Fecal Incontinence

• Clinical evaluation

• Sometimes imaging tests and anorectal manometry

Physical examination should evaluate gross sphincter function and perianal sensation and rule out a rectal mass or rectal prolapse.

Anal sphincter endoscopic ultrasound, pelvic and perineal MRIs, and anorectal manometry are also useful.

• Program of stool regulation

• Perineal exercises, sometimes with biofeedback

• Sometimes a surgical procedure

Treatment of fecal incontinence includes a bowel management program to develop a predictable pattern of defecation. The program includes intake of adequate fluid and sufficient dietary bulk. Sitting on a toilet or using another customary defecatory stimulant (eg, coffee) encourages defecation. A suppository (eg, glycerin, bisacodyl) or a phosphate enema may also be used. If a regular defecatory pattern does not develop, a low-residue diet and oral loperamide may reduce the frequency of defecation.

Simple perineal exercises, in which the patient repeatedly contracts the sphincters, perineal muscles, and buttocks, may strengthen these structures and contribute to continence, particularly in mild cases. Biofeedback (to train the patient to use the sphincters maximally and to better appreciate physiologic stimuli) should be considered before recommending surgery in well-motivated patients who can understand and follow instructions and who have an anal sphincter capable of recognizing the cue of rectal distention. Approximately 64 to 89% of patients respond to biofeedback (1).

A defect in the sphincter as assessed by endoscopic ultrasound can be sutured directly, but the efficacy of this repair deteriorates over time.

Sacral nerve stimulation has shown promise in the treatment of fecal incontinence (1). Electrodes are implanted on a temporary basis, and if a trial period demonstrates good results, the generator is implanted permanently with good success rates.

When all else fails, a colostomy can be considered.