Office-based management of fecal incontinence

Abstract

Fecal incontinence (FI) is a devastating disorder that is more prevalent than previously realized. FI is the involuntary loss of stool. Many factors contribute to the pathophysiology of FI, including advanced age, bowel irregularity, parity, and obesity. A detailed history and focused rectal examination are important to making the diagnosis and determining contributing causes. Although multiple diagnostic studies are available to assess the cause of FI, specific guidelines that delineate when testing should be done do not exist. Clinicians must weigh the risk, benefit, and burden of testing against the need for empiric treatment. All types of FI are initially managed in the same way, which includes lifestyle modification to reduce bowel derangements, improved access to toileting, and initiation of a bulking regimen to improve stool consistency. If initial conservative management fails, pharmaco-logic agents, biofeedback, or surgery may be indicated.

Keywords: Fecal incontinence; anal incontinence; bariatric surgery incontinence; fecal seepage; flatal incontinence; obesity incontinence.

Figure 1

High-resolution anorectal manometry showing a high-resolution topographic contour plot of resting anorectal motor function in a healthy control with normal resting internal anal sphincter tone (A) and in a patient with fecal incontinence (FI) and weak internal anal sphincter tone (B). Resting pressures in the patient with FI never exceed 30 mmHg. The high-resolution topographic contour plot shows maximal squeeze pressures in a healthy control with normal external anal sphincter squeeze pressure and endurance (C) and in a patient with FI demonstrating weak external anal sphincter squeeze pressure and rapid fatigue (D). The resting and squeeze event windows are shown within the dashed white lines. Pressures in mmHg are calibrated to the color contour chart on the left. A solid black contour line delineates all pressures at 30 mmHg or above.

Figure 2

Defecography anorectal images at rest (A), squeeze (B), and evacuation (C) and corresponding dynamic pelvic magnetic resonance imaging (D—F, respectively).

Figure 3

An algorithm for the management of fecal incontinence (FI). MRI=magnetic resonance imaging; SNS=sacral nerve stimulation.