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 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 due to flatus and/or occasional seepage of liquid stool.
- 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.
Obstetric injury to the pelvic floor may result in either temporary or persistent incontinence.
- 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 play 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
- Poor functional status—older age, female sex, obesity, limited physical activity
- 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
- 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 leverage maximal impact 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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