Description

• Involuntary passage of fecal material through the anal canal for >1 month in an individual >3 years of age
• Major incontinence is the involuntary excretion of feces. Minor incontinence includes incontinence to flatus and occasional seepage of liquid stool.
• Fecal incontinence was the 2nd-leading cause of nursing home placement:
  • Recurrent, involuntary loss of solid/liquid stools
  • Careful rectal exam to assess for rectal tone, voluntary squeeze, and overflow incontinence from fecal impaction
  • Endorectal ultrasound (EUS) is the simplest, most reliable, and least invasive test to find anatomic defects in the anal sphincters.
  • The goal of treatment should be to restore continence and improve quality of life.

• The prevalence of fecal incontinence increases with age.
• Idiopathic fecal incontinence: No identified cause; more common in middle-aged or elderly women.

Epidemiology

Incidence
Patients underreport fecal incontinence unless prompted. Studies may underestimate the number of patients affected.

• In younger persons: Women > Men
• 8% of adults overall
• 15% of adults age >70 years
• 56–66% of hospitalized older patients and >50% in nursing home residents
• 50–70% of patients who have urinary incontinence also suffer from fecal incontinence.

Pregnancy Considerations
Obstetrical injury to the pelvic floor, during pregnancy/delivery, may result in initial temporary incontinence, which usually improves, but many years later can result in subsequent incontinence.

• Fecal impaction and overflow diarrhea leading to fecal incontinence is a common scenario in older patients.
• Surgical history:
  • Anal surgery, including hemorrhoidectomy, anal fissure repair (sphincterotomy), and anal dilatation, may predispose to fecal incontinence as a short-term or long-term complication.

Risk Factors

• Physical status:
  • Older age, female sex, obesity, limited physical activity
• Neuropsychiatric conditions:
  • Multiple sclerosis, spinal cord injury, dementia, depression, stroke, diabetic neuropathy
• Trauma:
  • Prostatectomy, radiation
  • Risk factors at the time of delivery include the use of forceps and the need for an episiotomy.
  • Forceps delivery, occipitoposterior position, and prolonged 2nd stage of labor
• Other:
  • Diarrhea, inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), menopause, smoking, constipation
  • Potential association with child abuse and sexual abuse
  • Congenital abnormalities, such as imperforate anus/rectal prolapse
  • Fecal impaction is a common cause of fecal incontinence in the elderly.
  • See “Etiology” for other specific causes

General Prevention

• Behavioral and lifestyle changes: Obesity, limited physical activity/exercise, poor diet, and smoking are modifiable risk factors.
• Postmeal bowel regimen
• Pelvic floor muscle training during pregnancy

Pathophysiology

• Continence is dependent on the complex relationships involving temporal coordination of a variety of muscles, nerves, and reflex arcs.
• Important factors in maintaining continence include stool consistency, stool volume, colonic transit time, anorectal sensation, rectal compliance, anorectal reflexes, external and internal muscle sphincter tone, puborectalis muscle function, and the mental capacity.
• Disease processes/Structural defects that alter any of these aspects can contribute to fecal incontinence.
• Diabetes is the most common metabolic disorder that may lead to fecal incontinence secondary to neuropathy of pudendal nerve.

Etiology

• Congenital: Spina bifida and myelomeningocele with spinal cord damage
• Trauma: Anal sphincter damage from vaginal delivery and surgical procedures
• Medical: Diabetes, stroke, spinal cord trauma, degenerative disorders of the nervous system, inflammatory conditions, rectal neoplasia

Commonly Associated Conditions

• Age >70 years
• Urinary incontinence/Pelvic organ prolapse
• Chronic medical conditions, such as diabetes, dementia, cerebrovascular accidents, cord compression, dementia, depression, immobility, chronic obstructive pulmonary disease, IBS, urinary incontinence, or colectomy
• Obstetric injury at young age
• Surgeries in the anorectal area
• Stroke
• History of pelvic/rectal irradiation