• Introduction
• Case presentation
• Consensus Conference
• References
• Photographs

Introduction

By fecal incontinence we mean the involuntary loss of stool or gas.
As we mentioned before the rectum acts as a reservoir and the sphincter muscle has the function of keeping the bottom part of the reservoir closed. 
The rectum is normally empty and does not hold more than 500 cc, which is one pint of fluid at the time. 

The sphincter muscle becomes tired very quickly. In the young person its contraction does not last for more than 60 seconds. With aging , because of loss of muscular mass, the sphincter muscle gets thinner and weaker and it is usually difficult to keep it contracted for more than 30 seconds. 

It is easy to understand how, during some episodes of diarrhea, when a large volume of liquid stools is suddenly pushed into the rectum, neither the reservoir or the muscle could be adequate in preventing an accident. These conditions are usually temporary and full control is regained after the gastroenteritis or the diarrhea subsides. 

On the other hand, the permanent inability to control the flow of stools or gas needs to be further investigated since it could be the result of damage to the sphincter muscle as it could occur after childbirth , radiation therapy, hemorrhoidectomy or fistula surgery. 
Occasionally incontinence could be the result of nerve damage or a systemic condition such as diabetes. 

Incontinence could also be caused by the presence of anal and rectal tumors that interfere with the ability of the rectum to act as a reservoir, or with the proper closure of the anal canal. 
Rectal prolapse is almost always associated with some degree of incontinence. If corrective surgery for rectal prolapse is performed in the early stages, there is usually a good chance to regain full continence.

Case presentation

J.S. is a 60 yr. old female with a 22 yr. history of fecal incontinence. The symptoms started after the vaginal delivery of her first child and worsened after the delivery of her second child one year later. Initially she had difficulty controlling flatus or liquid stools. As she aged, incontinence to solid stools became an increasingly common problem. She would not talk about it to her doctor, but mentioned it to her daughter, who eventually convinced her to consult a gastroenterologist. The work-up consisted of a lower endoscopy, anorectal manometric studies and endorectal ultrasonography. A complete tear of the external anal sphincter was detected. Biofeedback was attempted but failed to produce any improvement. The patient was referred for surgical repair of her anal sphincter muscle. The surgical procedure was successful.

Pre-operative Endorectal Ultrasound:  the defect in the anal sphincter muscle is visible as a darker area within a white dotted outline at 12 o' clock	Post-operative Endorectal Ultrasound:   the defect in the anal sphincter muscle  has been repaired by overlapping the sphincter muscle, the white area within  the black dotted outline, between  12 and 3 o' clock.

Bibliography

Recommended reading:   Keeping control. By Marvin Schuster M.D. John Hopkins Press.

1 Epidemiology of fecal incontinence: the silent affliction. Johanson JF , Lafferty J. Department of Medicine, University of Illinois College of Medicine at Rockford 61107-5078, USA. Am J Gastroenterol 1996 Jan;91(1):33-6 

OBJECTIVE: Fecal incontinence represents an embarrassing social problem, the magnitude of which remains largely unknown. The study prospectively examined the prevalence and demographic distributions of fecal incontinence. METHODS: demographic data, in addition to information regarding the reason for visit, bowel habits, and the frequency, type, and severity of fecal incontinence, were collected from individuals at the time of visits to their primary care physician or gastroenterologist. RESULTS: Eight hundred and eighty-one individuals 18 yr. or older were included in the analysis. The overall prevalence of fecal incontinence was 18.4%. When stratified by frequency, 2.7, 4.5, and 7.1% of participants admitted to incontinence daily, weekly, or once per month or less, respectively. Incontinence increased progressively with age and was 1.3 times more common in males than females. Only one-third of individuals with fecal incontinence had ever discussed the problem with a physician. CONCLUSIONS: The prevalence of fecal incontinence appears to be more common than previously appreciated. Moreover, only a minority discussed it with a physician. It would seem important to more actively pursue this "silent affliction" particularly in patients who do not readily volunteer this information. 

2 Investigation of fecal incontinence with endoanal ultrasound. Rieger NA , Sweeney JL , Hoffmann DC , Young JF , Hunter A. Colorectal Unit, Royal Adelaide Hospital, Australia. Dis Colon Rectum 1996 Aug;39(8):860-4 

This study was undertaken to audit the results of endoanal ultrasound in patients with fecal incontinence. METHODS: Endoanal ultrasound was used to investigate 53 patients with fecal incontinence. Data for endoanal ultrasound were collected prospectively. Results were compared with clinical and obstetric history and with manometric and operative findings. RESULTS: Sphincter abnormalities were identified in 42 of 53 patients. A total of 28 anterior defects were thought to be obstetric in origin. 14 other defects were secondary to anal pathology or surgery. Patients with anterior external sphincter defects either had complete defects or proximal defects: 38% gave a history of obstetric tear, episiotomy, or forceps delivery, and 62% declared having had an apparently normal delivery. Only 50% had a sphincter weakness that was evident on clinical examination. Of those studied with manometry, only 21% had low squeeze pressures consistent with an external sphincter defect. CONCLUSIONS: Sphincter defects seen on ultrasound may not have a history of obstetric trauma or abnormal clinical and manometric findings. Endoanal ultrasound is recommended in all patients with fecal incontinence to detect occult sphincter defects. 

3 Diagnostic and therapeutic procedures in fecal incontinence in general practice of the surgically educated proctologist. Bock JU , Jongen J. Praxis fur Enddarmkrankheiten Kiel. Zentralbl Chir 1996;121(8):659-64 

Age related, about 10% of the general population suffer from fecal incontinence. In a surgical, proctological office diagnosis is possible with carefully taken history, physical examination, proctosigmoidoscopy, and anoscopy. Together with special examinations (endoanal ultrasound, electromyography, pudendal nerve terminal motor latency [PNTML], anorectal manometry, defaecography, transit time of the colon) the plan for medical and surgical treatment can be made. The basic medical conservative therapy consists of regulating the form of stool (high fiber diet and/or loperamid), training of the sphincter and pelvic muscles electrical stimulation or biofeedback training. Surgery is needed for any form of reconstruction of the sphincter or the sensitive area of the anal canal, post- and preanal repair, anal and rectal prolapse, (dynamic) gracilis sphincteroplasty, or for a terminal stoma in those patients, whose uncontrolled incontinence cannot be managed otherwise. After surgery it is needed to continue the medical therapy (regulating the bowel movements, biofeedback training, electrical stimulation of the sphincter). 

4 Anal sphincter defects in fecal incontinence: correlation between endosonography and surgery. Meyenberger C , Bertschinger P , Zala GF , Buchmann P. Department of Internal Medicine, University Hospital of Zurich, Switzerland. Endoscopy 1996 Feb;28(2):217-24 

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound provides accurate information about the anatomy of the anal sphincter. The purposes of this study were to evaluate the use of flexible echo endoscopes to examine the anal sphincters, to validate the diagnosis of internal and external sphincter defects obtained using echo endoscopes by comparison with surgical findings, and to assess the outcome after surgical sphincter repair. PATIENTS AND METHODS: 28 patients with fecal incontinence of traumatic origin in all but one were prospectively investigated by endosonography. The location and extent of the defects of the internal or external sphincters, or both, were compared with the surgical findings in all patients. The surgical outcome was defined as excellent, improved, or unchanged. RESULTS: At surgery, 25 of the 28 patients had an isolated internal sphincter defect (n = 15) or combined sphincter defect (n= 10). Endoscopic ultrasound identified all of the external anal sphincter defects (n = 10), and correctly excluded a defect in 15 of 18 patients (sensitivity, specificity, and accuracy 100%, 83% and 89%, respectively). All of the internal sphincter defects (n= 25) were detected by endosonography. In 3 patients, a postulated intact internal sphincter was confirmed by surgery (accuracy 100%). In two patients, the extent of the sphincter defect was underestimated. 19 of 25 patients who underwent surgery (76%) with proved sphincter defects experienced improvement, the figure reaching 87% (13 of 15) in patients who received isolated internal sphincter defect repair. CONCLUSIONS: Anal endosonography, even using flexible echo endoscopes, is an accurate method for identifying anal sphincter defects, and is the method of choice for preoperative sphincter mapping with special regard to internal sphincter repair, which can be carried out with excellent results

Consensus Conference Report

Treatment Options for Fecal Incontinence

On April 20 - 21, 1999, IFFGD sponsored a landmark meeting, the first Consensus Conference on Treatment Options for Fecal Incontinence. The meeting brought together 150 international experts in the field of incontinence to draft a Consensus Statement that identifies effective and appropriate treatment options. The full report was published in Diseases of the Colon & Rectum, Volume 44, Number 1, January, 2001

Abstract

Treatment Options for Fecal Incontinence
William E. Whitehead, Ph.D.,* Arnold Wald, M.D.,† Nancy J. Norton, B.S.,‡

From the *UNC Center for Functional Gastrointestinal & Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, †University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, and ‡International Foundation for Functional Gastrointestinal Disorders, Milwaukee, Wisconsin

PURPOSE:
Fecal incontinence is a socially devastating disorder which affects at least 2.2 percent of community dwelling adults and 45 percent of nursing home residents. Most incontinent patients can be helped, but physicians are poorly informed about treatment options. The aim of this study was to develop a consensus on treatment options by convening a conference of surgeons, gastroenterologists, nurses, psychologists, and patient advocates.

METHOD:
A 1-1/2 day conference was held in April, 1999. Experts from different disciplines gave overviews, followed by extended discussions. Consensus statements were developed at the end of the conference. This summary statement was drafted, circulated to all participants, and revised based on their input.

CONCLUSION:
1) Diarrhea is the most common aggravating factor for fecal incontinence, and antidiarrheal medications such as loperamide and diphenoxylate or bile acid binders may help. Fecal impaction, a common cause of fecal incontinence in children and elderly patients, responds to combinations of laxatives, education, and habit training in approximately 60 percent. These causes of fecal incontinence can usually be identified by history and physical examination alone.

2) In patients who fail medical management or have evidence of sphincter weakness, anorectal manometry and endoanal ultrasound are recommended as helpful in differentiating simple morphologic defects from afferent and efferent nerve injuries and from combined structural and neurologic injuries.

3) Biofeedback is a harmless and inexpensive treatment which benefits approximately 75 percent of patients but cures only about 50 percent. It may be most appropriate when there is neurologic injury (i.e., partial denervation), but it has been reported to also benefit incontinent patients with minor structural defects.

4) External anal sphincter placation with or without pelvic floor repair is indicated when there is a known, repairable structural defect without significant neurologic injury. It is effective in approximately 68 percent.

5) Salvage operations are reserved for patients who can not benefit from biofeedback or levator-sphincteroplasty. These include electrically stimulated gracilis muscle transpositions and colostomy.

6) Antegrade enemas delivered through stomas in the cecum or descending colon reduce or eliminate soiling in approximately 78 percent of children with myelomeningocele; this operation may come to be more widely applied.

7) Investigational treatments include implanted nerve stimulators, artificial sphincters, and anal plugs.

8) Patient characteristics which influence choice of treatment include mental status, mobility impairment, and typical bowel habits.

9) Additional research is needed to better define the mechanisms responsible for fecal incontinence, to assess the efficacy of these treatments, to develop better treatments for nursing home residents, and to identify predictors of outcome.

Key words: Fecal incontinence; Encopresis; Biofeedback; Sphincteroplasty; Electrical stimulation; Gracilis muscle; Artificial sphincter; Diarrhea; Constipation; Antegrade colonic lavage; Epidemiology; Quality of life

Whitehead WE, Wald A, Norton NJ. Treatment options for fecal incontinence. Dis Colon Rectum 2001;44:131-144.