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Fecal Incontinence. Seema Izfar. 2/29/12. Fecal Incontinence. affects estimated between 2-20% people, 50% nursing home residents at risk: parous females, cognitively impaired, elderly defined as “recurrent uncontrolled passage of fecal matter for at least one month”

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Fecal incontinence
Fecal Incontinence

  • Seema Izfar


Fecal incontinence1
Fecal Incontinence

  • affects estimated between 2-20% people, 50% nursing home residents

  • at risk: parous females, cognitively impaired, elderly

  • defined as “recurrent uncontrolled passage of fecal matter for at least one month”

  • “partial incontinence” - inability to control flatus or fecal soiling


  • continence: anal sphincters, pelvic floor, stool volume/consistency, rectal compliance, neurological function

  • pseudo-incontinence: hemorrhoidal prolapse, incomplete evacuation, poor hygiene, STDs, neoplasms, IBD

  • fecal urgency vs. incontinence

  • overflow incontinence

Obstetrical trauma
Obstetrical Trauma

  • anal sphincter injury

    • occult obstetrical injury in 25- 35% of vaginal deliveries (!!!!!!!!!!)

    • risk factors: forceps, episiotomy, primiparity

  • denervation of pelvic floor (compression/traction injury to pudendal)


  • iatrogenic injury following:

    • lateral internal sphincterotomy

    • fistulotomy (reported as high as 35-45%)

    • hemorrhoidectomy

    • radiation therapy

Congenital malformations
Congenital malformations

  • spina bifida

  • imperforate anus

  • myelomeningocele

  • related to dysfunction of pelvic floor as well as abnormal proprioception of rectum


  • history (obstetrical/ surgical), changes in bowel consistency, passive vs urge incontinence

  • quantify degree of incontinence

  • Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS)

Cc fecal incontinence scoring
CC Fecal Incontinence Scoring

  • 0 = perfect continence

  • 20= complete continence

    • never = 0,

    • rarely = <1x/month,

    • sometimes = >1x/month

    • usually = >1x/wk,

    • always = >1x/day


  • physical examination: evidence of trauma, skin excoriation, fistulae, protruding hemorrhoids

  • inspect perineal body

  • patulous anus - check for prolapse

Diagnostic studies
Diagnostic Studies

  • endoanal ultrasound - diagnostic cornerstone

    • internal sphincter - hypoechoic

    • external sphincter - hyperechoic

    • scar tissue - mixed echogenicity

    • measure perineal body thickness (PBT) - less than 10mm abnormal

Diagnostic studies1
Diagnostic Studies

  • Anorectal manometry - functional status of anal sphincters and distal rectum

  • station pull through or continuous pull through

    • measurements: resting pressure (IAS), squeeze pressure (2-3x baseline), high-pressure zone (length of IAS, in women 2-3cm), RAIR (rectoanal inhibitory reflex), rectal sensation and compliance

      • RAIR - IAS relaxation with EAS contraction with small volume rectal distention - enables sampling reflex

      • absent in Hirschsprungs, Chagas, dermatomyositis, scleroderma

Diagnostic studies2
Diagnostic Studies

  • pudendal nerve terminal motor latency - electical impulses to PN with time response of EAS - nml 2.0 +/- 0.2ms

    • pudendal neuropathy implicated in poor outcomes p sphincteroplasty

  • EMG

  • defecography

  • colonoscopy

Nonoperative management
Nonoperative Management

  • medical therapy

  • biofeedback

  • secca procedure

  • injectables

Medical therapy
Medical Therapy

  • bulking agents, constipating agents (lomotil, codeine, amytriptyline), laxative regimens with scheduled disimpaction (for overflow incontinence)

  • loperamide - synthetic opiod, inhibits small and large intesting Mu receptor - also increases IAS resting pressure, rectal sensation and increase RAIR


  • pioneered in 1974 (Miller-Abbot balloon used as sensor to improve quality of Kegel exercises)

  • published studies with improvement of continence in adults and children with biofeedback 70% of time

  • long-term benefit less clear

  • randomized controlled trial (Heyman et al.) with pelvic floor exercise vs manometric biofeedback with 44% vs 21% able to achieve complete continence

Secca procedure
Secca Procedure

  • high-frequency alternating current - modification of treatment for GERD

  • thermal energy - build collagen, shorten/remodel muscle

  • RF delivered 90s each quadrant at 5mm increments (usually 16-20 increments)

  • Takashi et al. 19 pts at 5 yr follow-up, in 16 pts >50% improvement


  • developed from treatment of urinary incontinence with injectable bulking agent

  • safe, minimally invasive, outpatient administration

  • silicone vs carbon-coated microbeads

  • maximum improvement 1-6 mos, durability 1-2 yrs

Operative treatment
Operative Treatment

  • overlapping sphincteroplasty

  • parks posterior anal repair

  • sacral nerve stimulation

  • artificial bowel sphincter

  • muscle transposition

  • fecal diversion

Anterior overlapping spincteroplasty
Anterior Overlapping Spincteroplasty

  • Anterior Overlapping sphincteroplasty - mainstay treatment for incontinence with ext sphincter defect

    • identification of ends with mobilization

    • levator plication at proximal extent of dissection

    • overlapping repair shown to be superior to end-to-end repair, though might be associated with evacuation difficulties

    • both with diminishing efficacy over time

Parks posterior anal repair
Parks Posterior Anal Repair

  • treatment of neurogenic fecal incontinence - lengthen the canal and correct anorectal angle

  • curved incision behind anus, dissection in interspincteric plane

  • plicate pubococcygeus and puborectalis

  • published poor long-term results - 33% at 5 yrs

Sacral nerve stimulation
Sacral Nerve Stimulation

  • developed for urinary incontinence

  • staged procedure - percutaneous nerve evaluation (2wks), pts with improvement 50% or greater offered permanent stimulator

  • test stimulate S2, S3,S4 - goal is S3 stimulation to contract levator ani, external anal sphincter, plantar flexion of first 2 toes

  • complications rare - lead migration, infection, pain

Sacral nerve stimulation2
Sacral Nerve Stimulation

  • largest prospective randomized trial with SNS - 16 centers, 120 pts with permanent stimulator placed

  • persistent benefit (50% reduction of symptoms) seen in 70% of pts at 36 mos f/u

  • interval measurements with 80% success

Artificial bowel sphincter
Artificial Bowel Sphincter

  • first reported in 1987

  • transverse perineal incision with subcutaneous tunneling around anal canal

  • reservoir in space of retzius, pump in labia or scrotum, subcutaneous catheter

  • pump to evacuate - fluid goes from cuff to reservoir - passively refills

Artificial bowel sphincter1
Artificial Bowel Sphincter

  • multicenter trial (2002) - 112 pts, 384 device-related complications in 99 pts

  • 25% infection

  • 46 revision rate

  • 85% pts reports successful outcome

Gracilis muscle transposition
Gracilis Muscle Transposition

  • first reported in 1952 for children with fecal incontinence 2/2 neurologic and congenital anomalies

  • mobilization of gracilis muscle with transposition of muscle around anal canal and fixation to the contralateral ischial tuberosity

  • poorer outcomes with h/o refractory diarrhea or constipation, obstetric injury, adv age

  • functionally pts can only control solid stool

  • skeletal muscle transposition - more easily fatigued

Gracilis muscle transposition1
Gracilis Muscle Transposition

  • complications: evacuatory dysfunction, perineal pain, infection

  • stimulated gracilopasty with lead placement migration/erosion/infection, nerve fibrosis

Fecal diversion
Fecal Diversion

  • creation of colostomy or ileostomy if all measure fail

    • uncontrolled perineal stoma --> controlled abdominal stoma

  • majority of pts best-served with end-sigmoidoscopy

    • pts with slow transit or chronic constipation may be better served with ileostomy


  • fecal incontinence is a socially devasting condition and a symptom describing many etiologies

  • based on these etiologies, there are many non-operative and operative methods of improving quality of life