II. Definitions

  1. Fecal Incontinence
    1. Involuntary loss of bowel function with an inability to prevent stool passage
    2. Contrast with Encopresis as seen in children

III. Epidemiology

  1. Prevalence: 2-6% (21% in elderly, and up to 50% in Nursing Homes)

IV. Types

  1. Overflow
    1. Results from Fecal Impaction
  2. Reservoir
    1. Decreased rectal capacity
  3. Rectosphincteric
    1. Structural injury to anal sphincter
    2. Neurologic innervation disrupted to the anal sphincter

V. Causes

  1. Anal sphincter defects (e.g. related to prior obstetric or other surgical procedures)
  2. Rectal Prolpase
  3. Neuropathy
  4. Inflammatory Bowel Disease
  5. Central Nervous System disorders

VI. History

  1. Rectal fullness or stool urgency
  2. Urinary Incontinence
  3. Fecal Impaction
  4. Dementia history
  5. Medications
    1. Laxative abuse
    2. See Diarrhea Secondary to Medications
  6. Anal sphincter injury history
    1. Colorectal surgery history
    2. Fourth Degree Perineal Laceration with child birth
  7. Neurologic injury history
    1. Cerebrovascular Accident history
    2. Spinal Cord Injury
    3. Cauda equina symptoms

VII. Exam

  1. Neurologic Exam
    1. Perianal Sensation
    2. Anal Wink (evaluate sacral reflex)
  2. Digital Rectal Exam
    1. Assess for Fecal Impaction
    2. Assess for Rectal Tone
    3. Assess for Rectal Prolapse

VIII. Imaging: Refractory cases to evaluate sphincter defects

  1. Pelvic MRI or
  2. Endoanal Ultrasound

IX. Evaluation: Measures used by colorectal specialists

  1. Rectal Tone quantification
    1. Anorectal manometry (balloon catheter within Rectum measures pressures with rest and contraction)
  2. Evaluate for colon masses
    1. Lower endoscopy
  3. Evaluate for anal sphincter defect
    1. Ultrasound
    2. MRI

X. Management: General

  1. Treat and prevent Fecal Impaction
    1. Schedule stooling times after meals (especially in Dementia)
    2. Allow for easy restroom access
    3. Fiber supplementation (30 grams/day) with adequate fluid intake (e.g. 64 ounce non-caffeinated fluid per day)
  2. Consider biofeedback
  3. Diarrhea related Incontinence
    1. Loperamide (Imodium)
      1. Limit to occasional use only (e.g. travel)
      2. Risk of Constipation, Fecal Impaction and subsequent worse Fecal Incontinence
  4. Other general measures
    1. Barrier ointments (e.g. Zinc Oxide)

XI. Management: Surgery

  1. Indications
    1. Refractory Fecal Incontinence not responding to general measures
    2. Anal spincter dysfunction
      1. Anal sphincter Muscle injury
      2. Rectal Prolapse
  2. Surgical repair options
    1. Overlapping sphincter repair (sphincteroplasty)
      1. Good short-term results but recurs in most patients after 5 years
      2. Glasgow (2012) Dis Colon Rectum 55(4):482-90 [PubMed]
    2. Anal Bulking Agent injection
      1. Maeda (2013) Cochrane Database Syst Rev (2): CD007959 [PubMed]
    3. Sacral Nerve Stimulation
    4. Pelvic floor reconstruction
    5. Colostomy or artificial bowel sphincter

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