Faecal Incontinence

Essentials

• Faecal incontinence associated with acute gastroenteritis does not indicate proctological investigations unless it becomes prolonged or recurrent.
• Inquire actively about faecal incontinence in patients with anorectal problems, as incontinence is not often reported spontaneously.

Epidemiology

• The prevalence of faecal incontinence in the general population is generally reported to be approximately 2-3%. In a Finnish population survey, up to 5% of adult subjects suffered from symptoms of faecal incontinence occurring at least twice a month.
• The symptom is most common in the elderly but a considerable proportion of the patients are of working age.

Aetiology

• Acute infectious diarrhoea
• Adverse effects of medicines
• Faecal impaction (overflow incontinence)
• Over-consumption of laxatives (common in the elderly)
• Injuries of the anal sphincter
  • Operations: anal fistula, dilatation of the anus, haemorrhoid surgery
  • Delivery
  • Pelvic fractures and other direct injuries
• Rectal prolapse
• Rectal intussusception
• Anorectal tumours
• Functional problems of the pelvic floor muscles
• Congenital malformations
• Irritable bowel syndrome
• Neurological diseases: sequelae of cerebral infarction, multiple sclerosis, tetraplegia, intervertebral disk herniation, dementia
• Proctitis, colitis
• Idiopathic (neurogenic)

Examination of a patient with faecal incontinence

• Ask about the duration and frequency of the symptom, consistency of leaking faeces (hard? diarrhoea?), surgery on the lower abdomen, the anal canal and the back, and, particularly, neurological diseases and drugs used by the patient (over-consumption of laxatives).
• Proctological examination is the basis of diagnosis: inspection, digital rectal examination, proctoscopy and colonoscopy. These examinations are always indicated, with the exception of transient infectious diarrhoea.
• Urinary retention or urinary overflow incontinence developing together with faecal incontinence suggest spinal cord disease.
• Inspection
  • A widely open anus suggests injury of the anal sphincter or rectal prolapse/intussusception.
  • Ask the patient to strain down as if defecating and observe the motion of the perineum. If the perineum is lowered to the level of the ischial tuberosities, the patient has a pelvic floor prolapse which is suggestive of a neurogenic damage.
  • Identify eventual rectal prolapse, and vaginal or uterine prolapse in female patients.
• Digital rectal examination
  • Determine the tone of the anal sphincter, both at rest and during contraction.
  • Examine the relaxation of the muscles of the pelvic floor in association with straining.
• Proctoscopy and colonoscopy
  • Identify tumours and inflammation.
  • When the patient strains down during proctoscopy, possible rectal prolapse or intussusception can be detected.

Treatment Surgery for Faecal Incontinence in Adults, Surgery for Total Rectal Prolapse in Adults, Sacral Nerve Stimulation for Faecal Incontinence in Adults

Indications for specialist consultation

• Total incontinence or daily soiling of the underwear, unless the cause is definitely untreatable (severe dementia or neurological disease).

Treatment options in specialized care

• Faecal incontinence associated with rectal prolapse or intussusception is corrected by surgical suspension of the rectum in 75% of the patients.
• A severed sphincter muscle can be surgically repaired.
• The surgical treatment options include repair of a ruptured anal sphincter, plastic corrections of pelvic floor muscles and the perineum, and substitution of the anal sphincter. In some cases an antegrade continence enema (ACE) stoma is made. This allows to keep the bowel empty when sphincter function cannot be restored.
• Sacral neuromodulation has shown good results in faecal incontinence Biofeedback and/or Sphincter Exercises for the Treatment of Faecal Incontinence in Adults.