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fecal incontinence; anal incontinence; bowel incontinence; includes: encopresis

Involuntary passage of gas or feces. Classification: - passive fecal incontinence - patient is not aware of the passage of feces - urge fecal incontinence - passage of feces despite attempts by the patient to prevent it - seepage fecal incontinence - unintentional passage of feces following a normal bowel movement - may present as soiling of underwear Etiology: 1) inability to get to toilet - immobility, deconditioning* 2) constipation with overflow fecal incontinence 3) medications are associated with urge fecal incontinence - laxative use - magnesium-containing anti-acids - metformin - SSRI 4) fecal impactation 5) rectal sphincter injury - obstetrical injury (peripartum injury) - reduced anal sphincter & puborectalis contraction - sensation is normal [13] 6) pudendal nerve damage is associated with passive or seepage fecal incontinence a) pudendal nerve entrapment - reduced anal sensation - weakness of external anal sphincter - puborectalis strength normal b) spinal cord compression/cauda equina syndrome - weakness of puborectalis - external anal sphincter strength normal c) diabetic nephropathy 7) diarrhea - microscopic colitis [14] - IBS-D - inflammatory bowel disease, especially during flare [14] - bile acid diarrhea (cholecystectomy) - chronic infectious diarrhea - lactose intolerance - celiac disease - small intestinal bacterial overgrowth [14] 8) altered mental status a) dementia b) stroke 9) seizures [5] * even if patient's loss of ability to perform activities of daily living (ADL) (i.e. inability to get to the toilet) occurred after a hospitalization, inability to perform ADL rather than the hospitalization is the most likely contributing factor to fecal incontinence [12] Epidemiology: 1) 2% of population; 2) increased prevalence in elderly & women - 5-6% of community-living elderly [12] - prevalence of 16% in elderly > 70 years of age [1] - 10-64% of nursing home residents [12] - 80% of women with fecal incontinence are postmenopausal 3) only 1/3 of patients consult physician 4) more common in women with urinary incontinence 5) encopresis in children who have been toilet trained Pathology: - loss of normal function controlling fecal continence a) dysfunction of smooth & voluntary muscles - decreased rectal compliance [12] b) lack of reflex coordination c) diminished anorectal sensation [12] Laboratory: - serum TSH - serum electrolytes - serum calcium [5] Special laboratory: - electroencephalography (EEG) to assess absence seizures in elderly cognitive & functional change associated with new-onset fecal & urinary incontinence [2] Radiology: - abdominal radiograph for colonic distension by excessive feces [5] Management: 1) bowel management a) high-fiber diet b) bulking agents c) planned evacuations 2) biofeedback a) uses sensing device to monitor voluntary sphincter activity b) displayed to patient as pressure change or electromyographic activity c) positive reinforcement is given to improve the patient's voluntary sphincter response 3) pharmaceutical agents a) loperamide b) enemas daily or every other day c) avoid offending agents 4) treatment of fecal impactation 5) smoking cessation 6) weight reduction if obese 7) exercise 8) surgery a) sphincter repair b) colostomy c) sacral nerve stimulation [6] - stimulating electrode is placed in the sacral foramen, usually at the S3 level [6] 9) injection of dextranomer in stabilized hyaluronic acid (NASHA Dx) into the submucosa of the anal canal as a bulking agent [6] - consider after conservative measures have failed [6] 10) inflatable vaginal device (Eclipse System) FDA-approved for women with fecal incontinence [7] 11) prevention (see prevention of fecal & urinary incontinence)

Related

cauda equina syndrome fecal impactation feces (stool) prevention of fecal & urinary incontinence

Specific

encopresis

General

incontinence

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2015, 2018, 2021.
  2. Journal Watch 22(24):185, 2002 Meschia M, Pifarotti P, Gattei U, Crosignani PG. Injection therapy for the treatment of stress urinary incontinence in women. Gynecol Obstet Invest. 2002;54(2):67-72. Review. PMID: 12566746
  3. Shamliyan TA et al, Systematic review: Randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008, 148:459 PMID: 18268288
  4. Landefeld CS et al National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med. 2008 Mar 18;148(6):449-58. Epub 2008 Feb 11. PMID: 18268289
  5. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  6. Wald A. New treatments for fecal incontinence: Update for the gastroenterologist. Clin Gastroenterol Hepatol 2014 Feb 19 PMID: 24534548 http://www.cghjournal.org/article/S1542-3565%2814%2900234-1/abstract
  7. FDA News Release. February 12, 2015 FDA permits marketing of fecal incontinence device for women http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm434130.htm
  8. Costilla VC, Foxx-Orenstein AE, Mayer AP, Crowell MD. Office-based management of fecal incontinence. Gastroenterol Hepatol (N Y). 2013 Jul;9(7):423-33. PMID: 23935551
  9. Agency for Healthcare Research and Quality (AHRQ) Research Review. March 21, 2016 Treatments for Fecal Incontinence https://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=2201
  10. Saga S, Vinsnes AG, Morkved S, Norton C, Seim A. Prevalence and correlates of fecal incontinence among nursing home residents: a population-based cross-sectional study. BMC Geriatr. 2013 Aug 30;13:87. doi: 10.1186/1471-2318-13-87. PMID: 24119057 Free PMC Article
  11. Yu SW, Rao SS. Anorectal physiology and pathophysiology in the elderly. Clin Geriatr Med. 2014 Feb;30(1):95-106. Review. PMID: 24267605 Free PMC Article
  12. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  13. NEJM Knowledge+ Gastroenterology
  14. Menees S, Chey WD. Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies. Gastroenterol Clin North Am. 2022 Mar;51(1):71-91. PMID: 35135666 Review.
  15. Pasricha T, Staller K. Fecal Incontinence in the Elderly. Clin Geriatr Med. 2021 Feb;37(1):71-83. PMID: 33213775 PMCID: PMC7684943 Free PMC article. Review.
  16. Symptoms & Causes of Fecal Incontinence https://www.niddk.nih.gov/health-information/digestive-diseases/bowel-control-problems-fecal-incontinence/symptoms-causes