Incontinence, Fecal

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Defined as continuous or recurrent involuntary passage of fecal material through the anal canal for >1 month in an individual at least 4 years of age

  • Involves recurrent, involuntary loss of solid/liquid stool
  • Requires careful rectal exam to assess rectal tone, voluntary squeeze, and rule out overflow incontinence from fecal impaction
  • Endorectal ultrasound (EUS) is the simplest, most reliable, and least invasive method to detect anatomic anal sphincter defects.
  • The goal of treatment is to restore continence and/or improve quality of life.


Major incontinence is the involuntary evacuation of feces. Minor incontinence (fecal soilage) includes incontinence to flatus and occasional seepage of liquid stool.

Geriatric Considerations
  • The prevalence of fecal incontinence increases with age. It is an important cause for nursing home placement among the elderly.
  • Idiopathic fecal incontinence is more common in older women.


Patients often do not report fecal incontinence unless specifically queried (“silent affliction”). The number of affected patients is likely significantly underestimated.

  • Women > men
  • 7% of adults; 15% of adults age >90 years
  • 56–66% of hospitalized older patients and >50% of nursing home residents
  • 50–70% of patients who have urinary incontinence also suffer from fecal incontinence.

Pregnancy Considerations
Obstetric injury to the pelvic floor may result in either temporary or persistent incontinence.

Geriatric Considerations
  • Fecal impaction and overflow diarrhea leading to fecal incontinence is common in older patients.
  • Surgical history—particularly anal surgery, including hemorrhoidectomy, anal fissure repair (sphincterotomy), anal dilatation, or prior pelvic floor surgeries

Etiology and Pathophysiology

  • Continence requires the complex orchestration of pelvic musculature, nerves, and reflex arcs.
  • Stool volume and consistency, colonic transit time, anorectal sensation, rectal compliance, anorectal reflexes, external and internal sphincter muscle tone, puborectalis muscle function, and mental capacity each plays a role in maintaining fecal continence.
  • Disease processes or structural defects impacting any of these factors may contribute to incontinence.
  • Diabetes is the most common metabolic disorder leading to fecal incontinence through pudendal nerve neuropathy.
  • Congenital: spina bifida and myelomeningocele with spinal cord damage
  • Trauma: anal sphincter damage from vaginal delivery or surgical procedures
  • Medical: diabetes mellitus, stroke, spinal cord trauma, degenerative disorders of the nervous system, inflammatory bowel disorders, rectal neoplasia

Risk Factors

  • Poor functional status—older age, female sex, obesity, limited physical activity contributory
  • Neuropsychiatric conditions (dementia, depression)
  • Multiple sclerosis, spinal cord injury, stroke, diabetic neuropathy
  • Prostatectomy, radiation
  • Trauma: Risk factors for perineal trauma at the time of vaginal delivery include occipitoposterior presentation, prolonged second stage of labor, assisted vaginal delivery (forceps or vacuum-assist), and episiotomy.
  • 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

General Prevention

  • Behavioral and lifestyle changes: Obesity, limited physical activity/exercise, poor diet, and smoking are modifiable risk factors.
  • Postmeal bowel regimen—defecate regularly after meals to maximize effect of gastrocolic reflex.
  • Pelvic floor muscle training during and after pregnancy and pelvic surgery
  • Increase fiber intake (>30 g/day)

Commonly Associated Conditions

  • Increasing age (>65 years)
  • Urinary incontinence/pelvic organ prolapse
  • Chronic medical conditions—diabetes mellitus, dementia, stroke, spinal cord compression, depression, immobility, chronic obstructive pulmonary disease, IBS, and IBD
  • Perineal trauma (obstetric)
  • Anorectal surgery
  • History of pelvic/rectal irradiation

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