INTRODUCTION — Fecal incontinence has a significant social and economic impact and significantly impairs quality of life [1-4]. Fecal incontinence can contribute to the loss of the ability to live independently [5,6]. This topic will review the management of fecal incontinence in adults. Our recommendations are largely consistent with society guidelines and consensus statements [7-9]. The etiology and evaluation of fecal incontinence in adults is discussed in detail, separately. (See "Fecal incontinence in adults: Etiology and evaluation".)
TERMINOLOGY AND CLASSIFICATION
●Fecal incontinence is defined as the involuntary loss of solid or liquid feces.
●Anal incontinence is defined as the involuntary loss of solid or liquid feces or flatus.
Based on the mechanism of incontinence, fecal incontinence is divided into the following:
●Urge incontinence is characterized by the desire to defecate, but incontinence occurs despite efforts to retain stool.
●Passive incontinence is characterized by the lack of awareness of the need to defecate before the incontinent episode.
INITIAL MANAGEMENT — Initial management of fecal incontinence consists of supportive care and medical therapy.
Supportive care — Supportive measures include avoiding foods or activities known to worsen symptoms and improving perianal skin hygiene. This includes avoidance of incompletely digested sugars (eg, fructose, lactose) and caffeine. Patients should be advised to keep a food and symptom diary to identify factors that cause diarrhea and incontinence. The anoderm should be kept clean and dry, without excessive wiping or use of astringent cleaners. Alternatively, a premoistened pad or tissue can be used for wiping. We suggest application of a barrier cream (eg, zinc oxide) to the perianal skin. Incontinence pads can be used to protect both skin and clothing from fecal soiling [10]. Patients who have incontinence related to cognitive dysfunction or physical debility may benefit from assistance with a regular defecation program.
Medical therapy — Medical therapy should be aimed at reducing stool frequency and improving stool consistency. No specific medication has been proven to be of benefit for fecal incontinence, except for antidiarrheal drugs in patients with liquid stools [11-13].
●We begin by supplementing the diet with a bulking agent (eg, psyllium or methylcellulose 1 to 2 tablespoons per day) to improve stool consistency, especially in patients who have low-volume, loose stools. However, fiber may exacerbate incontinence in patients with decreased rectal compliance by increasing stool volume (eg, radiation proctitis, rectal stricture).
●In patients with diarrhea, it is important to treat the underlying etiology. In addition, we use the antidiarrheal agent loperamide to reduce fecal incontinence [14]. A systematic review of medical therapy for fecal incontinence identified 16 randomized studies with 558 participants [11]. In four randomized trials in which loperamide or diphenoxylate plus atropine was compared with placebo, use of these antidiarrheals resulted in a reduction in fecal urgency, episodes of incontinence, unformed stools, and use of pads. Anorectal physiological measurements showed no clear differences between treatment periods. As compared with diphenoxylate, loperamide may be more effective at reducing urgency associated with incontinence and has fewer central nervous system side effects [15].
For patients who do not respond to loperamide, other antidiarrheal agents such as bismuth subsalicylate or bile acid binders (eg, cholestyramine, particularly for patients with a history of cholecystectomy or ileocolonic resection), may be useful for alleviating symptoms [16].
●Patients with fecal impaction should be disimpacted, and concomitant constipation should be treated to prevent recurrent episodes [17,18]. (See "Management of chronic constipation in adults", section on 'Other laxatives'.)
●Evacuation of the rectum by using suppositories or enemas may reduce incontinence episodes [19]. This may be particularly helpful for patients with neurogenic bowel dysfunction due to spinal cord injury. Chronic gastrointestinal complications related to spinal cord injury and bowel management in patients with spina bifida are discussed separately. (See "Chronic complications of spinal cord injury and disease", section on 'Gastrointestinal complications' and "Myelomeningocele (spina bifida): Management and outcome", section on 'Bowel management'.)
Data comparing the efficacy of nonsurgical interventions for fecal incontinence are limited. In a trial including 300 women with ≥1 episode of fecal incontinence per month and normal stool consistency, loperamide (2 mg with ability to titrate the dose higher or lower) and six sessions of biofeedback (each intervention alone or in combination) resulted in no significant difference in fecal incontinence as compared with oral placebo and education after 24 weeks [13]. Clinical response was associated with higher symptom severity at baseline (adjusted odds ratio [aOR] 1.20, 95% CI 1.11-1.28) and being overweight compared with normal/underweight (aOR 2.15, 95% CI 1.07-4.34) [20].
SUBSEQUENT MANAGEMENT — If initial management fails, additional evaluation with anorectal manometry and endorectal ultrasound/magnetic resonance imaging should be performed to detect functional and structural abnormalities causing fecal incontinence. We reserve defecography for patients who have refractory symptoms, especially if surgery is being considered. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Additional studies'.)
Biofeedback — We suggest biofeedback therapy in patients with fecal incontinence if anorectal manometry demonstrates weakness of the external anal sphincter or decreased ability to perceive rectal distension because of nerve injury [4,21,22]. Biofeedback is a painless, noninvasive means of cognitively retraining the pelvic floor and the abdominal wall musculature and is particularly useful in individuals with intact anal sphincters and urge incontinence or decreased rectal sensation.
Biofeedback is not indicated in patients with the following:
●Isolated internal anal sphincter weakness
●Overflow incontinence associated with behavioral or psychiatric disorders
●Neurological disorders associated with substantial loss of rectal sensation and/or the inability to contract the external anal sphincter
●Decreased rectal storage capacity from resection, inflammation, or fibrosis
●Suspected or established major structural damage to continence mechanisms
Patients are guided to improve control of these muscles by electromyographic surface electrodes on an anal plug and an abdominal wall surface electrode. Biofeedback may improve fecal incontinence by enhancement of the ability to perceive rectal distension and improved coordination of the sensory and strength components that are required for continence. An effect on anal pressures has not been consistently demonstrated [23,24]. However, there are limited data to support biofeedback [25]. Although some studies have reported success rates between 38 and 100 percent, these studies have been small, have lacked a control group, have defined endpoints differently, or have had significant other methodological limitations [21,26-30].
Injectable anal bulking agents — We use the injectable anal bulking agent, dextranomer stabilized in hyaluronic acid, in patients with passive fecal incontinence. It is hypothesized that injection of anal bulking agents may enhance resting anal pressures and thereby improve fecal continence, especially in patients with passive fecal incontinence. Studies have suggested limited efficacy in the treatment of fecal incontinence while further studies are awaited [31-34].
●A randomized trial with 206 patients compared injection with dextranomer-hyaluronic acid with sham injections of no substance [32]. After six months of follow-up, 71 of 136 (52 percent) patients in the active treatment arm reported a 50 percent or greater reduction in incontinence episodes, compared with 22 of 70 patients (32 percent) in the sham arm. Complications included proctalgia, rectal hemorrhage, and an abscess (14, 7, and 1 percent, respectively). No significant improvements between active and sham patients were noted in three of the four parts of the fecal incontinence quality of life scale (lifestyle, depression and self-perception, and embarrassment scales), and only a small improvement was noted in the coping and behavior scale. Only 6 percent of treated patients were fully continent at six months. A limitation of the study was that patients were not characterized clinically as to whether they had urge or passive incontinence or manometrically. The limited efficacy of dextranomer-hyaluronic acid in this study may be due to the inclusion of patients with urge incontinence [35]. Patients with urge incontinence often have external anal sphincter weakness or decreased rectal compliance, and it is biologically plausible that they are unlikely to benefit from an injectable bulking agent.
●An open-label study included 115 patients with fecal incontinence treated with dextranomer-hyaluronic acid [33]. Of the 83 individuals who completed 24-month follow-up, 63 percent experienced a ≥50 percent reduction in the total number of episodes of fecal incontinence and a significant increase in the number of incontinence-free days at 24 months, as compared with baseline (22 versus 15 days).
●In a trial of 126 patients with fecal incontinence who were followed for two years, clinical improvement measured by incontinence scores was not significantly different for patients who received injection with dextranomer-hyaluronic acid compared with patients who had sphincter training with biofeedback [36].
In 2011, dextranomer-hyaluronic acid gel was approved by the United States Food and Drug Administration the treatment of fecal incontinence in adult patients who have failed conservative therapy. Four 1 mL injections into the deep submucosa are given in the proximal part of the high-pressure zone of the anal canal, approximately 5 mm above the dentate line. If the response is inadequate after a minimum of four weeks, treatment can be repeated a second time.
Other injectable materials have been used to augment the internal anal sphincter (eg, silicone biomaterial, collagen, carbon-coated microbeads), but there are limited data to support their use [37-40].
Anal sphincteroplasty — Anal sphincteroplasty is usually reserved for patients with fecal incontinence who do not respond to initial management and have evidence of anatomic sphincter injury on anorectal ultrasound/magnetic resonance imaging shortly after vaginal delivery. (See "Obstetric anal sphincter injury (OASIS)".)
Although short-term improvements in fecal incontinence have been reported in up to 85 percent of patients after anal sphincteroplasty, continence deteriorates thereafter, with an approximately 50 percent failure rate after 40 to 60 months [41-44].
Sacral nerve stimulation — We reserve sacral nerve stimulation for patients who are either not candidates for biofeedback or sphincteroplasty, or in whom they have failed [7]. Electrical stimulation of the sacral nerve roots can improve fecal continence in patients with anal sphincter defects and those with structurally intact anal sphincters [45-48]. The exact mechanism of action of sacral nerve stimulation is not known but its effects may occur at the pelvic afferent or central level rather than primarily peripheral motor neurostimulation [49]. Sacral nerve stimulation appears to be particularly effective in patients with neurologic disorders and those with fecal incontinence after lower anterior resection [50,51]. It involves placement of a temporary electrode into the sacral foramen to provide low-grade electrical stimulation. Patients who respond to a two-week trial then undergo placement of a permanent electrode connected subcutaneously to an embedded stimulator [45,46,50-58].
Sacral nerve stimulation may improve fecal continence by improving resting and squeeze pressures of the anal sphincter, rectal sensation, and increasing retrograde colonic propagating sequences [54,59,60]. The most common complications include dislocation of the electrode (12 percent) and infection (3 percent) [61]. Following stimulator implantation, a significant number of patients will require surgical revision for various indications (eg, device failure, electrode displacement or breakage, or battery depletion) [46,52,62].
●In a randomized trial that included 120 patients with fecal incontinence, patients were assigned to sacral nerve stimulation or optimal medical therapy consisting of pelvic floor exercises, bulking agents, and dietary changes [46]. The permanent sacral nerve stimulator was placed into 54 of the 60 randomized patients who had demonstrated improvement during a temporary trial period. In contrast with the control group, in which there was no significant improvement in the number of episodes of fecal continence and fecal incontinence quality of life scores at 12 months follow-up, use of the sacral nerve stimulator was associated with a significant increase in both as compared with baseline. In addition, 25 patients (47 percent) who underwent sacral nerve stimulation achieved complete continence. Complications included pain at the implant site (6 percent), seroma (2 percent), and tingling in the vaginal region (9 percent). There were no septic complications requiring explantation.
●In a prospective, multicenter cohort of 120 patients who received implantation of a sacral nerve stimulator, 86 percent achieved greater than 50 percent reduction in incontinent episodes per week, and 40 percent had no fecal incontinence at three-year follow-up [63,64]. The most common adverse events included implant-site pain, paresthesia, change in the sensation of stimulation, and infection (28, 15 12, and 10 percent, respectively).
●In another study, during a mean follow-up of 49 months, 36 of 87 patients (41 percent) who had undergone stimulator implantation required surgical revision [62]. Reasons for revision included infection (four patients), electrode displacement (two patients), electrode breakage (two patients), dysfunction due to an increase in impedance (four patients), pain with stimulation (seven patients), battery depletion (eight patients), and partial or total loss of clinical efficacy (nine patients).
Posterior tibial nerve stimulation (PTNS) has also been associated with short-term improvements in fecal incontinence in several series [65-69]. However, in a randomized trial in which 227 patients with fecal incontinence were assigned to PTNS or sham stimulation, there was no significant reduction in the number of episodes of fecal incontinence with PTNS [68]. However, additional studies are needed to assess the long-term efficacy of PTNS and to determine if there are sub-groups of patients who may benefit from treatment.
REFRACTORY SYMPTOMS — We reserve colostomy for patients with intractable symptoms who have failed nonsurgical management and who have failed or are not candidates for minimally invasive surgical interventions [8].
Dynamic graciloplasty or an artificial anal sphincter device may be used to treat refractory fecal incontinence. However, there are insufficient data to compare these treatment options [70,71]. Both procedures are associated with significant morbidity and should therefore be performed in centers of expertise.
Colostomy — Diversion of the fecal stream with a colostomy or ileostomy is definitive therapy for patients with intractable symptoms who have failed nonsurgical management and who have failed or are not candidates for minimally invasive surgical interventions [8]. (See "Overview of surgical ostomy for fecal diversion".)
Dynamic graciloplasty — Dynamic graciloplasty may improve fecal incontinence, but the procedure is complicated by considerable morbidity [72,73]. Dynamic graciloplasty involves continuous electrical stimulation of the gracilis muscle that is surgically transposed around the anal canal to increase resting tone [74]. The implantable pulse generator that provides the electrical stimulation is not available in the United States but is available in some other countries.
●In one series of 52 patients with fecal incontinence who underwent dynamic graciloplasty, 38 (73 percent) were continent after a median follow-up of two years [75]. The procedure was associated with improved bowel frequency, ability to postpone defecation, less anxiety, and improved quality of life.
●In a multicenter study that included 128 patients who underwent dynamic graciloplasty for fecal incontinence, during a median follow up of 24 months, 85 (66 percent) patients had a 70 percent or more reduction in stool incontinence [72]. However, 41 (32 percent) patients experienced a major wound complication, and therapy failed in 17 (40 percent).
Artificial anal sphincter — Although implantation of an artificial sphincter device has been associated with a clinically significant improvement in fecal continence, its use is limited by complications including explantation in up to one-third of patients [76,77].
The Acticon neosphincter consists of an occlusive cuff implanted around the anal canal, a pressure-regulating balloon implanted in the prevesical space, and a control pump with a septum port implanted in the labium or scrotum. The user is able to squeeze the control pump to permit defecation.
●A prospective study evaluating this device included 112 patients (86 women) who underwent implantation [78]. Repeated surgery was required to revise the implant in 51 patients (46 percent), some of whom needed more than one revision. The artificial anal sphincter had to be removed in 41 patients (37 percent); however, it was reimplanted in seven. In patients with a functioning artificial anal sphincter, there was improvement in quality of life and anal continence. A clinically significant improvement in fecal incontinence scores was observed in 53 percent of patients.
●A small, randomized trial included 14 patients with fecal incontinence that were assigned to conservative management that included dietary advice, medications, and biofeedback or placement of an artificial anal sphincter [79]. As compared with baseline, placement of an artificial anal sphincter, but not conservative management, resulted in a significant improvement in continence and quality of life at six months. However, complications led to permanent explantation of the device in one patient.
Other devices include a rectally inserted balloon with a sensing device that alerts the user to an imminent bowel movement, a synthetic sphincter device with a silastic inflatable cuff, and a magnetic anal sphincter [42,80-83].
Other — Although several other therapies have been evaluated in patients with fecal incontinence, there are limited data to support their use, and they cannot be routinely recommended.
●Radiofrequency ablation – Radiofrequency ablation (RFA) is a procedure that involves delivering temperature-controlled radiofrequency energy to the anorectal junction to create thermal lesions in the muscle while preserving mucosal integrity. RFA is a minimally invasive treatment for fecal incontinence that takes less than one hour to perform and is generally performed under local anesthesia and sedation. While some small, prospective studies have demonstrated efficacy, conflicting results have also been published, and randomized trials are lacking [84-88].
●Anal plugs (or anal insert device) may decrease fecal incontinence, but efficacy has not been established and for some patients, the device has been poorly tolerated [89-94]. In a randomized trial including 28 pediatric and 20 adult patients with fecal incontinence, use of an anal plug resulted in no significant difference in fecal incontinence compared with placebo, while the device remained in place for most patients [91].
●Phenylephrine – The role of phenylephrine in the treatment of fecal incontinence in patients with an intact internal anal sphincter but low resting pressures is unclear. In small, randomized trials, application of phenylephrine gel to the anal sphincter was associated with a significant improvement in anal sphincter tone and symptoms as compared with placebo [95-99]. However, another randomized trial did not demonstrate any improvement in fecal incontinence from baseline in patients treated with phenylephrine as compared with placebo [99]. Adverse effects of phenylephrine include localized dermatitis, stinging or burning sensation, and headaches.
●Anal sling – Surgical placement of a perianal sling designed to enhance the anorectal angle may be a potential option for patients, but additional studies are needed [100].
●Vaginal insert – A vaginal insert with a pressure-regulated pump to temporarily occlude the rectum has been shown to reduce incontinence episodes by 50 percent in approximately 80 percent of women at one month [101]. However, studies are needed to evaluate its efficacy in the long-term.
WHEN TO REFER — Referral to a specialist should be considered in patients who fail to respond to initial management with supportive care and medical therapy. Such patients require additional evaluation to detect functional and structural abnormalities causing fecal incontinence and to guide subsequent management. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Additional studies' and 'Subsequent management' above.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Fecal incontinence".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Fecal incontinence (The Basics)")
●Beyond the Basics topics (see "Patient education: Fecal incontinence (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Fecal incontinence is defined as the involuntary loss of solid or liquid feces. Anal incontinence is defined as the involuntary loss of solid or liquid feces or flatus. Fecal urge incontinence is characterized by the desire to defecate, but incontinence occurs despite efforts to retain stool. Passive fecal incontinence is characterized by the lack of awareness of the need to defecate before the incontinent episode. (See 'Terminology and classification' above.)
●Initial management of fecal incontinence consists of supportive care and medical therapy. Supportive care includes avoiding foods or activities known to worsen symptoms and maintenance of perianal skin hygiene. We suggest a bulking agent and antidiarrheals in patients with fecal incontinence due to diarrhea (Grade 2C). (See 'Initial management' above.)
●Referral to a gastroenterologist should be considered in patients who fail to respond to initial management. Such patients should undergo additional evaluation (eg, anorectal manometry, endorectal ultrasound/magnetic resonance imaging) to detect functional and structural abnormalities causing fecal incontinence and to guide subsequent management. (See 'When to refer' above.)
●For patients who fail to respond to initial management, options include biofeedback, injectable anal bulking agent, sacral nerve stimulation, and anal sphincteroplasty. Biofeedback therapy for fecal incontinence should only be considered in patients with manometric evidence of weakness of the external anal sphincter or decreased ability to perceive rectal distension because of nerve injury. We reserve anal injections of dextranomer stabilized in hyaluronic acid for patients with passive fecal incontinence and anal sphincteroplasty for patients who have a recognized anatomic sphincter injury shortly after vaginal delivery. We reserve sacral nerve stimulation for patients who are either not candidates for injectable anal bulking agents or sphincteroplasty or in whom they have failed. (See 'Subsequent management' above.)
●Fecal diversion with a colostomy or ileostomy should be reserved for patients with intractable symptoms who have failed nonsurgical management and who have failed or are not candidates for minimally invasive surgical interventions. Dynamic graciloplasty and artificial anal sphincter devices are associated with significant morbidity and should therefore only be used to treat refractory fecal incontinence. (See 'Refractory symptoms' above.)
