Journal of Clinical Outcomes Management. 2014 October;22(10)
References
The case patient underwent biofeedback therapy, and after 5 sessions had complete healing of the lesion and resolution of rectal bleeding and bowel symptoms.
Case Study 3
Initial Presentation and History
A 75-year-old woman is referred to a gastroenterologist with complaints of incomplete stool evacuation and intermittent fecal seepage. She passes stools daily but sits on the toilet for 15 to 20 minutes, and after straining will pass only a small amount of stool. She describes stools as type 4 on the Bristol scale with no blood or mucus. One to 2 hours after a bowel movement, she experiences some wetness in the perineal region and upon checking often notices that a tablespoon full of stool material has leaked out. Sometimes, she will pass another large stool. She denies any leakage of stool while sleeping. Occasionally, she has urgency and leaks stool before reaching the toilet. In the past, she has used digital maneuvers to facilitate stooling. This problem has interfered with shopping, socializing, and taking vacations.
Her past medical history is significant for narcolepsy, hypertension, tubal ligation, appendectomy, and inguinal hernia repair. Obstetric history is significant for 6 vaginal deliveries, 1 requiring episiotomy but no forceps use. Her current medications include estradiol vaginal cream, hydrochlorothiazide, pilocarpine, and amitriptyline 10 mg 3 times daily. She also reports stress urinary incontinence, particularly with sneezing and coughing.
Physical Examination
Physical examination reveals a well-nourished woman with normal vital signs and a normal general examination. Abdominal examination is normal. A rectal examination shows no fissures, but the anocutaneous reflex is absent on the right side. Resting and squeeze sphincter tones are normal, with good perineal descent and normal anal relaxation.
Laboratory Evaluation
Thyroid function tests, complete blood count, and liver biochemistry tests are normal. Results of anorectal manometry are shown in Table 3 . Defecography shows a slightly larger resting anorectal angle and an anterior rectocele ( Figure 3 ). Anal endosonography reveals a large sphincter defect in the external anal sphincter ( Figure 4 ).
What are the mechanisms involved in fecal incontinence?
What are the 3 clinical subtypes of fecal incontinence?
Mechanisms and Subtypes
Fecal incontinence is often an unvoiced problem that causes significant social stigma. Approximately 2% of the US population suffers from fecal incontinence [28], with a higher prevalence among women and elderly persons. Several mechanisms are involved in the pathogenesis of fecal incontinence. A common cause is injury to the external or internal anal sphincter, puborectalis muscle, or pudendal nerves, often after obstetric trauma. Hence, a detailed obstetric history including number of vaginal deliveries, use of forceps, tears, and episiotomy is important. Sphincter disruption, most commonly after surgery for hemorrhoid or anal fissure, can result in incontinence. Likewise, reduced rectal compliance causes urgency and fecal incontinence. Impaired rectal sensation results in the accumulation of stool and overflow. Patients rarely have a single cause, with 80% having more than one factor that leads to incontinence [29].
Clinically, fecal incontinence can be classified into 3 categories. Urge incontinence is characterized by the inability to control stool discharge despite active attempts to retain contents. These patients often have disruption or injury to the external anal sphincter. Fecal seepage is the involuntary discharge of less than 2 tablespoons of stool matter without awareness. Seepage can result from impaired rectal evacuation and dyssynergia. Often patients with seepage complain of incomplete evacuation. Passive incontinence refers to the involuntary discharge of stool contents without awareness. These patients often have underlying neuropathy and sphincter weakness [30,31].
