Fecal incontinence is a symptom of many disorders that can affect the nerves and muscles controlling defecation; it is not just due to exceptionally voluminous diarrhea. Underlying problems should be identified and treated, because that may improve incontinence. If treatment of the underlying problem does not correct incontinence, several approaches can be employed successfully. General approaches include stimulation of defecation at intervals to empty the rectum under supervised conditions; treatment of diarrhea, if present; addressing coexisting psychologic problems, such as depression; use of continence aids, such as adult diapers; and perineal skin care to prevent skin breakdown. Drug therapy includes use of constipating drugs, such as loperamide or diphenoxylate, that can impede the gastrocolic reflex, thereby limiting rectal filling and the likelihood of incontinence. Biofeedback training is useful in patients with some ability to sense rectal distention and to contract the external anal sphincter; instrumental learning using manometric or electromyographic biofeedback can be used to reinforce the rectoanal contractile response to rectal distention. Improvement in continence has been noted in up to 70% of suitable candidates with a single biofeedback training session. Patients with external anal sphincter disruption due to childbirth injury or other trauma may benefit from direct external anal sphincter repair (sphincteroplasty). In others, tightening up the anal canal by encirclement with nonabsorbable mesh (Thiersch procedure), perianal injection of fat, collagen, or synthetic gel, or radiofrequency electrical energy (Stretta procedure) may provide some palliation. Creation of a new sphincter mechanism by muscle transposition and encirclement of the anal canal is another approach that has been improved by use of electrical stimulators to keep the neosphincter contracted. Artificial anal sphincters patterned after artificial urinary sphincters have met with some success, but local infection remains problematic. When all else fails, fecal diversion (ileostomy, colostomy) can be effective in rehabilitating patients.

Introduction
Fecal incontinence, the involuntary passage of feces through the anus, is a common problem, affecting up to 7% of the general population ^[1*]. Fecal soiling is equally prevalent in men and women, but women are twice as likely to have gross incontinence as men. Incontinence is a special problem in the elderly and accounts for the decision to institutionalize many nursing home residents. The monetary and psychologic costs of fecal incontinence are substantial ^[2]. Despite this, fecal incontinence is not always reported by patients to their physicians and so every patient complaining of diarrhea or urgency should be asked directly about incontinence.

Incontinence is a symptom and not a disease; it is due to some disruption of the continence mechanisms and is not just a manifestation of a psychologic problem. The differential diagnosis of fecal incontinence includes anatomic derangements, neurologic diseases that affect the central nervous system and peripheral nerves, and both skeletal and smooth muscle diseases (Table 1).

The initial evaluation of fecal incontinence should be directed toward discovering the underlying cause of incontinence ^[1*]. The medical history, physical examination, and simple objective tests, such as anorectal manometry and anal endosonography, can define the likely etiology and can identify anatomic and physiologic assets and defects, knowledge of which is essential to plan appropriate therapy ^[3]. In addition, if loose stools are being produced, the cause for diarrhea should be investigated and treated, because it is likely to be due to a different process than that causing incontinence.

Treatment should be focused on the underlying problem, if it can be identified ^[4**]. For example, the neuropathy associated with poorly controlled diabetes mellitus is an important cause for incontinence. More successful control of hyperglycemia may result in improvement of continence in some patients. Adequate management of diarrhea may also improve fecal incontinence, because the continence mechanisms are under more stress when trying to control the passage of liquid stools than with formed stools.

Several general measures should be considered in all patients with fecal incontinence (Table 2). Every sentient patient with fecal incontinence considers himself or herself cursed with some rare disorder, because discussion of incontinence is still considered taboo. This leads to depression, which is compounded by the thought that nothing can be done for this symptom. Every patient with incontinence should be assured that something can be done to help him or her and that the physician will do everything possible to reach that goal. Use of continence aids, such as pads or diapers, can give the patient the confidence to venture out into public, and can go a long way toward relieving the social isolation that incontinent patients impose on themselves ^[5]. Finally, all patients with fecal incontinence should have thoughtful skin care: prompt cleansing after soiling, use of protective barrier creams, and avoidance of abrasion and residual soap films, which can minimize skin breakdown and secondary infection ^[6].

Unplanned episodes of incontinence can often be avoided by stimulating defecation at intervals in order to keep the rectum empty most of the time ^[7]. This is most frequently done for demented patients in nursing homes, but can be used in other settings as well. For this purpose, it is best to use glycerin or bisacodyl suppositories or small-volume enemas that will induce evacuation within a short period of time. Once defecation occurs, the patient can be bathed with the reasonable expectation that they will not have further bowel movements that day. Occasionally, an antidiarrheal drug like loperamide or diphenoxylate can be added at that point to reduce the chances of having a spontaneous bowel movement. Laxatives that are orally ingested have more unpredictable times of onset of action and may have a sustained effect, and, therefore, are less suitable for this purpose. Studies have shown that institution of a bowel program like this can reduce episodes of incontinence and improve the quality of life for nursing home residents with incontinence ^[8].

Use of antidiarrheal drugs also can improve continence in noninstitutionalized patients. A daily dose of loperamide or diphenoxylate given after a spontaneous evacuation will prevent activation of the gastrocolic reflex and defecation later in the day. Additional doses can be taken later in the day, if necessary. This is most effective in patients with incontinence for formed stool; higher-dose antidiarrheal therapy is needed in patients with chronic diarrhea. Although antidiarrheal drug therapy may not eliminate all episodes of incontinence, it usually provides enough relief to allow resumption of activities outside of the home. The downside risk of this approach is the development of constipation; a bowel movement should be stimulated with suppositories or with an enema if a bowel movement has not occurred for 3 days.

Another approach to the management of fecal incontinence is biofeedback training ^[9]. In this technique, patients are taught to contract the external anal sphincter in response to rectal distention in order to reinforce the rectoanal contractile response. The biofeedback element is provided by reporting back to the patient either manometric or electromyographic evidence of the strength of external anal sphincter contraction in response to rectal distention, usually with a balloon device. This is repeated over and over, usually with an attempt to reduce the volume of rectal distention over time. A single treatment is usually all that is necessary. For biofeedback training to be effective, the patient must be sentient, able to sense at least some rectal distention, and able to contract the external anal sphincter to some extent. No controlled studies are available, but unblinded reports suggest that up to 75% of patients capable of biofeedback training have a good response (reduction or elimination of incontinence) ^{[10, 11]}.

Surgery is the best option for patients with mechanical disruption of the external anal sphincter due to trauma, such as a vaginal tear during delivery ^[12]. Under those circumstances, sphincteroplasty with restitution of an intact sphincter is very successful ^[13]. If nerve injury has accompanied the trauma, results may be less satisfactory. In general, other operations, such as total pelvic floor repair and transposition of the gracilis muscle from the thigh, are more complicated and have a lower success rate ^{[14, 15]}. Recently, implantation of sacral nerve stimulators or electrical stimulation of the transposed gracilis muscle (stimulated graciloplasty) have been reported to provide satisfactory results in some patients ^{[16, 17, 18, 19, 20]}. Similarly, an artificial anal sphincter analogous to similar devices used to control urinary incontinence has been tried in some centers with mixed results ^{[21, 22, 23]}. Infection remains a hazard when implanting such devices in the perianal tissue.

Surgical techniques with more of a palliative intent include anal encirclement with mesh (Thiersch procedure); perianal injection of fat, collagen, or inert polymer; creation of a fistula from the skin to the right colon to allow antegrade enemas to clear the colon at intervals; and fecal diversion by colostomy or ileostomy ^{[24, 25]}. There are few studies to substantiate the effectiveness of these techniques, but they can produce adequate rehabilitation of an otherwise nonfunctional patient.

Treatment

Diet and lifestyle

1. Loose stools generally are more difficult to hold than formed stools. Therefore, foods that tend to exacerbate diarrhea (such as lactose in a lactase-insufficient person) should be excluded from the diet.
2. In demented or bedbound patients, an expectant, stimulated defecation program should be used to minimize unscheduled bowel movements, thereby reducing the opportunity for accidents to occur. Scheduled use of enemas or suppositories to clear feces from the left colon at a time when an attendant can properly toilet the patient has been shown to reduce episodes of incontinence and improve quality of life ^[8].
3. Use of continence aids, such as adult diapers, can give the patient enough confidence to resume activities outside the house ^[5].
4. Prompt cleansing of the soiled perineum with warm water after an episode of incontinence and use of a barrier cream will limit skin breakdown ^{[6, 26]}.

Pharmacologic treatment

1. Constipating drugs, such as diphenoxylate and loperamide, can inhibit the gastrocolic reflex and reduce episodes of incontinence.
2. In individuals without diarrhea, constipation can develop with these medications. This can be minimized by waiting to take the medication until after a spontaneous bowel movement (eg, after breakfast) and using the lowest effective dose.
3. In patients with diarrhea, more potent nonspecific antidiarrheals, such as codeine, morphine, and deodorized tincture of opium, may need to be employed if an underlying treatable cause for diarrhea cannot be identified ^[27].

Diphenoxylate with atropine

Standard dosage
One to two tablets (each containing 2.5 mg of diphenoxylate and 0.025 mg of atropine to discourage abuse) up to four times a day (before meals and at bedtime).

Contraindications
Ileus, bowel obstruction, urinary retention.

Main drug interactions
May potentiate sedative effects of other drugs.

Main side effects
Constipation, dry mouth.

Special points
Controlled substance.

Cost effectiveness
Cheap drug, but not uniformly effective. Low toxicity when used for this purpose makes empiric trial worthwhile.

Codeine
Standard dosage
30 to 120 mg up to four times a day (before meals and at bedtime).

Contraindications
Ileus, bowel obstruction, urinary retention.

Main drug interactions
May potentiate sedative effects of other drugs.

Main side effects
Constipation.

Special points
Controlled substance, subject to abuse.

Cost effectiveness
More potent antidiarrheal than diphenoxylate with atropine or loperamide; inexpensive. Best reserved for patients with more substantial diarrhea.

Deodorized tincture of opium
Standard dosage
Two to 20 drops (0.1 to 1 mL of standardized solution of 10 mg of morphine per milliliter) up to four times a day (before meals and at bedtime). Dosed as liquid for maximum dosing flexibility.

Contraindications
Ileus, bowel obstruction, urinary retention.

Main drug interactions
May potentiate sedative effects of other drugs.

Main side effects
Constipation.

Special points
Controlled substance, subject to abuse.

Cost effectiveness
Potent antidiarrheal. Best reserved for patients with severe diarrhea.

Morphine
Standard dosage
2 to 20 mg up to four times a day (before meals and at bedtime). Can be dosed as liquid (20 mg/mL) for maximum dosing flexibility.

Contraindications
Ileus, bowel obstruction, urinary retention.

Main drug interactions
May potentiate sedative effects of other drugs.

Main side effects
Constipation.

Special points
Controlled substance, subject to abuse.

Cost effectiveness
Most potent antidiarrheal. Best reserved for patients with severe diarrhea.

Surgery

1. When anatomic defects in the anal sphincter are responsible for incontinence (eg, tear due to a traumatic vaginal delivery), surgical repair of the damage results in a good functional result in greater than 70% of patients ^{[12, 13]}.
2. If nerve damage is present, results of surgery are less satisfactory. Attempts to tighten up the pelvic floor muscles in neuropathic incontinence succeed in only 50% of patients and may not be lasting ^[28].
3. Transposition of the gracilis muscle from the thigh to the perineum to create a neosphincter infrequently restores perfect continence, but may decrease incontinence. Use of an implanted stimulator to keep the neosphincter contracted can improve outcome ^{[19, 20]}.
4. Artificial anal sphincters modeled after artificial urinary sphincters can be implanted, but local infection remains problematic ^{[21, 22, 23]}.
5. Anal encirclement with nonabsorbable mesh, injection of fat or collagen around the anus, and delivery of radiofrequency electricity to the anal canal all can produce anal stenosis and reduce incontinence ^[24].
6. Palliative procedures include fecal diversion by ileostomy or colostomy, and creation of a cecocutaneous fistula to allow antegrade enemas to clear the colon ^[25].

Sphincteroplasty
Standard procedure
The external anal sphincter is exposed by incision into the perineum and the area of scarring is divided. The divided sphincter is then reapproximated in an overlapping fashion to produce a complete ring of viable muscle. The subcutaneous tissues and skin are then closed.

Contraindications
Dementia, severe neurogenic external anal sphincter weakness, external anal sphincter atrophy, gross perineal descent.

Complications
Local infection, anal stenosis.

Special points
Patients with suboptimal results may benefit from drug therapy or biofeedback training.

Cost effectiveness
In women with obstetric damage due to a deep tear, sphincteroplasty is the most effective therapy available (70% to 75% initial success rate). The operation usually involves hospitalization for a few days for pain control. Long-term results may not be as satisfactory as the initial success rate ^[29].

Total pelvic floor repair
Standard procedure
Following exposure of the pelvic floor muscles with perineal incisions, the puborectalis, ischiococcygeus, and iliococcygeus muscles are sutured together posteriorly to the anus and the levator muscles and external sphincter muscles are plicated anteriorly, thereby “tightening up” the pelvic floor.

Contraindications
Dementia, inability to tolerate general anesthesia.

Complications
Local infection, anal stenosis.

Special points
Best reserved for patients with neurogenic incontinence who have not lost too much muscle bulk.

Cost effectiveness
Less effective than anal sphincteroplasty (about 50% “improved,” but only 14% totally continent) ^[28]. The operation usually involves hospitalization for a few days for pain control. Progressive neuropathic weakness may cause failure with time.

Gracilis muscle transposition
Standard procedure
The gracilis muscle, which runs from the pelvis to the knee through the thigh, is divided from its insertion at the knee and is reflected back to the perineum. This free end is then wrapped around the anal canal to produce an intact ring of viable, innervated muscle. The native innervation is preserved and, in the original procedure, the patient is taught to contract the gracilis muscle to delay defecation. In modern versions of this surgery, an electrical stimulator that is controlled with a magnet is implanted and the muscle is stimulated to contract tonically to prevent defecation. The stimulator can be turned off to permit defecation when appropriate.

Contraindications
Dementia, neuropathy affecting the gracilis muscle, inability to tolerate loss of gracilis muscle function.

Complications
Local infection, hematoma, anal stenosis. Re-operation for complications needed in about 40% of patients.

Special points
Patients need to be selected carefully and procedure should only be done by surgeons skilled in its use.

Cost effectiveness
Surgical procedure is more intensive and costly than those described previously. The electrical stimulator costs about $15,000. Success rate of 70% in highly selected patients drives the use of this procedure in younger patients with otherwise untreatable incontinence ^{[19, 20]}.

Anal encirclement procedures
Standard procedure
Nonabsorbable suture or mesh material is tunneled around the anal canal and secured, producing a narrowing of the anal canal.

Contraindications
Severe dermatitis that might increase the risk of infection.

Complications
Local infection, anal stenosis.

Special points
The balance between increased resistance and frank obstruction is difficult to achieve and results are often unsatisfactory.

Cost effectiveness
The surgical procedure is simple and inexpensive, but complications and limited success reduce cost effectiveness substantially ^[30].

Perianal injection techniques
Standard procedure
Autologous fat harvested from elsewhere in the body, gluaraldehyde-treated cross-linked collagen, or synthetic gel is injected around the anal canal to produce a narrowing of the anal canal.

Contraindications
None.

Complications
Local infection, anal stenosis.

Special points
As with encirclement techniques, the balance between increased resistance and frank obstruction is difficult to achieve and results may be unsatisfactory. The procedure may be most effective in individuals with isolated internal anal sphincter dysfunction and intact external anal sphincter function.

Cost effectiveness
The procedure is simple and inexpensive. Limited experience makes it difficult to assess cost effectiveness at this point in time ^{[31, 32]}.

Antegrade continence enema
Standard procedure
A fistula is created between the cecum and the anterior abdominal wall by using the appendix or creating a cecostomy. This can be used to introduce a catheter to perfuse the colon at intervals, thereby reducing the opportunity for spontaneous episodes of incontinence.

Contraindications
None.

Complications
Wound infection.

Special points
Suitable for patients with impaired faculties to facilitate a scheduled defecation program.

Cost effectiveness
Allows for easier management of institutionalized patients and may reduce nursing time commitment to their care ^{[24, 25]}.

Fecal diversion (ileostomy, colostomy)
Standard procedure
The bowel is divided at the sigmoid colon and the proximal end is brought through a stab wound in the left lower quadrant to create a colostomy. The distal end is closed, creating a Hartman pouch. If an ileostomy is preferred, a double-barreled ileostomy is created in the terminal ileum by standard techniques. Proper pouching techniques are essential for the success of either procedure, and an enterostomal therapy nurse should be involved with patient management early on in the process.

Contraindications
Inability to tolerate general anesthesia, inability to care for stoma.

Complications
Wound infection.

Special points
Patients must be psychologically prepared to accept a stoma. Thorough familiarization with the procedure and the care of a stoma is essential.

Cost effectiveness
Although the surgery is expensive, the rehabilitation that can be achieved may well be worth the expense in selected patients.

Other treatments

Biofeedback training

Standard procedure
Biofeedback training utilizes a technique of instrumental learning borrowed from psychologists and is a form of operant conditioning. In this technique, patients are taught to reinforce the rectoanal contractile response in which rectal distention is coupled with external anal sphincter contraction. The patient is instrumented with a balloon-tipped catheter for rectal distention and is informed of the extent of external anal sphincter contraction in response to distention by manometric or electromyographic biofeedback. The technician works with the patient to maximize the external anal sphincter response to repeated rectal distensions. Typically, this can occur within a single, hour-long training session. The distending volume can be reduced gradually to minimize the threshold distention required to initiate the rectoanal contractile response ^[9].

Contraindications
Inability to cooperate with the training sessions, inability to sense some level of rectal distention, inability to contract the external anal sphincter.

Complications
None.

Special points
Anorectal manometry should be done before scheduling biofeedback training to be certain that the patient can sense some degree of rectal distention and can contract the external anal sphincter.

Cost effectiveness
Biofeedback training is cheap and effective, producing substantial improvement in about 70% of individuals who are candidates for it. It is easily the most cost-effective treatment available for fecal incontinence, as a single session is all that is needed in most patients ^{[10, 11]}.

Emerging therapies

Sacral nerve stimulation
Sacral nerve stimulation has been used by some centers as a treatment for fecal incontinence ^{[17, 18]}. Electrodes are placed on sacral nerve roots and electricity is applied to stimulate the nerves. Temporary (transcutaneous) stimulation is used initially; patients who respond can have a subcutaneous pulse generator placed subsequently. Most patients respond to therapy with a reduction in episodes of incontinence from a median of four episodes per week to a median of zero episodes per week. Anal canal pressures increase and rectal sensation becomes more acute, no complications are noted, and response is maintained for at least 2 years on average.

Anal plug
The device consists of a catheter with a 20-mL cuff, flatus vent holes, and a sensor that signals the entry of stool into the rectum and alerts the patient through a beeper that a bowel movement is imminent ^[33]. The cuff is deflated and the catheter is removed to permit voluntary defecation. Use of the device was associated with a reduction in incontinent episodes in a small study ^[33].

References and Recommended Reading

_{Schiller LR: Fecal incontinence. In Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. Edited by Feldman M, Friedman L, Sleisenger MH. Philadelphia: WB Saunders; 2002: 164-180.
Standard textbook chapter detailing pathophysiology, diagnosis, and treatment of fecal incontinence.}

Mellgren A, et al.: Long-term cost of fecal incontinence secondary to obstetric injuries. Dis Colon Rectum 1999, 42:857-865.

Rao SS: How useful are manometric tests of anorectal function in the management of defecation disorders? Am J Gastroenterol 1997, 92:469-475.

Whitehead WE: Treatment options for fecal incontinence. Dis Colon Rectum 2001, 44:131-142.

Shirran E: Absorbent products for the containment of urinary and/or faecal incontinence in adults. Cochrane Database Syst Rev 2000, 2:CD001406.

Lewis-Byers K: An evaluation of two incontinence skin care protocols in a long-term care setting. Ostomy Wound Manage 2002, 48:44-51.

Chassagne P, et al.: Does treatment of constipation improve faecal continence in institutionalized elderly patients? Age Ageing 2000, 29:159-164.

Schnelle JF, et al.: Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents. J Am Geriatr Soc 2002, 50:1595-1596.

Rao SS: The technical aspects of biofeedback therapy for defecation disorders. Gastroenterologist 1998, 6:96-103.

Norton C: Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2000, 2:CD00211.

Pager CK: Long-term outcomes of pelvic floor exercise and biofeedback treatment for patients with fecal incontinence. Dis Colon Rectum 2002, 45:997-1003.

Rieger N: Surgical intervention for faecal incontinence in women: an update. Curr Opin Obstet Gynecol 2002, 14:545-548.

Young CJ: Successful overlapping anal sphincter repair: Relationship to patient age, neuropathy, and colostomy formation. Dis Colon Rectum 1998, 41:344-349.

Van Tets WF: Pelvic floor procedures produce no consistent changes in anatomy or physiology. Dis Colon Rectum 1998, 41:365-369.

Faucheron JL: Is fecal continence improved by nonstimulated gracilis muscle transposition? Dis Colon Rectum 1994, 37:979-983.

Baeten CG: Second-line treatment for faecal incontinence. Scand J Gastroenterol 2002, 236(suppl):72-75.

Kenefick NJ, et al.: Sacral nerve stimulation for faecal incontinence due to systemic sclerosis. Gut 2002, 51:881-883.
Kenefick NJ, et al.: Medium-term results of permanent sacral nerve stimulation for faecal incontinence. Br J Surg 2002, 89:896-901.
Wexner SD, et al.: Long-term efficacy of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 2002, 45:809-818.
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Shaul DB: Avoidance of leakage and strictures when creating an invisible conduit for antegrade colonic enemas. J Pediatr Surg 2002, 37:1768-1771.
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Schiller LR: Antidiarrheal pharmacology and therapeutics. Aliment Pharmacol Ther 1995, 9:87-106.
Korsgen S: Long-term results of total pelvic floor repair for postobstetric fecal incontinence. Dis Colon Rectum 1997, 40:835-839.

Halverson AL: Long-term outcome of overlapping anal sphincter repair. Dis Colon Rectum 2000, 43:813-820.
Sainio AP: Anal encirclement with polypropylene mesh for rectal prolapse and incontinence. Dis Colon Rectum 1991, 34:905-908.
Shafik A: Perianal injection of autologous fat for treatment of sphincteric incontinence. Dis Colon Rectum 1995, 38:583-587.
Kumar D: Gluteraldehyde cross-linked collagen in the treatment of faecal incontinence. Br J Surg 1998, 85:978-979.

Giamundo P, et al.: The procon incontinence device: a new nonsurgical approach to preventing episodes of fecal incontinence. Am J Gastroenterol 2002, 97:2328-2332.

Lawrence R. Schiller, MD
Current Treatment Options in Gastroenterology 2003, 6:319-327
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