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Fecal Incontinence: Etiology, Diagnosis, and Management

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Fecal incontinence is a debilitating condition affecting primarily the elderly. Many patients suffer in silence resulting in both underdiagnosis and undertreatment often culminating in an overall poor quality of life.

Methods

We sought to review the etiology, diagnosis, and treatment of fecal incontinence based on current literature. Additionally, newer treatment methods such as Solesta will be evaluated.

Results

There are many diagnostic modalities available to assess the degree and severity of the patient’s incontinence; however, a thorough history and physical exam is critical. Initial attempts at treatment focus on medical management primarily through stool texture modification with the aid of bulking agents. Failure of medical therapy is often followed by a graded increase in the complexity and invasiveness of the available treatment options. The selection of the most appropriate surgical option, such as overlapping sphincteroplasty and neuromodulation, is multifactorial involving both surgeon and patient-related factors. Neuromodulation has received increased attention in the last decade due to its documented therapeutic success, and newer office-based procedures, such as the Solesta injection, are showing promising results in properly selected patients. Finally, diversion remains an option for select patients who have failed all other therapies.

Conclusion

The etiology of fecal incontinence is multifactorial, involving a complex interplay between stool consistency and anatomic integrity. The diagnosis and treatment of fecal incontinence continue to evolve and are showing promising results.

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Conflict of Interest

Authors: Karim Alavi, M.D., MPH, has nothing to disclose. Sook Yee Chan, M.D., has nothing to disclose. Paul Wise, M.D., has nothing to disclose. Andreas M. Kaiser, M.D., receives speaker fees from GI Health Foundation and royalties from Uptodate and McGraw Hill Publisher. Ranjan Sudan, M.D., has nothing to disclose. Liliana Bordeianou, M.D., has nothing to disclose. Editors-in-Chief: Jeffrey B. Matthews, M.D., has nothing to disclose. Charles Yeo, M.D., has nothing to disclose. CME Overseers: Arbiter: Jeffrey B. Matthews, M.D., has nothing to disclose. Vice-Arbiter: Guilherme M. Campos, M.D., Ph.D., has nothing to disclose. Question Reviewers: Deepa Taggarshe, M.D., has nothing to disclose. I. Michael Leitman, M.D., has nothing to disclose.

Author information

Authors and Affiliations

  1. Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, 67 Belmont Street, Worcester, MA, 01605, USA

    Karim Alavi & Sook Chan

  2. Division of Colon and Rectal Surgery, Washington University School of Medicine, St Louis, MO, USA

    Paul Wise

  3. Division of Colon and Rectal Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA

    Andreas M. Kaiser

  4. Department of Surgery, Duke University School of Medicine, Durham, NC, USA

    Ranjan Sudan

  5. Division of Colon and Rectal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Liliana Bordeianou

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  1. Karim Alavi
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  2. Sook Chan
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Correspondence to Karim Alavi.

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CME QUESTIONS

1. A 45 year old female with a remote history of obstetrical trauma is being evaluated for fecal incontinence. Which of the following studies is most appropriate for determining the presence of external anal sphincter (EAS) injury?

a. Pudendal nerve terminal motor latency studies

b. Anal manometry

c. Two-dimensional endo-anal ultrasound

d. Balloon expulsion test

2. A 60 year old female without a history of prior trauma presents with intolerable and life altering fecal incontinence. All conservative measures to improve continence have failed. Initial workup demonstrates intact sphincters and PNTML with normal conduction but diminished resting and squeeze pressure. Her colonoscopy was normal. She has failed biofeedback. What would be the next most appropriate step in her management?

a. Artificial Bowel Sphincter

b. Dynamic Graciloplasty

c. Sacral nerve stimulation

d. Diverting colostomy

3. A 35 year old female presents with severe fecal incontinence and a distal rectovaginal fistula 6 months following a forceps delivery. Anoscopy reveals a thin perineal body and a distal rectovaginal fistula. EUS demonstrates a 100 degree gap in the external sphincter with an associated internal sphincter injury. Nerve function is preserved. Which of the following is the most appropriate next step in her management?

a. Diverting colostomy

b. Rectovaginal fistula repair, including overlapping sphincteroplasty

c. Sacral nerve stimulation

d. Artificial bowel sphincter

4. A 70 year old male presents without a prior history of anorectal trauma presents with worsening fecal incontinence. Anorectal manometry demonstrates decreased resting and squeeze pressures but intact PNTML bilaterally. EUS is normal as is a recent colonoscopy. All conservative measures have failed. Which of the following is the most appropriate next step in this patient’s management?

a. Diverting colostomy

b. Sacral nerve stimulation

c. Solesta injection

d. Biofeedback therapy

Answers:

1. c

2. c

3. b

4. d

Learning Objectives

1. To be able to discuss the etiology of fecal incontinence.

2. To understand and appreciate the workup, including all available diagnostic modalities, of fecal incontinence.

3. To understand the differing medical, office-based, and surgical modalities available for the management of fecal incontinence including data on long-term outcomes.

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Alavi, K., Chan, S., Wise, P. et al. Fecal Incontinence: Etiology, Diagnosis, and Management. J Gastrointest Surg 19, 1910–1921 (2015). https://doi.org/10.1007/s11605-015-2905-1

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  • DOI: https://doi.org/10.1007/s11605-015-2905-1

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