Effective Management of Fecal Incontinence Requires Thorough Physical Exam, History

According to the 2009—2010 National Health and Nutrition Examination Survey, fecal incontinence has a 9% prevalence rate in the United States. Effective management of this often-embarrassing condition requires a thorough patient history and exam and recognition of its diverse etiology.

Fecal incontinence has an average annual cost per patient of $4,110 due to lost job productivity and the cost of medical supplies, said Yolanda V. Scarlett, MD, assistant professor of medicine and medical director, GI Motility Laboratory, University of North Carolina at Chapel Hill.

Scarlett outlined diagnosis, evaluation, and treatment strategies for fecal incontinence during a presentation at the 2014 American Gastroenterological Association Clinical Congress of Gastroenterology and Hepatology in Miami Beach, FL.

Mechanisms of fecal incontinence include structural abnormalities such as rectal prolapse or anal sphincter disruption and functional abnormalities. Several studies have shown that loose stool consistency is a major cause associated with fecal incontinence. “Diarrhea is a significant risk factor,” Scarlett said.

A detailed history is crucial to get to the root of fecal inconsistency. That should include inquiring about the number of incontinent bowel movements a day, any co-existing medical conditions, and other medical history. It’s also important to ask the patient about their stool characteristics, even if the patients are uncomfortable discussing it. To help with the latter problem, Scarlett suggested using the Bristol Stool Chart to get patients to talk.

In addition to a digital exam, diagnostic testing for fecal incontinence may include anorectal manometry, endoanal ultrasound imaging, a rectal compliance test, and defecography. Patients with previous radiation, inflammatory bowel disease, and surgical procedures could benefit from the rectal compliance test, as any of these factors could increase the risk for fecal inconsistency, Scarlett said.

Tests used less frequently for fecal incontinence include needle electromyography, magnetic resonance imaging of the anal sphincters, and magnetic resonance defecography.

Fecal incontinence treatment should focus on the underlying cause and include supportive guidance, medications, dietary changes, pelvic floor biofeedback, anal sphincter bulking agents, colostomy, and sacral nerve electrostimulation. Use of an artificial sphincter is another treatment option, but studies show that while it improves the patient’s symptoms over 12 months, there is not as much visible improvement after five years, Scarlett said.

Scarlett illustrated several of these points during her discussion of the case of a 47-year-old woman with fecal incontinence who had experienced involuntary passage of formed stool a few times a week over eight months. She was symptomatic despite Kegel exercises. The patient had a median episiotomy with her first delivery. Her rectal exam showed diminished resting and squeeze tone in the anal canal. The patient went for an anorectal manometry, and she eventually had pelvic floor biofeedback. However, the patient needed further help and then had endoanal imaging. She was referred for sacral nerve stimulation which eventually helped the problem.