Fecal Incontinence

Here’s your RoshReview Question of the Week!

Which of the following physical exam findings would be present in a woman with fecal incontinence and disruption of the external anal sphincter?

• Absence of perianal creases

• Loss of the anocutaneous reflex

• Obtuse anorectal angle

• Protrusion of the rectal mucosa

Find out the right answer by clicking on what you think the answer is, and find out how to save 20% on a RoshReview QBank Subscription for CREOG studying!

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What is Fecal Incontinence? 

• Definition

  • Part of accidental bowel leakage - where there is loss of normal control of the bowels. The other aspect of ABL is leakage of stool and gas (anal incontinence) 

  • Fecal incontinence - specifically is leakage of stool 

  • National Health and Nutritional Examination Survey defined it as: loss of solid or liquid stool or mucus at least once in previous 30 days 

• How common is it?

  •  NHANES survey; 8.3% prevalence (in 4308 community dwelling adults 

  • Prevalence increases with age (2.6% in 20s to 15.3% in adults 70 and older) 

  • Likely underestimated since 75-80% of individuals with fecal incontinence don’t seek help or report them to their health care provider 

• Risk factors 

  • Loose or watery stool 

  • Increased frequency of stools (more than 21 a week) ← ok, who is pooping more than 3x a day, and how can I get to this level of regularity  

  • Having 2 or more chronic illnesses 

  • Urinary incontinence, obesity, smoking, increasing age, decreased physical activity, anal intercourse, history of OASIS, history of pelvic radiation

What are the causes of fecal incontinence? 

• Neurologic - ie. spinal cord injuries, spina bifida, and CVAs 

• Non-neurologic

  • Most common in women are non-neurologic, usually after OASIS, may occur even remote from delivery 

  • Medications can also cause

Why do we care? 

• Effect on quality of life

  • Significant effect 

  • Can cause depression, social isolation, shame, embarrassment, etc 

  • Can also worsen sexual function 

How do we evaluate? 

• Screen!

  • ACOG says women with risk factors should be screened because they are often reluctant to disclose  

  • Should ask in women with other pelvic floor disorders 

  • Other risk factors that can be considered: Age >50, residence in nursing home, prior OASIS, history of pelvic irradiation, engagement in anal intercourse, presence of urinary incontinence, chronic diarrhea, diabetes, obesity, rectal urgency 

• History and physical 

  • Ask about underlying neurological disorders and also modifiable risk factors for fecal incontinence (ie. obesity, diabetes, smoking, anal sex, certain medications that cause loose stools) 

  • Symptoms: what type of leakage (solid, liquid, gas, mucus), timing, frequency, severity (volume of loss), if there is fecal urgency, and how this affects their life 

  • There are a few validated surveys 

    • FI Severity Index, FI Quality of Life Scale, Fecal incontinence and Constipation Assessment Questionnaire 

  • Physical exam should include vaginal exam, exam of perineal area, and rectal exam (prior anal sphincter surgery/trauma) 

    • “Dovetail” sign - loss of normal puckering around the anus anteriorly

    • Digital rectal exam - sensitivity and specificity is overall low for detection of complete anal sphincter disruption 

    • Can also consider endoanal ultrasonography 

• Other tests

  • Anal sphincter imaging/defecography/anorectal manometry not recommended for routine evaluation 

  • However, if anatomic defect or dysfunction is suspected or if clinical exam findings are inconclusive, can refer for ancillary testing 

  • Can also consider referring to urogynecology/colorectal surgery for further evaluation if not sure in clinic 

How do we manage and treat FI? 

• Medical

  • Should be multidisciplinary approach 

    • Consider pelvic floor PT and management with urogynecology 

    • Also can consider gastroenterology

  • Medications

    • While loose stool itself does not cause fecal incontinence, it can worsen it and be a risk factor

      • Try something to bulk up stool - ie. fiber supplementation, dietary manipulation, bowel scheduling, etc 

    • Lifestyle management - should be offered in conjunction with everything else 

      • Wearing pads, diapers, briefs, etc 

      • Anal plugs ← 51% of people reported some sort of adverse event, like urgency, irritation, pain, soreness.

  • How effective are non-surgical treatments? 

    • Associated with modest short-term efficacy and low risk of adverse events, so should be recommended for initial management unless there is a fistula or rectal prolapse on exam 

    • However, lacking evidence for effectiveness of treatment beyond 6 months 

• Surgical

  • Anal Sphincter Bulking Agents - not really surgery, kind of in between? 

    • Include things like dextranomer in stabilized hyaluronic acid, silicon biomaterial, carbon-coated beads 

    • May be effective in decreasing FI episodes up to 6 months 

  • Who is eligible for surgeries?

    • Not first line except for the two indications mentioned above (fistula or prolapse)

    • Proven to only provide short term improvement and have more complications than medical treatments/lifestyle modifications 

    • If patients fail medical treatments → can have surgery 

    • Refer to urogynecologist or qualified specialist to do them  

  • Neuromodulation 

    • Sacral nerve stimulation is possible for ABL 

      • Implantation of wire electrode near third sacral nerve root 

      • Two step → if initial testing is beneficial, then permanent battery is attached to wire electrode 

      • 2013 systemic review: 63% success rate (50% or greater reduction of FI) in the short term (<1 year), 58% in medium term (17-36 months), 54% (44-118 months)

    • Peripheral tibial nerve stimulation is not approved for FI 

  • Anal Sphincter Repair 

    • Sphincteroplasty can be considered with anal sphincter disruption and fecal incontinence symptoms who have failed conservative treatment 

    • Can do it end to end or overlapping sphincteroplasty 

    • Most studies:

      • Found to have similar outcomes 

      • Some evidence has shown that there can be significant deterioration in fecal incontinence over time after either type of repair, with 50% of women reporting symptoms 5-10 years after their repair

    • Most common adverse effect is wound infection (6-35% of cases!!) 

  • Other surgeries can be considered:

    • Radiofrequency anal sphincter remodeling 

    • Gracilis muscle transposition 

    • Diverting colostomy