Fecal incontinence (FI) is the involuntary passage of fecal matter through anus or inability to control the discharge of bowel contents. Its severity can range from an involuntary passage of flatus to complete evacuation of fecal matter. Depending on the severity of disease, it has a significant impact on a patient’s quality of life .
The prevalence of FI is difficult to estimate because often, this condition is underreported due to social stigma. The overall reported prevalence of FI ranges from 2% to 21% with a median of 7.7%. There is significant variation depending on age. Prevalence of FI is reported as 7% in women younger than 30 years which rises to 22% in their seventh decades. In geriatric patients, prevalence is reported as high as 25% to 35% of nursing home residents and 10% to 25% of hospitalized patients. In fact, FI is the second leading cause of nursing home placement in the geriatric population. 
It is vital to understand the physiology of continence to understand the pathophysiology of incontinence. The anatomical structures which help to maintain control of bowel function are the following:
Fecal incontinence can be differentiated as the following three different subtypes:
Essential history to assess underlying etiology in FI include:
A detailed neurological exam should be performed to evaluate for neurological disease. A detailed rectal exam is a key in the evaluation of FI; it can be best divided into following steps, but the accuracy of rectal exam and evaluation of various structures depend to a large extent on examiner’s experience:
If diarrhea is suspected as a primary reason for incontinence:
If incontinence is without any diarrhea then more specific testing should be pursued. The most valuable tests for the evaluation of FI are anorectal manometry and endoscopic ultrasound. Defecography is usually reserved for refractory symptoms or before operative planning intervention.
Directed at improving stool consistency and reducing stool frequency
If the above therapy fails, further investigation should be done with anorectal manometry with imaging (EUS/MRI).
Indicated for patients with impaired external sphincter tone and loss of sensation to rectal distention if detected during manometry. Biofeedback therapy is based on the concept of cognitive retraining of the pelvic floor and abdominal musculature to overcome the above defects. Studies report a wide range of success rate ranging from 38 % to 100%. This wide variation is due to small-scale studies with methodological limitation with a different definition of outcomes.
In patients with refractory symptoms that do not respond to the above measures.
Surgical approaches can be divided into four categories:
Fecal incontinence has multiple causes and is best managed by an interprofessional team that includes a pediatric surgeon, colorectal surgeon, dietitian, internist, a pediatrician, and a mental health worker. The treatment depends on the cause; the majority of non-congenital causes can be managed with conservative treatment and a change in diet but most congenital disorders require corrective surgery. The outcomes do depend on the cause, but in a significant number of people, recurrence is common and the quality of life is poor .
|||Grossi U,De Simone V,Parello A,Litta F,Donisi L,Di Tanna GL,Goglia M,Ratto C, Gatekeeper Improves Voluntary Contractility in Patients With Fecal Incontinence. Surgical innovation. 2018 Dec 14; [PubMed PMID: 30547721]|
|||Arbuckle JL,Parden AM,Hoover K,Griffin RL,Richter HE, Prevalence and Awareness of Pelvic Floor Disorders in Adolescent Females Seeking Gynecologic Care. Journal of pediatric and adolescent gynecology. 2018 Dec 5; [PubMed PMID: 30529498]|
|||Thubert T,Cardaillac C,Fritel X,Winer N,Dochez V, [Definition, epidemiology and risk factors of obstetric anal sphincter injuries: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. Gynecologie, obstetrique, fertilite [PubMed PMID: 30385355]|
|||Kitaguchi D,Nishizawa Y,Sasaki T,Tsukada Y,Ito M, Clinical benefit of high resolution anorectal manometry for the evaluation of anal function after intersphincteric resection. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2018 Dec 8; [PubMed PMID: 30537066]|
|||Vande Velde S,Van Renterghem K,Van Winkel M,De Bruyne R,Van Biervliet S, Constipation and fecal incontinence in children with cerebral palsy. Overview of literature and flowchart for a stepwise approach. Acta gastro-enterologica Belgica. 2018 Jul-Sep; [PubMed PMID: 30350531]|
|||van der Schans EM,Paulides TJC,Wijffels NA,Consten ECJ, Management of patients with rectal prolapse: the 2017 Dutch guidelines. Techniques in coloproctology. 2018 Aug; [PubMed PMID: 30099626]|
|||Pratt T,Mishra K, Evaluation and management of defecatory dysfunction in women. Current opinion in obstetrics [PubMed PMID: 30247166]|
|||Bouchoucha M,Devroede G,Rompteaux P,Bejou B,Sabate JM,Benamouzig R, Clinical and psychological correlates of soiling in adult patients with functional gastrointestinal disorders. International journal of colorectal disease. 2018 Jul 10; [PubMed PMID: 29987361]|
|||Cauley CE,Savitt LR,Weinstein M,Wakamatsu MM,Kunitake H,Ricciardi R,Staller K,Bordeianou L, A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation. Diseases of the colon and rectum. 2019 Jan; [PubMed PMID: 30451749]|
|||Wagg A,Gove D,Leichsenring K,Ostaszkiewicz J, Development of quality outcome indicators to improve the quality of urinary and faecal continence care. International urogynecology journal. 2018 Oct 16; [PubMed PMID: 30327849]|