Fecal Incontinence

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 pelvic floor strengthening (Kegel) exercises (alternating 5-second squeeze and 10-second rest for 10 minutes twice daily) may be helpful

• 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