Fecal Incontinence in Adults

Background

• Fecal incontinence is a common defecatory disorder that involves the recurrent, unintentional passage of solid and/or liquid stool.
• Fecal incontinence most commonly occurs in adults > 65 years old and adults who are hospitalized, or are living in home healthcare or long-term care settings.
• The most significant risk factors for the development of fecal incontinence are bowel disturbances, especially diarrhea and rectal urgency, as well as chronic illness and increased disease burden.
• Fecal incontinence can also result from anal sphincter injury or weakness, such as caused by neuropathy and/or pregnancy with vaginal delivery, anatomical disturbances of the pelvic floor, including rectal prolapse or excessive perineal descent, as well as other factors affecting anorectal or pelvic floor structure or function such as injury, including from prior surgery, or inflammatory disease.

Evaluation

• Patients with fecal incontinence may present with:
  • Marked rectal urgency and an inability to hold stool despite active attempts (urge incontinence)
  • Involuntary passage of stool without awareness (passive incontinence)
  • Leakage of liquid stool in setting of constipation and fecal impaction (overflow incontinence)
  • Stained undergarments or small volume leakage, usually manifesting around the time of defecation (fecal seepage)
• Patients may be reluctant to report fecal incontinence episodes and may report secondary symptoms of incontinence including pruritus, perianal skin irritation or infection, urinary tract infection, and abdominal pain.
• Diagnosis of fecal incontinence is made clinically from patient-reported symptoms of the unintentional passage of solid or liquid stool.
• Validated fecal incontinence scales and questionnaires are available to assess type, volume, frequency, and duration of bowel leakage and are also used to rate severity.
• Additional testing may not be necessary, but may be used to determine severity and underlying cause, or may be considered for patients who fail to respond to treatment if available. Options for testing include:
  • Anorectal manometry to assess anal canal pressures and rectal sensation
  • Endoanal and pelvic floor ultrasound to assess anal sphincter muscles and puborectalis muscle
  • Rectal balloon expulsion test to assess impaired rectal evacuation
  • Defecography to assess anorectal function, structural abnormalities, and anal sphincter muscle atrophy
  • Neurophysiological testing in patients with spinal cord lesions or with suspected neurogenic sphincter weakness
• Perform colonoscopy to evaluate patients with red-flag symptoms such as passage per rectum of bright-red or maroon blood or the admixtures with stool to screen for malignancy regardless of patient age.

Management

• Initiate conservative management including dietary modifications and increasing dietary fiber intake through high-fiber foods or supplements (Strong Recommendation), advising patients to avoid foods and supplements that have laxative properties and to keep track of and limit dietary triggers, food preparation methods, and meal times that exacerbate fecal incontinence symptoms.
• Consider supportive measures, including use of incontinence diapers and other absorbent disposables. protective ointments, gentle soaps and wipes, and deodorants.
• Consider behavioral-based therapies in select patients to improve fecal incontinence symptoms, including education to modify toileting habits, bowel management programs, and pelvic floor muscle training (PFMT) (Weak Recommendation).
• Consider offering multiple behavioral-based therapies, including education, optimization of toileting habits, dietary modification, and PFMT.
• Offer biofeedback, which combines PFMT with visual or auditory feedback, as initial treatment in patients with preserved voluntary sphincter contraction (Strong recommendation), or in patients not responsive to diet modification, education, and other conservative management (Strong recommendation).
• Consider use of medications to optimize stool consistency, treat underlying bowel conditions, and/or decrease bowel motility (Weak recommendation); recommended first-line therapies for patients with fecal incontinence include adsorbents, bile acid binders, antidiarrheal agents, or agents to decrease intestinal motility or decrease urgency sensation.
• Reserve surgical management for fecal incontinence for patients who have failed other therapies or have a condition that clearly requires surgery.
  • Consider injection or implantation of bulking agents for patients with fecal incontinence not responsive to conservative management and biofeedback, especially those with passive incontinence (Weak recommendation).
  • Consider anal sphincteroplasty for patients with fecal incontinence and anal sphincter disruption who have failed conservative treatment or in cases of fecal incontinence occurring shortly after acute sphincter injury (such as vaginal birth) (Weak recommendation), or perform sphincteroplasty in symptomatic patients with defined defects of the external anal sphincter (Strong recommendation).
  • Consider creation of an end stoma in patients with severe fecal incontinence who have not responded to or do not wish to pursue other therapies to improve quality of life (Weak recommendation).
• Only in select patients with severe incontinence who have not responded to conservative treatment or have extensive sphincter destruction, bowel dysfunction after surgery, neurogenic incontinence, or congenital malformation, offer implantation of artificial bowel sphincter (Strong recommendation); high rates of explantation and infection limit mainstream use.
• Other management options include:
  • Perform sacral nerve stimulation for management of moderate-severe fecal incontinence in patients with and without sphincter defects that have failed conservative treatments (Strong recommendation).
  • Barrier devices, including anal plugs, vaginal balloons, and other devices that impede defecation can offer immediate relief in patients with passive fecal incontinence by mechanically blocking passage of stool.