From the Guidelines
The workup for fecal incontinence should begin with a thorough history and physical examination to identify potential causes and guide management, followed by a stepwise approach including conservative therapies, pelvic floor retraining with biofeedback therapy, and specialized testing such as anorectal manometry and endoanal ultrasound, as recommended by the most recent and highest quality study 1.
Initial Assessment
The initial assessment should include:
- A thorough history to identify potential causes and guide management
- A physical examination, including a digital rectal exam to evaluate sphincter tone, perineal sensation, and rectal masses
- Laboratory tests, such as complete blood count, comprehensive metabolic panel, thyroid function tests, and possibly serum glucose to rule out systemic causes
Specialized Testing
Specialized testing may include:
- Anorectal manometry to measure sphincter pressures and rectal sensation
- Endoanal ultrasound to evaluate sphincter integrity
- Defecography to assess pelvic floor function during defecation
- Possibly colonoscopy to exclude inflammatory or neoplastic conditions
- Neurophysiologic testing like pudendal nerve terminal motor latency may be considered for suspected neurogenic causes, as suggested by 1
Stepwise Approach
A stepwise approach should be followed, including:
- Conservative therapies, such as dietary modifications, pelvic floor physical therapy, and medications like loperamide or fiber supplements, which can benefit approximately 25% of patients, as stated in 1
- Pelvic floor retraining with biofeedback therapy for patients who do not respond to conservative measures
- Perianal bulking agents, such as intraanal injection of dextranomer, for patients who do not respond to biofeedback therapy
- Sacral nerve stimulation for patients with moderate or severe fecal incontinence who do not respond to conservative measures and biofeedback therapy, as recommended by 1
Treatment Options
Treatment options may include:
- Dietary modifications
- Pelvic floor physical therapy
- Medications like loperamide or fiber supplements
- Biofeedback therapy
- Surgical interventions, such as sphincteroplasty or sacral nerve stimulation, in severe cases, as suggested by 1 and 1
From the Research
Evaluation of Fecal Incontinence
The evaluation of fecal incontinence includes:
- A directed history and physical examination, with particular attention paid to integrity of the perineum and rectum, and a complete neurologic evaluation 2
- Diagnostic tools such as stool studies, anorectal manometry, defecography, electromyography, pudendal nerve conduction, and endoanal ultrasound may be employed in an outpatient setting 2
- A comprehensive history and physical examination including endoscopic assessment can identify the cause of most cases of fecal incontinence 3
- Physiologic tests, including anorectal manometry, cinedefecography and electromyography, may be required for proper diagnosis and treatment 4
- Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment 5
Diagnostic Considerations
Diagnostic considerations for fecal incontinence include:
- Conditions associated with fecal incontinence, such as diarrheal states, fecal impaction, idiopathic neurologic injury, surgical and obstetric injury, pelvic trauma, collagen vascular disease, and neurologic impairment related to stroke, diabetes, or multiple sclerosis 2
- Fecal impaction with overflow incontinence can be identified by patient history and physical examination 6
- Diarrhea is a common aggravating factor that is frequently modulated by dietary changes, antidiarrheal agents, and occasionally by bile salt binders 6
Treatment Options
Treatment options for fecal incontinence include:
- Conservative methods, such as dietary restriction, stool bulking agents, and biofeedback 2
- Surgery may be the best option for cases refractory to medical treatment, or for those patients with rectocele or obstetrical injury 2
- Biofeedback therapy is effective in most patients and has no side effects 3
- Structural damage to the anus may be repaired by surgery, like sphincter repair 3
- Pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and colonic diversion may be considered 5