Summary
Fecal incontinence is the involuntary passage of feces over a period of ≥ 3 months. Fecal incontinence affects ≥ 8% of adults in the US and prevalence increases with age. The etiology of fecal incontinence is frequently multifactorial; causes include anal disorders (e.g., anal sphincter weakness following obstetric injury), rectal disorders (e.g., rectal cancer), neurological conditions (e.g., spinal cord injury), and/or abnormal stool consistency (e.g., diarrhea). Clinical evaluation involves a focused history to characterize the fecal incontinence and associated symptoms. For certain causes of fecal incontinence (e.g., spinal cord injury or anorectal cancer), the patient should be promptly referred for specialist management. Otherwise, initial management consists of empiric supportive care, with or without pharmacological treatment. Patients who do not improve after a trial of empiric supportive care should be referred to a specialist for advanced diagnostic studies (e.g., anorectal physiology testing) to determine the best management approach. Advanced management options include bowel management programs (e.g., administering scheduled suppositories), pelvic floor muscle therapy, and/or invasive procedures (e.g., anal sphincteroplasty).
Definitions
- Fecal incontinence: the involuntary passage of feces over a period of ≥ 3 months [1][2]
- Fecal urge incontinence: the involuntary passage of feces despite deliberate effort to retain stool [3]
- Passive fecal incontinence: the involuntary passage of feces without awareness [3]
Epidemiology
- Prevalence: ≥ 8% of adults (median prevalence); up to 50% among nursing home residents [2][3]
- Sex: ♀ > ♂ [1][2]
-
Risk factors [2]
- Age > 65 years
- Conditions that cause fecal incontinence: See “Etiology.”
- Urinary incontinence
Epidemiological data refers to the US, unless otherwise specified.
Etiology
Anal disorders [2][3]
- Anal sphincter weakness or injury
- Obstetric nerve injuries and obstetric lacerations (due to, e.g., instrumental delivery, prolonged second stage of labor) [1]
- Proctology and gynecology surgical procedures (e.g., fistula surgery; , hemorrhoidectomy, hysterectomy)
- Systemic sclerosis
- Medications (e.g., antianginal medications, antihypertensives)
- Other
Rectal disorders [2][3]
- Disorders of rectal reservoir or sensory function (due to, e.g., radiation proctitis)
- Pelvic floor dysfunction: may involve rectal prolapse and/or rectocele
- Rectal cancer
Neurological disorders [2][3]
- Spinal cord injury and cauda equina syndrome
- Pudendal nerve injury
- Multiple sclerosis
- Diabetes mellitus
- Major neurocognitive disorder
- Stroke
- Impaired functional status (e.g., decreased mobility) may cause functional incontinence or exacerbate incontinence due to other causes.
Stool disorders [2][3]
- Constipation, fecal impaction, and/or retention causing overflow
-
Causes of chronic diarrhea, e.g.:
- Inflammatory bowel disease
- Irritable bowel syndrome
- Medications (e.g., metformin)
Fecal incontinence is multifactorial in 80% of patients. [1]
Clinical evaluation
Focused history [1][3]
-
Involuntary passage of feces
- Onset and duration: chronic and/or recurring
- Frequency, consistency, and volume (e.g., small amount vs. a complete bowel movement)
- Urge fecal incontinence or passive fecal incontinence
- Impact on quality of life (e.g., activities of daily living, work, relationships)
- Past medical history (i.e., procedures or conditions associated with fecal incontinence; see “Etiology”)
-
Additional clinical features
- Stool consistency and volume outside of incontinence episodes
- Hematochezia and/or mucus
- Tenesmus
- Flatus: volume, flatus incontinence
- Abdominal pain and/or distention
- Urinary incontinence
- Neurological symptoms (e.g., lower limb weakness, abnormal sensory function)
- Weight loss
Ask about fecal incontinence in patients with risk factors. Patients may not report it due to embarrassment or a belief that it is a normal part of aging. [2][3]
Focused physical examination
-
Perianal area [1][2]
- Fecal staining
- Surgical scars and/or fistulas
- Rectal prolapse (may only be visible during Valsalva maneuver)
- Skin rashes and/or excoriation
- Anocutaneous reflex
-
Digital rectal examination [1]
- Anal sphincter tone and squeeze pressure
- Rectal mass, stricture, and/or hemorrhoids
- Fecal impaction
- Pelvic examination: signs of pelvic floor dysfunction (e.g., pelvic organ prolapse)
- Focused neurological examination: Assess motor function and sensory function for, e.g., clinical features of spinal cord injury or cauda equina syndrome. [3]
Common causes
| Conditions associated with fecal incontinence [3] | ||||
|---|---|---|---|---|
| Condition | Characteristic clinical features | Diagnostics | Management | |
| Anal or colorectal cancer |
|
|
| |
| Neurological disorders |
|
|
| |
| Severe pelvic floor dysfunction |
|
|
| |
| Anal fistulas |
|
| ||
| Hemorrhoids |
|
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| Changes in bowel habit |
| |||
Management
Approach [1]
- Fecal incontinence is diagnosed clinically.
- Promptly refer to a specialist for management if there is suspicion for serious conditions associated with fecal incontinence (e.g., colorectal cancer, spinal cord injury).
- Initial management of fecal incontinence consists of supportive care; pharmacological treatment may be considered.
- If initial management is unsuccessful, refer for specialist multidisciplinary management. [3]
Refer urgently for specialist assessment if there are red flags for colorectal cancer (e.g., hematochezia, unexplained weight loss) or neurological symptoms. [1][2]
Initial management
Supportive care [1][3]
Educate patients about self-management techniques.
- Lifestyle measures
- Perianal dermatitis prevention and management: e.g., barrier cream, gentle soaps, wet wipes
Pharmacological treatment [3]
Pharmacological treatment aims to optimize stool consistency and reduce the frequency of defecation.
- Dietary fiber supplementation: bulk-forming laxatives (e.g., psyllium )
- Antidiarrheals: only in patients with diarrhea (e.g., loperamide )
Specialist management [1][3]
Specialist management may be considered if initial management is unsuccessful.
Diagnostic studies
-
Anorectal physiology testing [3]
- Anorectal manometry: first-line diagnostic test
- Rectal sensory test
- Balloon expulsion test: evaluates the ability to evacuate a simulated stool (i.e., a latex balloon filled with 50 mL of fluid, attached to a catheter) in patients with suspected pelvic floor dyssynergia
- Endoanal ultrasound: to assess anal sphincter structural defects [1]
- Barium defecography: second-line study to assess for pelvic floor dysfunction and structural abnormalities (e.g., rectocele) [1][3]
Advanced interventions [1]
- Bowel management program (e.g., scheduled suppositories or enemas, regular transanal irrigation) [1][3]
- Pelvic floor muscle therapy: may involve biofeedback (e.g., pressure sensors that provide auditory feedback) [3]
- Invasive procedures (e.g., anal sphincteroplasty or sacral neuromodulation) [1][2]