Definition
A.Fecal incontinence (FI) is the involuntary loss of bowel function, ranging from an occasional leakage of mucus or stool when passing flatus to complete loss of bowel control. There are three classifications of FI:
1.Passive incontinence—characterized by impaired awareness of the need to defecate prior to the incontinent episode.
2.Urge incontinence—characterized by the desire to retain fecal material followed by an incontinent episode
3.Fecal seepage—leakage of fecal material after normal evacuation of stool:
a.Overflow incontinence secondary to fecal impaction.
b.Reservoir secondary to diminished colonic or rectal capacity.
c.Rectosphincteric dysfunction: Structural or neurologic damage to the anal sphincter.
Incidence
A.Incidence is dependent on the population studied. Overall incidence is 7.7% with a range from 2% to 21%. The American College of Gastroenterology (ACG) estimates that more than 18 million Americans have FI. Due to the embarrassing nature of the problem it is often underreported.
B.Up to 21% of institutional patients have FI. It is the second most common cause of nursing home placement.
C.Incidence increases with age, female gender, and institutionalization.
D.Literature notes 7% incidence of coexisting fecal and urinary incontinence among women and a 4% incidence of FI alone.
Pathogenesis
A.FI is a multifactorial problem and generally a deficiency in one area does not lead to incontinence. Stool continence requires the ability to hold stool (sphincter function), the ability to sense the presence of stool in the rectum (anorectal sensation), the ability to relax and hold the stool (rectal compliance), the mental capabilities to recognize the urge, and the physical ability to go to the toilet, as well as colonic transit of a stool with volume and consistency.
Predisposing Factors
A.Fecal impaction/constipation.
B.Diarrhea (viral/bacteria etiology).
C.Obstetrics:
1.Forceps delivery.
2.Episiotomy.
3.Vaginal tears.
4.Large baby (>9.5 pounds).
D.Neurologic/spinal etiology of rectosphincter dysfunction:
1.Lumbar disc herniation with subsequent cauda equina syndrome.
2.Spinal cord injury.
3.Multiple sclerosis.
4.Spina bifida.
5.Meningocele/myelomeningocele.
6.Imperforated anus.
7.Diabetes.
8.Stroke.
E.Trauma.
F.Hemorrhoids/hemorrhoidectomy.
G.Rectocele.
H.Rectal prolapse.
I.Dementia.
J.Radiation for rectal/pelvic cancer.
K.Inflammatory bowel disease (IBD).
L.Inactivity (constipated-related bowel control problems).
M.Vitamin B12 deficiency.
N.Hypothyroidism.
O.Severe learning disability.
P.Urinary incontinence.
Q.History of postmenopausal hormone use.
Common Complaints
A.Leakage of mucus/stool when passing flatus.
B.Uncontrolled passing of stool.
Other Signs and Symptoms
A.Inability to get to the toilet in time.
Subjective Data
A.Ask about the following bowel-related issues:
1.When did the FI start and how often does the patient have bowel control problems?
2.Is the patient incontinent of mucus, liquid, and/or solid stools? Does he or she leak a little or have full incontinence?
3.Is the patient able to control passing gas?
4.Does he or she have an urge to have a bowel movement (BM) or just have loss of control?
5.Are hemorrhoids present?
6.What foods make the FI worse?
7.Does the patient have to do a self-rectal evacuation of stool? How often?
8.Does the patient have anal intercourse? How often? Use of penetrating objects?
9.Is there a history of impaction?
10.Does the patient wear a pad or an adult diaper?
B.Obtain a detailed obstetrical history:
1.Number of vaginal deliveries.
2.Use of forceps.
3.Infant birth weights.
4.Need for episiotomy for each vaginal delivery.
5.Presence of vaginal tears.
6.Stool incontinence after deliveries.
C.Has the patient been diagnosed with Crohn’s or ulcerative colitis (UC)? Is the patient currently under treatment? Is the patient compliant with his or her treatments?
D.Review full medical history, especially for diabetes, pelvic radiation, neurologic disease, and back injury.
E.Inquire about urinary incontinence.
F.Review surgical history, including pelvic/rectal surgeries.
G.Review all medications currently being taken, including over-the-counter (OTC) and herbal products. Specifically, evaluate for laxative abuse and recent antibiotic use.
H.Are any other family members ill?
I.Has the patient recently traveled or gone camping, which would identify infectious causes? (Refer to entries on diarrhea and infectious diseases.)
Physical Examination
A.Check temperature (if applicable), pulse, respirations, blood pressure (BP), and weight.
B.Inspect:
1.Inspect general appearance.
2.Examine the back and lower limbs.
3.Inspect the perianal area for fecal matter, dermatitis, excoriation, fistula, abscess, rectal prolapse, hemorrhoids, and scars.
4.Evaluate if the anal sphincter is open or closed at rest.
C.Auscultate:
1.Auscultate the abdomen.
D.Palpate:
1.Palpate all quadrants of the abdomen to evaluate distension, tenderness, and masses.
E.Anorectal examination: A negative digital rectal examination does not rule out proximal impaction:
1.Evaluate anal stenosis, resting tone.
2.Check presence of impacted stool.
3.Assess the puborectalis muscle by palpating the posterior anal canal:
a.Ask the patient to bear down as if having a BM. (An intact puborectalis displaces the examining finger anteriorly.)
b.Ask the patient to squeeze the provider’s finger.
4.Stroke the perianal skin bilaterally to check for an anal wink
anocutaneous reflex.
F.Perform pelvic examination to evaluate the presence of a cystocele, rectocele, enterocele, vaginal prolapse, and fistula.
G.Mental status:
1.Make a cognitive assessment, such as the Mini-Mental State Examination (MMSE).
2.Assess for depression.
Diagnostic Tests
A.Stool studies to rule out infectious etiology (refer to section Diarrhea
in this chapter)
B.Abdominal x-ray.
C.Sigmoidoscopy/colonoscopy—flexible sigmoidoscopy is reserved for patients younger than age 40.
D.Rectal manometry.
E.Anorectal ultrasound.
F.Defecography.
G.MRI.
H.Anal electromyography (EMG).
I.Thyroid function tests.
J.Hydrogen breath tests to evaluate lactose/fructose intolerance.
Differential Diagnoses
A.FI.
B.Constipation/fecal impaction.
C.Diarrhea secondary to infectious etiology.
D.IBD.
E.Postradiation therapy.
Plan
Optimal treatment of fecal incontinence is dependent on identifying the underlying cause of the symptoms. The goal of therapy is to reduce the number of stools and increase the consistency. The best prevention of fecal incontinence is an empty rectum.
A.Patient teaching:
1.Discuss keeping a stool diary for a week. A BM record is available at www.nhsggc.org.uk/media/241191/nhsggc-bristol-stool-chart.pdf.
2.Discuss keeping a food diary for a week to assist in identifying any foods that cause, trigger, or worsen FI such as coffee, fatty or greasy foods, dairy products (lactose intolerance), sugar-free gum/artificial sweeteners, and cured/smoked meats.
3.Discuss a high-fiber diet. Give patient a dietary sheet on a high-fiber diet (see section High-Fiber Diet
of Appendix B).
4.Discuss the need for additional fluids, 8 to 10 glasses of water, to help prevent constipation. Caffeine, carbonated beverages, alcohol, and milk may cause diarrhea.
5.Discuss the need for manual disimpaction.
6.Remove physical barriers that prevent getting to the bathroom.
7.Discuss tips to help deal with bowel incontinence/hygienic measures:
a.Use the toilet before leaving home.
b.Identify public restrooms before they are needed.
c.Carry a bag of supplies and change clothes as soon as possible.
d.Pants with elastic are easier to pull down than pants that have buttons.
e.Wear disposable underwear/absorbent pads.
f.Use water without soap; soap dries and irritates.
g.Use baby wipes.
h.Use a moisture-barrier cream, such as zinc oxide.
i.Use fecal deodorant to disguise odor.
B.Conservative treatment:
1.Bowel retraining program:
a.Schedule defecation throughout the day, especially after meals.
2.Biofeedback:
a.Biofeedback requires the ability to comprehend and follow directions, motivation, and cooperation:
i.Auditory or visual feedback for reeducation of the pelvic floor muscles.
ii.Rectal sensitivity training utilizing a rectal balloon.
iii.Anal sphincter exercises.
3.Pelvic floor exercises.
4.Anal plug—can be irritating and is most effective for patients with decreased anal sensation.
C.Dietary management: Counsel patient on nutrition and low-fat, low-cholesterol, and low-sodium diets. Give diet handouts.
D.Pharmaceutical therapy.
Solutions containing magnesium, phosphate, or citrate should be used with caution or avoided, especially with patients who have heart failure (HF), or chronic renal failure secondary to the absorption of these electrolytes increases fecal impaction:
1.Mainstay of treatment: Loperamide hydrochloride (Imodium): 2 to 4 mg two or three times a day to control symptoms. Maximum daily dose for loperamide is 16 mg.
2.Diphenoxylate hydrochloride/atropine (Lomotil):
a.Contains an opioid Schedule V medication under the Controlled Substance Act. May produce sedation and dizziness.
b.Two tablets four times a day until diarrhea is controlled.
c.Maintenance dose two tablets per day.
3.Bulking agents to increase formed stools (used for diarrhea and constipation)—may worsen incontinence in patients with decreased rectal compliance but is useful in patients with low-volume loose stools:
a.Methylcellulose (Citrucel)—one to two tablespoons daily.
b.Psyllium (Metamucil).
4.Fecal impaction:
a.Polyethylene glycol (MiraLax).
b.Enemas (predictable and have a timely response).
c.Suppositories.