In this article, the author discusses risk factors for and symptoms of fecal incontinence, initial assessment, conservative treatments, and indications for referral. Ultimately, the goal of this article is to help providers better assess and manage fecal incontinence and improve quality of life for women.

Key words: fecal incontinence, anorectal examination, anal sphincter, pelvic floor

Fecal incontinence (FI), defined as the involuntary leakage of gas, fluid, or solid stool occurring for at least a month’s duration, affects nearly 13 million women in the United States.^1–3 FI itself is not defined as a disease but rather as a symptom of an underlying disorder.² Potential causes include neurologic diseases (focal brain defects secondary to stroke, tumor, trauma, multiple sclerosis), anal sphincter injury/trauma, inflammatory bowel disease, fecal impaction, rectal neoplasms, decreased pelvic floor muscle strength, and pelvic organ or rectal prolapse, although sometimes the cause may remain unknown.^4,5 Although FI affects a significant number of women, this topic is generally not discussed openly in society.² Many women manage their symptoms privately rather than discussing them with a healthcare provider (HCP) because of embarrassment and shame.^3,5

FI may have social, emotional, psychological, and physical impacts with a significant effect on quality of life. It is associated with social isolation and depression.^1,6 Work and daily life may need to be arranged around access to a bathroom. FI prevalence increases with age and is a contributing factor to admission to long-term healthcare facilities for older individuals.⁶ 

Underreporting of symptoms results in unnecessary suffering by women experiencing FI.⁶ Treatments are available that may effectively resolve symptoms or at least decrease frequency and amount of leakage to positively impact quality of life.^5,6 HCPs in primary care settings should be aware of risk factors for FI, ask women about symptoms, provide an initial evaluation, initiate conservative treatments, and make referrals as appropriate. Risk factors for fecal incontinence are listed in Box 1. ^2,3,5,7

Assessment

Health history

A comprehensive health history is critical in confirming the diagnosis of FI, identifying potential causes, and determining the impact on quality of life.^1–3 A detailed history of FI includes baseline bowel pattern, onset of symptoms, frequency, urgency, amount and consistency of leakage, any noted blood in stool, aggravating factors, and triggers.³ Past treatments as well as current day-to-day management of the condition should be reviewed.^2,3 The health history should also include medical conditions, surgeries, obstetric injuries, other pelvic floor/anorectal trauma or injury, physical mobility limitations, current medications, and any associated symptoms (eg, gastrointestinal, urinary, gynecologic, sexual, neurologic).^2,3,5 An assessment of the effect of FI on the patient’s quality of life includes asking about changes in daily activities made in response to symptoms as well as screening for depression and anxiety.^2–7

Physical examination

Physical examination for a patient experiencing FI includes a pelvic examination with assessment for pelvic organ prolapse and pelvic muscle strength. The anorectal examination includes inspection of the perianal skin for irritation or fecal matter and the rectal opening for any gaping, prolapse, or external fistula. Perianal sensation should be assessed by lightly stroking the skin immediately surrounding the anus, which should elicit a reflexive contraction.⁵ A digital rectal examination is included to assess anal sphincter tone (resting pressure versus squeezing pressure) and to rule out any palpable rectal masses or stool impaction.^2,3

Laboratory and diagnostic tests

Blood and stool testing may be relevant to rule out any suspected infection.^2,3 Anal manometry can be utilized to accurately assess sphincter muscle resting tone, squeeze pressures, and rectal sensation.² An internal sphincter defect can be detected when low resting pressures are noted, while an external sphincter defect is diagnosed with low squeeze pressures.² Referral for further diagnostic testing is indicated if an anatomic dysfunction and/or a defect is noted or if findings are inconclusive. Tests may include anorectal ultrasound, pelvic magnetic resonance imaging, and colonoscopy. Red flags indicating a need for an evaluation for colorectal cancer are listed in Box 2.⁵

Management

Generally, conservative therapeutic options are appropriate as first-line treatment of FI.^2,3,7 Nonsurgical options have demonstrated at least short-term efficacy with minimal risk and few if any adverse effects.⁵ Many of these interventions can provide improvement in incontinence and give patients a sense of control. A combination of nonsurgical therapies is often most effective.^1–4 Surgical options may be considered following failure of nonsurgical therapies or when the patient has an anatomic defect such as a fistula or rectal prolapse.^4,5

The use of a food/symptom diary can help the patient identify what foods to avoid that may trigger loose stools or urgency. Common trigger foods include dairy products, spicy foods, caffeine, alcohol, and greasy or fatty foods.⁸

Dietary and supplementary fiber can help to normalize stool consistency.⁹ A randomized controlled trial showed that adding 16 g of fiber daily resulted in a significant decrease in the episodes of fecal incontinence by 51% in an exposure group compared to 11% in a placebo group.¹⁰ To avoid unpleasant gastrointestinal effects (ie, bloating, flatus, cramping), it is recommended to increase fiber slowly by about 5 g every 1 to 2 weeks.⁵ See Box 3 for dietary fiber guidelines.¹¹

Bowel habit training techniques can help develop consistent regularity, while setting a schedule to have a bowel movement. Setting regular times to have a bowel movement can improve rectal emptying and thus decrease episodes of fecal incontinence.¹²  

When FI is associated with diarrhea or loose stools, medications that slow intestinal motility may be helpful. Antidiarrheal medications such as loperamide and diphenoxylate with atropine may also increase internal anal sphincter tone.^4,5 Loperamide can be titrated up to 4 mg twice or 3 times daily with a maximum dosage of 16 mg/day. Antidiarrheal medications can lead to constipation and therefore education should be provided to patient to notify provider if they experience straining with bowel movement or hard stools. The patient can titrate their dose to prevent FI while not causing constipation.⁵ Patients with overflow FI associated with constipation or fecal impaction may benefit from the use of osmotic laxatives.⁵

Anal plug and vaginal bowel control devices are also available. Although anal plug devices are reported to cause adverse effects such as rectal urgency, irritation, pain, and soreness, they can be effective for individuals who are able to tolerate their use.^5,14 The vaginal bowel device is placed in the vagina and a balloon is inflated to occlude the rectum. The balloon must be deflated for voluntary bowel movements.¹⁵ This treatment has been successful in patients who do not have primarily watery fecal incontinence. Reported adverse effects include cramping, urinary symptoms, pelvic pain, and vaginal spotting.¹⁵

Pelvic floor physical therapy can help strengthen and better coordinate the anal sphincter and pelvic floor muscles. The evidence that this therapy is any more effective than other conservative treatments is insufficient, but studies have demonstrated an improvement in symptoms without adverse effects.⁵ The addition of biofeedback may improve the ability to isolate and contract the external sphincter muscle.^5,13

Fecal incontinence often leads to perianal skin breakdown, resulting in rash and irritation. Perianal skin care with gentle soaps and wipes and zinc oxide-based protective ointments can decrease irritation from fecal material. Disposable absorbent pads and pull-ups may be helpful.⁴

Sphincter bulking agents may be effective in decreasing mild FI for up to 6 months after injection. Biocompatible tissue-bulking agents are injected into the anal canal walls.¹⁶ Data regarding the long-term effects of sphincter bulking agents are lacking.

Finally, surgical treatment is indicated for repair of anatomic defects such as fistulas, rectal prolapse, and anal sphincter disruption.^2–5 Surgical treatment may also be considered for patients who have failed nonsurgical treatment options. These patients should be referred to a urogynecologist or another surgeon specializing in colorectal disease.⁵

Conclusion

Healthcare providers in primary care settings have an opportunity to improve quality of life for women with FI through screening, assessment, initiation of conservative interventions, and referrals when appropriate. Women may not bring up their symptoms because of shame and embarrassment. When the HCP asks about continence status routinely, especially for women with risk factors, patients benefit. Conservative treatments can help women with FI feel in control of their symptoms and allow them to continue normal activities that can reduce the risks for social isolation and depression. Improving both assessment and management of FI can ultimately improve overall quality of life for women experiencing these symptoms.

Summer A. Hinthorne is Clinical Instructor at the University of Illinois in Chicago, Peoria Regional Campus. She teaches graduate course work for DNP students. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Kargin S, Cifci S, Kaynak A, et al. The relationship between fecal incontinence and vaginal delivery in the postmenopausal stage. Turk J Obstet Gynecol. 2017;14(1):37-44.
2. Mayer AP, Files JA, Foxx-Orenstein AE. If you don’t ask her, she won’t tell you: fecal incontinence in women. J Womens Health (Larchmt). 2013;22(1):104-105.
3. Saldana Ruiz N, Kaiser AM. Fecal incontinence – challenges and solutions. World J Gastroenterol. 2017;23(1):11-24.
4. Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2015;58(7):623-636.
5. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 210. Fecal incontinence. Obstet Gynecol. 2019;133(4):e260-e273.
6. Schüssler-Fiorenza Rose SM, Gangnon RE, Chewning B, Wald A. Increasing discussion rates of incontinence in primary care; a randomized controlled trial. J Womens Health (Larchmt). 2015;24(11):940-949.
7. Condon M, Mannion E, Molloy DW, O’Caoimh R. Urinary and faecal incontinence: point prevalence and predictors in a university hospital. Int J Environ Res Public Health. 2019;16(2).
8. National Institute for Health and Care Excellence. Faecal incontinence in adults: management. Clinical guideline. London, UK: NICE; 2007.
9. Eswaran S, Muir J, Chey WD. Fiber and functional gastrointestinal disorders. Am J Gastroenterol. 2013;108(5):718-727.
10. Bliss DZ, Savik K, Jung HJG, Whitebird R, et al. Dietary fiber supplementation for fecal incontinence: a randomized clinical trial. Res Nurs Health. 2014;37(5):367-378.
11. US Department of Agriculture, US Department of Health and Human Services. Appendix 7. Nutritional goals for age-sex groups based on dietary reference intakes and dietary guideline recommendations. In: Dietary Guidelines for Americans 2015-2020. 8th ed. Washington, DC: USDA, DHHS; 2015:97-98.
12. Bove A, Bellini M, Battaglia E, et al. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol. 2012;18(36):4994-5013.
13. Norton C, Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev. 2012;(7):CD002111.
14. Deutekom M, Dobben AC. Plugs for containing faecal incontinence. Cochrane Database Syst Rev. 2015;(7):CD005086.
15. Richter HE, Matthews CA, Muir T, et al. A vaginal bowel-control system for the treatment of fecal incontinence. Obstet Gynecol. 2015;125(3):540-547.
16. Forte ML, Andrade KE, Butler M, et al. Treatments for Fecal Incontinence. Comparative Effectiveness Review No. 165. AHRQ Publication No. 15(16)-EHC037-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2016.