (if the patient cannot sense this, overflow may occur before the patient can take appropriate action); (4) intact pelvic nerves and muscles; and (5) the ability to reach a toilet in a timely fashion.

MINOR INCONTINENCE

Many patients complain of inability to control flatus or slight soilage of undergarments that tends to occur after bowel movements or with straining or coughing. This may be due to local anal problems such as prolapsed hemorrhoids that make it difficult to form a tight anal seal or isolated weakness of the internal anal sphincter, especially if stools are somewhat loose. Patients should be treated with fiber supplements to provide greater stool bulk. Coffee and other caffeinated beverages should be eliminated. The perianal skin should be cleansed with moist, lanolin-coated tissue (baby wipes) to reduce excoriation and infection. After wiping, loose application of a cotton ball near the anal opening may absorb small amounts of fecal leakage. Prolapsing hemorrhoids may be treated with band ligation or surgical hemorrhoidectomy. Control of flatus and seepage may be improved by Kegel perineal exercises. Conditions such as ulcerative proctitis that cause tenesmus and urgency, chronic diarrheal conditions, and irritable bowel syndrome may result in difficulty in maintaining complete continence, especially if a toilet is not readily available. Loperamide may be helpful to reduce urge incontinence in patients with loose stools and may be taken in anticipation of situations in which a toilet may not be readily available. Older patients may require more time or assistance to reach a toilet, which may lead to incontinence. Scheduled toileting and the availability of a bedside commode are helpful. Elderly patients with chronic constipation may develop stool impaction leading to “overflow” incontinence.

MAJOR INCONTINENCE

Complete uncontrolled loss of stool reflects a significant problem with central perception or neuromuscular function. Incontinence that occurs without awareness suggests a loss of central awareness (eg, dementia, cerebrovascular accident, multiple sclerosis) or peripheral nerve injury (eg, spinal cord injury, cauda equina syndrome, pudendal nerve damage due to obstetric trauma or pelvic floor prolapse, aging, or diabetes mellitus). Incontinence that occurs despite awareness and active efforts to retain stool suggests sphincteric damage, which may be caused by traumatic childbirth (especially forceps delivery), episiotomy, prolapse, prior anal surgery, and physical trauma.

Physical examination should include careful inspection of the perianal area for hemorrhoids, rectal prolapse, fissures, fistulas, and either gaping or a keyhole defect of the anal sphincter (indicating severe sphincteric injury or neurologic disorder). The perianal skin should be stimulated to confirm an ...

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