Fecal incontinence: New therapies, age-old problem

Fecal incontinence is a socially embarrassing condition that affects approximately 18 million adults in the United States.¹ Its true incidence is likely much higher than reported, however, as many patients are reluctant to discuss it.

A recent study found that nearly 20% of women experience fecal incontinence at least once a year, and 9.5% experience it al least once a month.² Only 28% of these women had ever discussed their symptoms with a physician, however.³ Women who did seek care were more likely to consult a family physician or internist (75%) than a ­gynecologist (7%).³

Until recently, few options were available for patients with fecal incontinence who had not benefited from conservative measures. Many patients simply had to live with their symptoms or undergo a diverting ostomy to control the chronic involuntary drainage.

Recent years have seen the development of new minimally invasive and highly successful techniques to treat fecal incontinence. Greater awareness of the prevalence of fecal incontinence and its devastating impact on quality of life is needed for this problem to be fully addressed, however. In this article, we review the recommended evaluation of a patient who reports fecal incontinence and describe the range of treatment options.

Fecal incontinence is a symptom, not a diagnosis
Although the most common historical factor contributing to fecal incontinence is obstetric trauma, there are several other causes of this condition. A detailed history and physical examination are vital to determine whether the patient is experiencing true fecal incontinence, or whether she is leaking for other reasons—so-called pseudo-incontinence.

Conditions that can mimic fecal incontinence include:

• prolapsing hemorrhoids
• anal fistula
• sexually transmitted infection
• benign or malignant anorectal neoplasms
• dermatologic conditions.

True fecal incontinence may be active (loss of stool despite the patient’s best effort to control it) or passive (loss of stool without the patient’s awareness). Among the causes of true fecal incontinence are:

• anal sphincter injury (obstetric tear, anorectal surgery such as fistulotomy, or trauma)
• denervation of the pelvic floor from pudendal nerve injury during childbirth
• chronic rectal prolapse
• neurologic conditions (spina bifida, myelomeningocele)
• noncompliant rectum from inflammatory bowel disease
• radiation proctitis.

The maintenance of continence requires a complex interaction between the sphincter muscle, the puborectalis muscle (which acts as a sling), rectal capacity and compliance, stool volume and frequency, and neurologic mechanisms.

Diagnosis and management require an experienced physician
We believe that patients reporting fecal incontinence are best worked up and managed by a physician who is well versed in the various diagnoses associated with fecal incontinence, as well as the most current treatments.

Diagnosis entails some detective work
When a patient reports fecal incontinence, she should be asked to elaborate on the circumstances surrounding the complaint and the frequency of its occurrence, duration of symptoms, and nature of the incontinence (gas, liquid, or solid).
Validated quality-of-life instruments, such as the Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS) may be helpful in documenting the severity of the symptoms and improvement after treatment (TABLE).⁴

One factor that current scoring systems fail to capture is urgency. In many instances, urgency is the symptom most distressing to the patient. Be sure to ask about it.

A detailed obstetric history also is important. It is not uncommon for a patient to develop symptoms 20 years or longer after the injury. Also review the patient’s medical history for inflammatory bowel disease, neurologic disorders, and any history of pelvic radiation for help in determining the cause of symptoms.

In addition, ask the patient about any other pelvic floor symptoms, such as voiding dysfunction and problems with pelvic organ prolapse. And question her about stool consistency and frequency. In some cases, diarrhea can lead to fecal incontinence and is usually managed conservatively.

Physical exam: Focus on the perineum and anus
A detailed physical examination is warranted to determine the state of the ­patient’s ­sphincter musculature and rule out other causes of pseudo-incontinence, such as hemorrhoids or anal fistula. Inspect the perineum for thinning of the perineal body and scars from prior surgery.
A patulous anus may be a sign of rectal prolapse. To check for it, ask the patient to strain on the commode. If rectal prolapse is present, it will become apparent upon straining. If prolapse is detected, surgical treatment of the prolapse would be the first step in managing the incontinence.

A simple test of neurologic function is to try to elicit an anal “wink” in response to a pinprick.

A digital rectal exam allows the assessment of resting and squeeze tone, as well as the use of accessory muscles, such as the gluteus maximus, during squeezing.