Incontinence, Fecal


Continuous or recurrent involuntary passage of feces through the anal canal for >1 month in an individual who has previously achieved continence.

  • Recurrent, involuntary loss of stool
  • Assess rectal tone, voluntary squeeze, and differentiate overflow incontinence from fecal impaction
  • Endorectal ultrasound (EUS) is the simplest, most reliable, and least invasive method to detect 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 includes passage of flatus and/or occasional seepage of liquid stool. Categories include urge and passive incontinence.

Geriatric Considerations

  • Fecal incontinence increases with age and is an important cause for nursing home placement among the elderly.
  • Idiopathic fecal incontinence is more common in older women.


Patients are often embarrassed and do not report fecal incontinence unless specifically queried (“silent affliction”).


  • 7% of adults; 15% of adults aged >90 years; women > men
  • 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 fecal incontinence.

Geriatric Considerations

  • Fecal impaction with overflow diarrhea is common in older patients.

Etiology and Pathophysiology

  • Continence requires the complex orchestration of pelvic musculature, nerves, and reflex arcs.
  • Stool volume/consistency, colon transit time, anorectal sensation, rectal compliance, anorectal reflexes, external/internal sphincter muscle tone, puborectalis muscle function, and mental capacity all play a role in maintaining continence.
  • Congenital: spina bifida and myelomeningocele with spinal cord damage
  • Trauma: anal sphincter damage from vaginal delivery or surgical procedures
  • Medical: diabetes mellitus (most common metabolic disorder causing incontinence through pudendal nerve neuropathy), stroke, spinal cord trauma, neurodegenerative disorders, inflammatory bowel disease (IBD), rectal neoplasia

No clear genetic association detected in the genome-wide association study.

Risk Factors

  • Poor functional status—older age, female sex, obesity, limited physical activity
  • Potential association with child abuse and adult sexual abuse
  • Neurologic/neuropsychiatric conditions—multiple sclerosis, spinal cord injury, stroke, diabetic neuropathy (dementia, depression)
  • Trauma: pelvic surgery, vaginal delivery, radiation. Risk factors during vaginal delivery include occipitoposterior presentation, prolonged second stage of labor, assisted vaginal delivery (forceps or vacuum-assist), and episiotomy.
  • Diarrhea, IBD, irritable bowel syndrome (IBS), menopause, smoking, constipation, fecal impaction
  • Congenital abnormalities, such as imperforate anus/rectal prolapse

General Prevention

  • Behavioral/lifestyle changes: Obesity, limited physical activity/exercise, poor diet, and smoking are modifiable risk factors.
  • Post meal bowel regimen—defecate regularly after meals to maximize positive 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)
  • 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; urinary incontinence/pelvic organ prolapse

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