Anal Incontinence

  • Sanjiv K. Patankar
  • Negar M. Salehomoum


Anal incontinence (AI) is the involuntary loss of either flatus or stool and a socially awkward and underreported diagnosis. A detailed history and physical examination are indicated for evaluation of incontinence. Diagnostic testing modalities include anorectal manometry, electromyography, pudendal nerve terminal motor latency, endoanal ultrasound, and defecography, along with scoring systems to rate the severity of incontinence and resulting quality of life indicators. Patients with AI should be educated on maintaining anal hygiene. Conservative measures include dietary modification, pharmacologic agents, and bowel management regimens. Mild AI is managed through pelvic floor exercises or biofeedback therapy. Those with intact sphincters and weak pudendal nerves are suitable for sacral nerve stimulation. Defective sphincters are managed through sphincteroplasty or an artificial bowel sphincter. Some require a colostomy to control incontinence. Treatment is best individualized.


Fecal Incontinence Anal Sphincter Anal Canal External Anal Sphincter Internal Anal Sphincter 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36:77–97.PubMedCrossRefGoogle Scholar
  2. 2.
    Whitehead WE, Borrud L, Goode PS, et al. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology. 2009;137:512–7.PubMedCrossRefGoogle Scholar
  3. 3.
    MacLennan AH, Taylor AW, Wilson DH, et al. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG. 2000;107:1460–70.PubMedCrossRefGoogle Scholar
  4. 4.
    Nelson R, Norton N, Cautley E, et al. Community-based prevalence of anal incontinence. JAMA. 1995;274:559–61.PubMedCrossRefGoogle Scholar
  5. 5.
    Teunissen TA, van den Bosch WJ, van den Hoogen HJ, et al. Prevalence of urinary, fecal and double incontinence in the elderly living at home. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15:10–3; discussion 13.Google Scholar
  6. 6.
    Whitehead WE. Diagnosing and managing fecal incontinence: if you don’t ask, they won’t tell. Gastroenterology. 2005;129:6.PubMedCrossRefGoogle Scholar
  7. 7.
    Jorge JMN. Anorectal anatomy and physiology. In: Beck DE, Wexner SD, editors. Fundamentals of anorectal surgery. 2nd ed. London: W.B. Saunders; 1998. p. 557.Google Scholar
  8. 8.
    Miller R, Bartolo DC, Cervero F, et al. Anorectal sampling: a comparison of normal and incontinent patients. Br J Surg. 1988;75:44–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Papachrysostomou M, Pye SD, Wild SR, et al. Significance of the thickness of the anal sphincters with age and its relevance in faecal incontinence. Scand J Gastroenterol. 1994;29:710–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Bartolo DC, Read NW, Jarratt JA, et al. Differences in anal sphincter function and clinical presentation in patients with pelvic floor descent. Gastroenterology. 1983;85:68–75.PubMedGoogle Scholar
  11. 11.
    Laurberg S, Swash M. Effects of aging on the anorectal sphincters and their innervation. Dis Colon Rectum. 1989;32:737–42.PubMedCrossRefGoogle Scholar
  12. 12.
    Ryhammer AM, Laurberg S, Sorensen FH. Effects of age on anal function in normal women. Int J Colorectal Dis. 1997;12:225–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Schiller LR. Constipation and fecal incontinence in the elderly. Gastroenterol Clin North Am. 2001;30:497–515.PubMedCrossRefGoogle Scholar
  14. 14.
    Bartolo DC, Paterson HM. Anal incontinence. Best Pract Res Clin Gastroenterol. 2009;23:505–15.PubMedCrossRefGoogle Scholar
  15. 15.
    Samarasekera DN, Bekhit MT, Preston JP, et al. Risk factors for anal sphincter disruption during child birth. Langenbecks Arch Surg. 2009;394:535–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Sultan AH, Kamm MA, Hudson CN, et al. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ. 1994;308:887–91.PubMedCrossRefGoogle Scholar
  17. 17.
    Oberwalder M, Connor J, Wexner SD. Meta-analysis to determine the incidence of obstetric anal sphincter damage. Br J Surg. 2003;90:1333–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Sultan AH, Kamm MA, Hudson CN, et al. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329:1905–11.PubMedCrossRefGoogle Scholar
  19. 19.
    Starck M, Bohe M, Valentin L. Results of endosonographic imaging of the anal sphincter 2–7 days after primary repair of third- or fourth-degree obstetric sphincter tears. Ultrasound Obstet Gynecol. 2003;22:609–15.PubMedCrossRefGoogle Scholar
  20. 20.
    Ekin M, Kupelioglu LC, Yasar L, et al. The coexistence of anal incontinence in women with urinary incontinence. Arch Gynecol Obstet. 2009;280:971–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Rosa G, Lolli P, Piccinelli D, et al. Fistula in ano: anatomoclinical aspects, surgical therapy and results in 844 patients. Tech Coloproctol. 2006;10:215–21.PubMedCrossRefGoogle Scholar
  22. 22.
    Hyman N, O’Brien S, Osler T. Outcomes after fistulotomy: results of a prospective, multicenter regional study. Dis Colon Rectum. 2009;52:2022–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Bode WE, Culp CE, Spencer RJ, et al. Fissurectomy with superficial midline sphincterotomy. A viable alternative for the surgical correction of chronic fissure/ulcer-in-ano. Dis Colon Rectum. 1984;27:93–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Mousavi SR, Sharifi M, Mehdikhah Z. A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg. 2009;13:1279–82.PubMedCrossRefGoogle Scholar
  25. 25.
    Nelson RL. Operative procedures for fissure in ano. Cochrane Database Syst Rev. 2010:CD002199.Google Scholar
  26. 26.
    Sames P. Experiences of Lord’s procedure for the treatment of hemorrhoids. Proc R Soc Med. 1972;65:782–3.PubMedGoogle Scholar
  27. 27.
    Creve U, Hubens A. The effect of Lord’s procedure on anal pressure. Dis Colon Rectum. 1979;22:483–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Senagore AJ, Singer M, Abcarian H, et al. A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum. 2004;47:1824–36.PubMedCrossRefGoogle Scholar
  29. 29.
    Gravie JF, Lehur PA, Huten N, et al. Stapled hemorrhoidopexy versus milligan-morgan hemorrhoidectomy: a prospective, randomized, multicenter trial with 2-year postoperative follow up. Ann Surg. 2005;242:29–35.PubMedCrossRefGoogle Scholar
  30. 30.
    Ho YH, Cheong WK, Tsang C, et al. Stapled hemorrhoidectomy—cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum. 2000;43:1666–75.PubMedCrossRefGoogle Scholar
  31. 31.
    Arbman G, Krook H, Haapaniemi S. Closed vs. open hemorrhoi­dectomy—is there any difference? Dis Colon Rectum. 2000;43:31–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Brusciano L, Ayabaca SM, Pescatori M, et al. Reinterventions after complicated or failed stapled hemorrhoidopexy. Dis Colon Rectum. 2004;47:1846–51.PubMedCrossRefGoogle Scholar
  33. 33.
    Oughriss M, Yver R, Faucheron JL. Complications of stapled hemorrhoidectomy: a French multicentric study. Gastroenterol Clin Biol. 2005;29:429–33.PubMedCrossRefGoogle Scholar
  34. 34.
    Rockwood TH, Church JM, Fleshman JW, et al. Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum. 2000;43:9–16; discussion 16–7.Google Scholar
  35. 35.
    Bartram CI, Sultan AH. Anal endosonography in faecal incontinence. Gut. 1995;37:4–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Taylor SA. Imaging pelvic floor dysfunction. Best Pract Res Clin Gastroenterol. 2009;23:487–503.PubMedCrossRefGoogle Scholar
  37. 37.
    Tan JJ, Chan M, Tjandra JJ. Evolving therapy for fecal incontinence. Dis Colon Rectum. 2007;50:1950–67.PubMedCrossRefGoogle Scholar
  38. 38.
    Pinedo G, Garcia E, Zarate AJ, et al. Are topical oestrogens useful in faecal incontinence? Double-blind randomized trial. Colorectal Dis. 2009;11:390–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Scaglia M, Delaini G, Destefano I, et al. Fecal incontinence treated with acupuncture—a pilot study. Auton Neurosci. 2009;145:89–92.PubMedCrossRefGoogle Scholar
  40. 40.
    Oom DM, Gosselink MP, Schouten WR. Anterior sphincteroplasty for fecal incontinence: a single center experience in the era of sacral neuromodulation. Dis Colon Rectum. 2009;52:1681–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Zutshi M, Tracey TH, Bast J, et al. Ten-year outcome after anal sphincter repair for fecal incontinence. Dis Colon Rectum. 2009;52:1089–94.PubMedCrossRefGoogle Scholar
  42. 42.
    Wong WD, Congliosi SM, Spencer MP, et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum. 2002;45:1139–53.PubMedCrossRefGoogle Scholar
  43. 43.
    Altomare DF, Binda GA, Dodi G, et al. Disappointing long-term results of the artificial anal sphincter for faecal incontinence. Br J Surg. 2004;91:1352–3.PubMedCrossRefGoogle Scholar
  44. 44.
    Gallas S, Leroi AM, Bridoux V, et al. Constipation in 44 patients implanted with an artificial bowel sphincter. Int J Colorectal Dis. 2009;24:969–74.PubMedCrossRefGoogle Scholar
  45. 45.
    Wexner SD, Jin HY, Weiss EG, 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;52:1550–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Leroi AM, Damon H, Faucheron JL, et al. Sacral nerve stimulation in faecal incontinence: position statement based on a collective experience. Colorectal Dis. 2009;11:572–83.PubMedCrossRefGoogle Scholar
  47. 47.
    Govaert B, Melenhorst J, Nieman FH, et al. Factors associated with percutaneous nerve evaluation and permanent sacral nerve modulation outcome in patients with fecal incontinence. Dis Colon Rectum. 2009;52:1688–94.PubMedCrossRefGoogle Scholar
  48. 48.
    Boyle DJ, Knowles CH, Lunniss PJ, et al. Efficacy of sacral nerve stimulation for fecal incontinence in patients with anal sphincter defects. Dis Colon Rectum. 2009;52:1234–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Matzel KE, Lux P, Heuer S, et al. Sacral nerve stimulation for faecal incontinence: long-term outcome. Colorectal Dis. 2009;11:636–41.PubMedCrossRefGoogle Scholar
  50. 50.
    Altomare DF, Ratto C, Ganio E, et al. Long-term outcome of sacral nerve stimulation for fecal incontinence. Dis Colon Rectum. 2009;52:11–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Meurette G, La Torre M, Regenet N, et al. Value of sacral nerve stimulation in the treatment of severe faecal incontinence: a comparison to the artificial bowel sphincter. Colorectal Dis. 2009;11:631–5.PubMedCrossRefGoogle Scholar
  52. 52.
    Efron JE. The SECCA procedure: a new therapy for treatment of fecal incontinence. Surg Technol Int. 2004;13:107–10.PubMedGoogle Scholar
  53. 53.
    Efron JE, Corman ML, Fleshman J, et al. Safety and effectiveness of temperature-controlled radio-frequency energy delivery to the anal canal (Secca procedure) for the treatment of fecal incontinence. Dis Colon Rectum. 2003;46:1606–16; discussion 1616–8.Google Scholar
  54. 54.
    Lefebure B, Tuech JJ, Bridoux V, et al. Temperature-controlled radio frequency energy delivery (Secca procedure) for the treatment of fecal incontinence: results of a prospective study. Int J Colorectal Dis. 2008;23:993–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Parisien CJ, Corman ML. The Secca procedure for the treatment of fecal incontinence: definitive therapy or short-term solution. Clin Colon Rectal Surg. 2005;18:42–5.PubMedCrossRefGoogle Scholar
  56. 56.
    Takahashi T, Garcia-Osogobio S, Valdovinos MA, et al. Extended two-year results of radio-frequency energy delivery for the treatment of fecal incontinence (the Secca procedure). Dis Colon Rectum. 2003;46:711–5.PubMedCrossRefGoogle Scholar
  57. 57.
    Kim DW, Yoon HM, Park JS, et al. Radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence? Am J Surg. 2009;197:14–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Shafik A. Polytetrafluoroethylene injection for the treatment of partial fecal incontinence. Int Surg. 1993;78:159–61.PubMedGoogle Scholar
  59. 59.
    Danielson J, Karlbom U, Sonesson AC, et al. Submucosal injection of stabilized nonanimal hyaluronic acid with dextranomer: a new treatment option for fecal incontinence. Dis Colon Rectum. 2009;52:1101–6.PubMedCrossRefGoogle Scholar
  60. 60.
    Davis K, Kumar D, Poloniecki J. Preliminary evaluation of an injectable anal sphincter bulking agent (Durasphere) in the management of faecal incontinence. Aliment Pharmacol Ther. 2003;18:237–43.PubMedCrossRefGoogle Scholar
  61. 61.
    de la Portilla F, Vega J, Rada R, et al. Evaluation by three-dimensional anal endosonography of injectable silicone biomaterial (PTQ) implants to treat fecal incontinence: long-term localization and relation with the deterioration of the continence. Tech Coloproctol. 2009;13:195–9.PubMedCrossRefGoogle Scholar
  62. 62.
    Shafik A. Perianal injection of autologous fat for treatment of sphincteric incontinence. Dis Colon Rectum. 1995;38:583–7.PubMedCrossRefGoogle Scholar
  63. 63.
    Soerensen MM, Lundby L, Buntzen S, et al. Intersphincteric injected silicone biomaterial implants: a treatment for faecal incontinence. Colorectal Dis. 2009;11:73–6.PubMedCrossRefGoogle Scholar
  64. 64.
    Tjandra JJ, Chan MK, Yeh HC. Injectable silicone biomaterial (PTQ) is more effective than carbon-coated beads (Durasphere) in treating passive faecal incontinence—a randomized trial. Colorectal Dis. 2009;11:382–9.PubMedCrossRefGoogle Scholar
  65. 65.
    Aghaee-Afshar M, Rezazadehkermani M, Asadi A, et al. Potential of human umbilical cord matrix and rabbit bone marrow-derived mesenchymal stem cells in repair of surgically incised rabbit external anal sphincter. Dis Colon Rectum. 2009;52:1753–61.PubMedCrossRefGoogle Scholar
  66. 66.
    Lorenzi B, Pessina F, Lorenzoni P, et al. Treatment of experimental injury of anal sphincters with primary surgical repair and injection of bone marrow-derived mesenchymal stem cells. Dis Colon Rectum. 2008;51:411–20.PubMedCrossRefGoogle Scholar
  67. 67.
    Ferreira Galvao FH, Seid VE, Santos RM Nunes dos, et al. Anorectal transplantation. Tech Coloproctol. 2009;13:55–9.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Division of Colo-rectal Surgery, Department of SurgerySaint Peter’s University HospitalEast BrunswickUSA
  2. 2.Department of General SurgeryUMDNJ-Robert Wood Johnson Medical SchoolNew BrunswickUSA

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