Case Study: Fecal Incontinence

Fecal Incontinence: An Overview of etiologies, assessments, and management

Fecal incontinence (FI) is a medical condition that can be socially crippling and devastating. It is defined as the recurrent uncontrolled passage of stool for at least 1 month. (1) This condition will cause patients to literally stay locked in their homes and can be a major deciding factor for placing loved ones into a nursing home. (2) It true incidence of this condition varies greatly due to the negative stigmata and loss of autonomy associated it. The median prevalence of FI is 7.7% with a range of 2 – 21%. It affects both males and females equally and it increases with age. (3) Risk factors for developing FI include parous females, patients with cognitive or
Patient handouts filled out prior to obtaining a history are invaluable. They allow the patients to admit to and describe their symptoms without having to initiate the conversation. An obstetric and surgical history, as well as a bowel diary will help further assist you in determining the etiology as well as choosing the type of treatment necessary. It is also important to discuss with the patient if they are having any other pelvic floor complaints, as these tend to be associated with FI. There are multiple scoring systems available to objectively evaluate the severity of the patients symptoms. Wexner scale, Cleveland Clinic Incontinence Score, Fecal Incontinence Severity Index, and Fecal Incontinence Quality of Life Scale are just a few that are commonly used. Physical exam begins with inspection of the perianal skin and perineum. Scars from previous surgery or injuries and the length of the perineum should be noted. The ability of the anus to be approximated and not patulous is also evaluated at this time. Sensation to the perianal skin and perineum is then evaluated. The anorectal “wink” reflex is evaluated to determine to evaluate for neurologic dysfunction. A digit rectal exam will evaluate for any anorectal masses. Voluntary squeeze during exam will determine strength and straining will evaluate perineal
The degree of hemorrhoidal dysfunction, the quality and scarring of the distal rectum is evaluated at this time. Any masses or inflammation is also seen at this time. Endoanal ultrasound and MRI are both used to evaluate the anal canal and distal rectum. Disruption of the internal and external anal sphincter and muscles of the pelvic floor, fistulous pathology, masses are seen on both of these modalities. Endoanal US, which can be performed in the office, has a learning curve associated with its technique and there tends to be greater user variability as opposed to MRI. (18) Anorectal manometry is peformed in offices and pelvic floor centers and gives objective information on resting pressure, squeeze pressure, presence or absence of the rectoanal inhibitory reflex, rectal sensation and compliance. Pudendal nerve testing and EMGs are available, but are rarely used. They do have a role in when excessive scarring is seen on EUS, but pudendal injury does not preclude attempting to surgical treat a patient with FI(19), but it does put them at risk for failure of sphincteroplasty.