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 the disease, it has a significant impact on a patient’s quality of life .
Patients with fecal incontinence have an unintentional loss of liquid or solid stool. In true anal incontinence, there is loss of control of the anal sphincter which leads to the untimely release of feces. On the other hand, fecal incontinence can also result from enlarged skin tags, poor hygiene, hemorrhoids, rectal prolapse and fistula in ano. Other common causes include the use of laxatives, inflammatory bowel disease, and parasitic infections.
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. The 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. 
Overall, it appears that rates of fecal incontinence are on the rise. Following cesarean section, fecal incontinence is very common. Other factors linked to fecal incontinence include advanced age, vaginal delivery, and depression.
Finally, the cost of managing fecal incontinence is enormous. The public spends hundreds of millions of dollars on adult diapers to control fecal and urinary incontinence.
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:
To maintain fecal continence, there is a complex interplay of several organ systems and nerves. As the fecal mass presents to the rectum, this causes distension. The sensation of rectal distension is transmitted by the parasympathetic nerves (S2-S4), which induces relaxation of the rectoanal inhibitor reflex and contraction of the rectoanal contractile reflex. The rectal lining has a rich supply of nerve endings that can sample if the mass is liquid or solid. It is believed that abnormal sampling and lowered anorectal sensation most likely contribute to fecal incontinence in many individuals. Any pathology that interferes with these processes like trauma, stroke, vaginal delivery or paralysis can result in fecal incontinence.
Fecal incontinence can be differentiated as the following three different subtypes:
Essential history to assess underlying etiology in FI include:
There are Tools for evaluating fecal incontinence based on surveys.
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 rates ranging from 38 % to 100%. This wide variation is due to small-scale studies with methodological limitations 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:
Recently injection of silicone has been shown to augment the function of the internal anal sphincter. Others have shown promise with carbon-coated microbeads. Sacral nerve stimulation is a minimally invasive approach for fecal incontinence. The stimulator may benefit patients with minor anal sphincter deficits due to a neurological issue. The two step procedure involves initially placing temporary external electrodes into the sacral foramen. The stimulation decreases symptoms of fecal incontinence by enhancing the squeeze and resting anal pressures and colonic motility. Patients who respond, then undergo permanent placement of an embedded neurostimulator. While good outcomes have been reported in several studies, the surgery can be associated with hematoma, seroma, and infection. In addition, lead migration and paresthesias are not uncommon. To counter these problems. sacral transcutaneous electrical nerve stimulation is now being evaluated.
Another relatively new method to manage fecal incontinence is the use of an injectable anal bulking agent. The hyaluronic acid derivative is injected into the anal mucosa and if the treatment can be repeated. Early results show that some patients may have a reduction in episodes of fecal incontinence.
In 2015, the vaginal bowel control device was approved for fecal incontinence. The vaginal insert has an inflatable balloon which exerts pressure through the vaginal wall onto the rectal area, and thus reducing fecal incontinence. The device does need regular cleaning and can be inflated and deflated as needed.
The prognosis for most patients with fecal incontinence is guarded. Short term outcomes after sphincteroplasty vary from 30-60%. Satisfactory results are seen in less than 50% of patients in the long term. The quality of life is poor and mental anguish is common.
Fecal incontinence is a complex issue that is not easy to manage. The vast number of methods used to manage the condition is an indication that no method works reliably. Patients with fecal incontinence have enormous mental anguish, depression, and anxiety. The overall quality of life is poor. Complications are mainly related to surgery which includes the following:
Fecal incontinence has multiple causes and is best managed by an interprofessional team that includes a pediatric surgeon, colorectal surgeon, dietitian, internist, a pediatrician, colorectal nurse, 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.
Because of severe depression and anguish, a mental health nurse should be consulted. The dietitian should educate the patient on a high fiber diet. The pharmacist should educate the patient on drugs that will slow down colonic motility and avoidance of laxatives. The nurse should also educate the patient on kegel exercises to strengthen the pelvic floor muscles. Long term follow-up is necessary as only a few patients obtain a cure from fecal incontinence. Close communication between the team members is essential in order to improve outcomes.
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