Incontinence, Fecal

Incontinence, Fecal is a topic covered in the 5-Minute Clinical Consult.

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Basics

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.

Description

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.

Epidemiology

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


Prevalence
  • 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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Citation

* When formatting your citation, note that all book, journal, and database titles should be italicized* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Incontinence, Fecal ID - 117518 ED - Baldor,Robert A, ED - Domino,Frank J, ED - Golding,Jeremy, ED - Stephens,Mark B, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117518/all/Incontinence__Fecal PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -