Fecal Incontinence

  • Julia Saraidaridis
  • Liliana Bordeianou


Fecal incontinence is a common problem in the population with a devastating effect on quality of life. Initial work-up involves a thorough history and physical exam with a trial of conservative therapy. If conservative measures prove ineffective, the patient should undergo a pelvic floor evaluation including anal manometry, anal endosonography, and defecography to rule out potentially surgically ameliorated fecal incontinence. For patients who have a discrete sphincter defect, an overlapping sphincteroplasty can provide significant improvement in continence. For those patients without a sphincter defect or for those who fail sphincter repair, a trial of sacral neuromodulation (SNM) is merited. For those patients for whom SNM is inadequate, there are a variety of sphincter augmentation procedures including Secca® radiofrequency energy application, anal sphincter injectables, muscle transpositions, artificial bowel sphincter, or magnetic anal sphincter. For those who fail all therapies, permanent colostomy can provide relief from intractable fecal incontinence. Figure 9.6 shows a flow-chart showing the evaluation and treatment decision-making for patients with fecal incontinence.


Fecal incontinence Pelvic floor testing Anal manometry Anal endosonography Defecography Sphincteroplasty Artificial anal sphincter 


  1. 1.
    Paquette IM, et al. The American Society of Colon and Rectal Surgeons’ clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. 2015;58(7):623–36.CrossRefGoogle Scholar
  2. 2.
    Sharma A, et al. Systematic review of the prevalence of faecal incontinence. Br J Surg. 2016;103(12):1589–97.CrossRefGoogle Scholar
  3. 3.
    Brown HW, et al. Accidental bowel leakage in the mature women’s health study: prevalence and predictors. Int J Clin Pract. 2012;66(11):1101–8.CrossRefGoogle Scholar
  4. 4.
    Nelson R, Furner S, Jesudason V. Fecal incontinence in Wisconsin nursing homes: prevalence and associations. Dis Colon Rectum. 1998;41(10):1226–9.CrossRefGoogle Scholar
  5. 5.
    Brown HW, Wexner SD, Lukacz ES. Factors associated with care seeking among women with accidental bowel leakage. Female Pelvic Med Reconstr Surg. 2013;19(2):66–71.CrossRefGoogle Scholar
  6. 6.
    Parks AG. Royal Society of Medicine, Section of Proctology; Meeting 27 November 1974. President’s address. Anorectal incontinence. Proc R Soc Med. 1975;68(11):681–90.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, editors. The ASCRS textbook of colon and rectal surgery. New York: Springer; 2016.Google Scholar
  8. 8.
    Carlo R. Colon, rectum and anus : anatomic, physiologic and diagnostic bases for disease management. New York: Springer; 2016.Google Scholar
  9. 9.
    Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36(1):77–97. Review.CrossRefGoogle Scholar
  10. 10.
    Rockwood TH, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum. 1999;42(12):1525–32.CrossRefGoogle Scholar
  11. 11.
    Rockwood TH, et al. Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum. 2000;43(1):9–16. discussion 16–7.CrossRefGoogle Scholar
  12. 12.
    Faltin DL, et al. Diagnosis of anal sphincter tears by postpartum endosonography to predict fecal incontinence. Obstet Gynecol. 2000;95(5):643–7.PubMedGoogle Scholar
  13. 13.
    Pinsk I, Brown J, Phang PT. Assessment of sonographic quality of anal sphincter muscles in patients with faecal incontinence. Color Dis. 2009;11(9):933–40.CrossRefGoogle Scholar
  14. 14.
    Felt-Bersma RJ, Klinkenberg-Knol EC, Meuwissen SG. Anorectal function investigations in incontinent and continent patients. Differences and discriminatory value. Dis Colon Rectum. 1990;33(6):479–85. discussion 485–6.CrossRefGoogle Scholar
  15. 15.
    Lam TJ, Kuik DJ, Felt-Bersma RJ. Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients. Color Dis. 2012;14(2):214–23.CrossRefGoogle Scholar
  16. 16.
    Zutshi M, et al. Anal physiology testing in fecal incontinence: is it of any value? Int J Color Dis. 2010;25(2):277–82.CrossRefGoogle Scholar
  17. 17.
    Birnbaum EH, et al. Pudendal nerve terminal motor latency influences surgical outcome in treatment of rectal prolapse. Dis Colon Rectum. 1996;39(11):1215–21.CrossRefGoogle Scholar
  18. 18.
    Bliss DZ, et al. Dietary fiber supplementation for fecal incontinence: a randomized clinical trial. Res Nurs Health. 2014;37(5):367–78.CrossRefGoogle Scholar
  19. 19.
    Markland AD, et al. Loperamide versus psyllium fiber for treatment of fecal incontinence: the fecal incontinence prescription (Rx) management (FIRM) randomized clinical trial. Dis Colon Rectum. 2015;58(10):983–93.CrossRefGoogle Scholar
  20. 20.
    Santoro GA, et al. Open study of low-dose amitriptyline in the treatment of patients with idiopathic fecal incontinence. Dis Colon Rectum. 2000;43(12):676–81. discussion 1681–2.CrossRefGoogle Scholar
  21. 21.
    Croswell E, Bliss DZ, Savik K. Diet and eating pattern modifications used by community-living adults to manage their fecal incontinence. J Wound Ostomy Continence Nurs. 2010;37(6):677–82.CrossRefGoogle Scholar
  22. 22.
    Rao SS, et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil. 2015;27(5):594–609.CrossRefGoogle Scholar
  23. 23.
    Heymen S, et al. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Dis Colon Rectum. 2009;52(10):1730–7.CrossRefGoogle Scholar
  24. 24.
    Lukacz ES, Segall MM, Wexner SD. Evaluation of an anal insert device for the conservative management of fecal incontinence. Dis Colon Rectum. 2015;58(9):892–8.CrossRefGoogle Scholar
  25. 25.
    Deutekom M, Dobben AC. Plugs for containing faecal incontinence. Cochrane Database Syst Rev. 2015;7:CD005086.Google Scholar
  26. 26.
    Varma A, et al. Obstetric anal sphincter injury: prospective evaluation of incidence. Dis Colon Rectum. 1999;42(12):1537–43.CrossRefGoogle Scholar
  27. 27.
    Goetz LH, Lowry AC. Overlapping sphincteroplasty: is it the standard of care? Clin Colon Rectal Surg. 2005;18(1):22–31.CrossRefGoogle Scholar
  28. 28.
    Mik M, et al. Anterior overlapping sphincteroplasty—who benefits from the surgery? Pol Przegl Chir. 2014;86(1):33–8.CrossRefGoogle Scholar
  29. 29.
    Giordano P, et al. Previous sphincter repair does not affect the outcome of repeat repair. Dis Colon Rectum. 2002;45(5):635–40.CrossRefGoogle Scholar
  30. 30.
    Shek KL, Guzman-Rojas R, Dietz HP. Residual defects of the external anal sphincter following primary repair: an observational study using transperineal ultrasound. Ultrasound Obstet Gynecol. 2014;44(6):704–9.CrossRefGoogle Scholar
  31. 31.
    Mellgren A, et al. A posterior anal sling for fecal incontinence: results of a 152-patient prospective multicenter study. Am J Obstet Gynecol. 2016;214(3):349. e1–8.CrossRefGoogle Scholar
  32. 32.
    Carrington EV, et al. A systematic review of sacral nerve stimulation mechanisms in the treatment of fecal incontinence and constipation. Neurogastroenterol Motil. 2014;26(9):1222–37.CrossRefGoogle Scholar
  33. 33.
    Thin NN, et al. Systematic review of the clinical effectiveness of neuromodulation in the treatment of faecal incontinence. Br J Surg. 2013;100(11):1430–47.CrossRefGoogle Scholar
  34. 34.
    Wexner SD, et al. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg. 2010;251(3):441–9.CrossRefGoogle Scholar
  35. 35.
    Hull T, et al. Long-term durability of sacral nerve stimulation therapy for chronic fecal incontinence. Dis Colon Rectum. 2013;56(2):234–45.CrossRefGoogle Scholar
  36. 36.
    Matzel KE, et al. Sacral nerve stimulation for faecal incontinence: long-term outcome. Color Dis. 2009;11(6):636–41.CrossRefGoogle Scholar
  37. 37.
    Tjandra JJ, et al. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis Colon Rectum. 2008;51(5):494–502.CrossRefGoogle Scholar
  38. 38.
    Faucheron JL, Voirin D, Badic B. Sacral nerve stimulation for fecal incontinence: causes of surgical revision from a series of 87 consecutive patients operated on in a single institution. Dis Colon Rectum. 2010;53(11):1501–7.CrossRefGoogle Scholar
  39. 39.
    van der Wilt AA, et al. Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence. Br J Surg. 2011;104(9):1167–76.CrossRefGoogle Scholar
  40. 40.
    Knowles CH, et al. Percutaneous tibial nerve stimulation versus sham electrical stimulation for the treatment of faecal incontinence in adults (CONFIDeNT): a double-blind, multicentre, pragmatic, parallel-group, randomised controlled trial. Lancet. 2015;386(10004):1640–8.CrossRefGoogle Scholar
  41. 41.
    Herman RM, et al. Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence—a blinded assessment in an animal model. Color Dis. 2015;17(5):433–40.CrossRefGoogle Scholar
  42. 42.
    Ruiz D, et al. Does the radiofrequency procedure for fecal incontinence improve quality of life and incontinence at 1-year follow-up? Dis Colon Rectum. 2010;53(7):1041–6.CrossRefGoogle Scholar
  43. 43.
    Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence in adults. Cochrane Database Syst Rev. 2013;2:CD007959.Google Scholar
  44. 44.
    Pickrell KL, et al. Construction of a rectal sphincter and restoration of anal continence by transplanting the gracilis muscle; a report of four cases in children. Ann Surg. 1952;135(6):853–62.CrossRefGoogle Scholar
  45. 45.
    Salmons S, Henriksson J. The adaptive response of skeletal muscle to increased use. Muscle Nerve. 1981;4(2):94–105.CrossRefGoogle Scholar
  46. 46.
    Cavina E, et al. Construction of a continent perineal colostomy by using electrostimulated gracilis muscles after abdominoperineal resection: personal technique and experience with 32 cases. Ital J Surg Sci. 1987;17(4):305–14.PubMedGoogle Scholar
  47. 47.
    Madoff RD, et al. Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial. Gastroenterology. 1999;116(3):549–56.CrossRefGoogle Scholar
  48. 48.
    Wexner SD, Baeten C, Bailey R, Bakka A, Belin B, Belliveau P, Berg E, Buie WD, Burnstein M, Christiansen J, Coller J, Galandiuk S, Lange J, Madoff R, Matzel KE, Påhlman L, Parc R, Reilly J, Seccia M, Thorson AG, Vernava AM 3rd. Long-term efficacy of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum. 2002;45(6):809–18.CrossRefGoogle Scholar
  49. 49.
    Gregorcyk SG. The current status of the Acticon Neosphincter. Clin Colon Rectal Surg. 2005;18(1):32–7.CrossRefGoogle Scholar
  50. 50.
    Wong WD, et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum. 2002;45(9):1139–53.CrossRefGoogle Scholar
  51. 51.
    Gallas S, et al. Constipation in 44 patients implanted with an artificial bowel sphincter. Int J Color Dis. 2009;24(8):969–74.CrossRefGoogle Scholar
  52. 52.
    Wexner SD, et al. Factors associated with failure of the artificial bowel sphincter: a study of over 50 cases from Cleveland Clinic Florida. Dis Colon Rectum. 2009;52(9):1550–7. Scholar
  53. 53.
    Pakravan F, Helmes C. Magnetic anal sphincter augmentation in patients with severe fecal incontinence. Dis Colon Rectum. 2015;58(1):109–14.CrossRefGoogle Scholar
  54. 54.
    Lehur PA, et al. Magnetic anal sphincter augmentation for the treatment of fecal incontinence: a preliminary report from a feasibility study. Dis Colon Rectum. 2010;53(12):1604–10.CrossRefGoogle Scholar
  55. 55.
    Sugrue J, et al. Long-term experience of magnetic anal sphincter augmentation in patients with fecal incontinence. Dis Colon Rectum. 2017;60(1):87–95.CrossRefGoogle Scholar
  56. 56.
    Wong MT, et al. The magnetic anal sphincter versus the artificial bowel sphincter: a comparison of 2 treatments for fecal incontinence. Dis Colon Rectum. 2011;54(7):773–9.CrossRefGoogle Scholar
  57. 57.
    Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet. 1990;336(8725):1217–8.CrossRefGoogle Scholar
  58. 58.
    Norton C, Burch J, Kamm MA. Patients’ views of a colostomy for fecal incontinence. Dis Colon Rectum. 2005;48(5):1062–9.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Colon and Rectal SurgeryLahey ClinicBurlingtonUSA
  2. 2.Department of General Surgery, Pelvic Floor Disorders CenterMassachusetts General HospitalBostonUSA

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