Keywords

Fecal incontinence, diagnosis, treatment, biofeedback therapy.

Abstract

Fecal incontinence is a common problem that is underreported, underdiagnosed and poorly managed. It profoundly affects the quality of life and psychological function. It is often due to multiple pathogenic mechanisms and rarely due to a single factor. Disruption of the normal anatomy or physiology of the ano-rectal unit often leads to fecal incontinence, although other factors may play a role. Today, several diagnostic tests are available that can provide useful insights regarding the pathophysiology of fecal incontinence. The treatment of fecal incontinence involves restoring the patients’ quality of life and improving bowel function. Currently, several approaches are available including anti-diarrheal drugs, biofeedback therapy and surgery, and using one or more of these options, it is often possible to rehabilitate most of these patients

Introduction

The prevalence estimates for fecal incontinence vary from 2.2 to 18.4% (1,2). This depends on the definition of incontinence, the frequency of occurrence, and how the demographic information was collected (1,2). Although it affects people of all ages, its prevalence is disproportionately higher in women, the elderly and nursing home residents (3,4). Interestingly, recent epidemiologic studies suggest that men and women may have similar prevalence (5,6), although most gastroenterologists see more women than men with this problem.

Clinical Subtypes

There are three broad subtypes: 1) passive incontinence refers to the involuntary discharge of stool or gas without awareness; 2) urge incontinence refers to the discharge of fecal matter in spite of active attempts to retain bowel contents; and 3) fecal seepage- the leakage of small amount of stool without awareness or staining of undergarments following an otherwise normal evacuation (7). The severity of incontinence can range from unintentional elimination of flatus to the seepage of liquid fecal matter to complete evacuation of bowel contents.

The ability to maintain continence requires structural and functional integrity of the neuromuscular apparatus of the anorectum including the internal and external anal sphincters, pelvic floor musculature pudendal nerve function, rectal compliance and rectal sensation (Figure 1). When one or more of these mechanisms of continence are disrupted to an extent that others are unable to compensate, incontinence ensues (8).

Figure 1

Medical Evaluation

History

The first step in the evaluation of fecal incontinence is to establish a rapport with the patient. Patients are often reluctant to discuss their symptoms and may take refuge under the terms “diarrhea” or “urgency”. Hence, patients with bowel dysfunction should be asked about fecal incontinence. Thereafter, an assessment of its timing and duration, its nature (i.e., incontinence of flatus, liquid or solid stool), and its impact on the quality of life is important. The use of pads or other devices and the ability to discriminate between formed or unformed stool and gas should be documented. A detailed inquiry of obstetric history and co-existing problems such as diabetes mellitus, pelvic radiation, neurological problems, spinal cord injury, dietary history and a history of co-existing urinary incontinence is useful. A prospective stool diary may also be helpful (7).

Clinical Grading

Several grading systems have been proposed. Although many surgeons use the Cleveland Clinic grading system (9), recently a modification of this has been validated by the St. Mark’s investigators (10). This system can provide an objective method of quantifying the degree of incontinence and it can also be useful for assessing the efficacy of therapy. However a simple analog score that assesses severity may just be as good as the St. Mark’s score (11). Symptom assessment can also provide useful insights regarding the underlying mechanism(s), but may not correlate well with manometric findings. In one study, leakage had sensitivity of 98.9%, a specificity of 11% and a positive predictive value of 51% for detecting low resting anal sphincter pressures (12). The positive predictive value for detecting a low squeeze pressure was 80% (12).Thus, for an individual patient with incontinence, history and clinical features alone are insufficient to define the pathophysiology.

Physical Examination

A detailed physical and neurological examination should be performed to rule out a systemic or neurological disorder. The perineal inspection and digital rectal examination is best performed with the patient lying in the left lateral position and with good illumination. Upon inspection, the presence of fecal matter, prolapsed hemorrhoids, dermatitis, scars, skin excoriation, the absence of perianal creases or a gaping anus may be noted. These features suggest either sphincter weakness or chronic skin irritation and provide clues regarding the underlying etiology. Excessive perineal descent or rectal prolapse can be demonstrated by asking the patient to attempt defecation. An outward bulge that exceeds 3 cm is usually defined as excessive perineal descent (13). The perianal sensation should also be checked. The anocutaneous reflex examines the integrity of the connection between the sensory nerve and the skin, the intermediate neurons in the spinal cord segments S2, S3, and S4 and the motor innervation of external anal sphincter. Impaired or absent anocutaneous reflex suggests either afferent or efferent neuronal injury (14). A digital rectal examination should assess the resting sphincter tone, length of anal canal, the integrity of the puborectalis sling, the acuteness of the anorectal angle, and the strength of the anal muscle and the elevation of the perineum during voluntary squeeze. The sensitivity, specificity and positive predictive value of digital rectal examination- as an objective test for evaluating anal sphincter function is very low (15).

Investigation of Fecal Incontinence

Several tests are available for identifying the underlying mechanisms of fecal incontinence (16,17). The selection of diagnostic tests will depend on probable etiologic factors, symptom severity, impact on quality of life and the patient’s age. These tests are often complementary (Figure 2). A flexible sigmoidoscopy or colonoscopy is usually desirable in most patients to exclude mucosal disease or colon cancer. However, in patients with long-standing fecal incontinence without diarrhea, these tests may not be routinely useful.

Figure 2

Anorectal Manometry

Anorectal manometry can provide useful information regarding anorectal function (15,16,17) (Figure 3). A reduced resting pressure on anorectal manometry correlates well with internal anal sphincter dysfunction and a reduced squeeze pressure correlates well with external anal sphincter defects (18) (Fig. 4). Two large studies have reported that maximum squeeze pressure has the greatest sensitivity and specificity for discriminating patients with fecal incontinence from those who are continent and healthy controls (15,19). Also, during abrupt increases of intra-abdominal pressure such as when coughing, there is a reflex contraction of the external anal sphincter (19,20). This reflex response causes the anal sphincter pressure to rise above that of the intra-rectal pressure to preserve continence. This reflex response is absent in patients with lesions of the cauda equina or sacral plexus (21,22).

Figure 3	Figure 4

Anorectal manometry is also useful in the evaluation of the responses to biofeedback training, as well as in the assessment of objective improvement following drug therapy or surgery (17,23,24). The American and European Motility Societies have recently published a position paper that recommends minimum standards for manometry testing (25).

Sensory Testing

Rectal sensation and compliance can be measured by incremental balloon distention or by using a barostat. Often, three types of rectal sensory thresholds can be detected: 1) first sensation; 2) urge to defecate; and 3) maximum tolerable volume (17). A higher threshold for rectal sensory perception is associated with autonomic neuropathy, congenital neurogenic anorectal malformation, (spina bifida, Hirschsprung disease, myelomeningocele), and functional and somatic alterations of the rectal reservoir, such as magarectum and descending perineum syndrome (26,27). In patients with fecal incontinence both hyper and hyposensitivity can be seen. In some patients, rectal sensory thresholds may be altered because of changes in the compliance of the rectal wall (28), and hence alterations in sensory data should be interpreted along with measurement of rectal compliance (29).

Many patients with fecal incontinence have significant impairment of electric and thermal anal canal sensation (30,31). At present, it is unclear whether assessment of anal canal sensation plays any role in the diagnosis or treatment of fecal incontinence (17). Rectal compliance reflects both the distensibility and the ability of the rectum to accommodate. It is measured by assessing the changes in rectal pressure during graded balloon distention (17). Patients with incontinence often have impaired rectal compliance. Rectal compliance is also reduced in patients with colitis (28), low spinal cord lesions and diabetics (32,33). In contrast, compliance is increased in high spinal cord lesions (22,34).

Imaging the Anal Canal

Anal endosonography

Anal endosonography provides an assessment of the thickness and structural integrity of the external and internal anal sphincter muscle and can detect the presence of scarring, thinning of sphincter, loss of muscle tissue and other local pathology (35,36). Anal endosonography has confirmed findings observed histologically (37), physiologically (38), and during surgery (39). Visualization of EAS can be problematic as echogenecity of this is similar to ischioanal fat. Although endosonography can distinguish between internal and external sphincter injury, the finding of a sphincter defect does not necessarily mean that it is the cause of fecal incontinence. The identification of abnormalities is dependent on the training and experience of the operator and the test is subject to an inter-observer variability. In one study interobserver agreement for diagnosis of sphincter defect was reported to be very good (40), whereas another study reported lack of reproducibility of anal sphincter diameter by endoanal ultrasound in healthy volunteers (41). Anal endosonography is a simple and inexpensive method of imaging the anal sphincters and is currently the preferred technique for examining the morphology of anal sphincter.

Defecography

This test provides information on the anorectal angle, pelvic floor descent, length of anal canal, presence of rectocele, rectal prolapse or mucosal intussusception. There is poor agreement between observers when measuring the anorectal angle (42). Many investigators have also questioned the rationale for performing defecography in patients with incontinence as it adds very little additional information to that obtained from manometry (17,43,44).

Magnetic resonance imaging (MRI)

MRI can visualize both the anal sphincter morphology and the global pelvic floor motion in real time and without radiation exposure. Endoanal MRI provides superior imaging with better spatial resolution of EAS. The addition of dynamic pelvic MRI, using fast imaging sequences or MRI colpocystography that involves filling the rectum with ultrasound gel as a contact agent and having the patient evacuate this while lying inside the magnet may facilitate better definition of the anorectal structures (45-47). With the availability of open-magnet units, dynamic MR imaging can be performed in a more physiologic position of patient sitting up (48). IAS is seen more clearly on anal endosonography, whereas the EAS is seen more clearly on MRI. Endoanal MR imaging, ultrasound and surgical findings were compared in 22 women. MR made the correct diagnosis in 95% of patients compared to 77% with endoanal ultrasound (45). Disadvantages of MRI defecography include limited availability, the high costs and lack of data comparing symptomatic subjects with normal volunteers. MRI defecography can detect a number of abnormalities in otherwise asymptomatic individuals (17). The functional significance of these morphological defects has been questioned (17,49). Inter-observer variability of enodanal MR may be higher than endoanal ultrasound (50).

Pudendal Nerve Terminal Latency (PNTML)

This test measures the functional integrity of the terminal portion of pudendal nerve, and can help to distinguish whether a weak sphincter is due to muscle or nerve injury. A prolonged nerve latency time suggests pudendal neuropathy. This may occur following obstetric or surgical trauma, excessive perineal descent or idiopathic fecal incontinence (51). A normal PNTML does not exclude pudendal neuropathy, because the presence of a few intact nerve fibers can give a normal result, whereas an abnormal latency time is more significant. Although, its routine usage has been questioned (17), two recent reviews of eight uncontrolled studies (51,52) suggest that patients with pudendal neuropathy generally have a poor surgical outcome when compared to those without neuropathy.

Clinical Utility of Tests for Fecal Incontinence

In one study, history and physical examination alone could detect an underlying cause in only 9 of 80 patients (11%) with fecal incontinence, whereas anorectal physiologic tests revealed an abnormality in 66% of patients (53). In another prospective study, anorectal manometry with sensory testing confirmed clinical impression of fecal incontinence, and management was altered in 76% of patients (16). A recent prospective study showed that a clinical diagnosis was confirmed in 51% of patients and a new diagnosis was established in the remaining patients by combining anorectal physiological testing with imaging (54). A large study of 350 patients, incontinent patients had lower resting and squeeze pressures, a smaller rectal capacity and leaked earlier following saline infusion in the rectum. Maximum squeeze pressure showed best discrimination. However there was complete overlap between continent and incontinent patients for all the tests and the authors concluded that physiological tests were not useful in predicting fecal incontinence (15). These findings have been further confirmed by another study, which showed that no single test is confirmatory in fecal incontinence, but combination of tests with clinical evaluation is helpful in evaluation of patient with fecal incontinence (55). These studies emphasize the wide range of normal values and the ability of the body to compensate for the loss of any one mechanism.

Newer Techniques in Diagnosis of Fecal Incontinence

Several newer techniques including dynamic Transperineal Ultrasound (56), Magnetic Pudenal Neurosimulation (57), and magnetic and electrical stimulation of sacroanal motor pathways are currently being investigated to provide better understanding of defecation dynamics (58).

Treatment

The goal of treatment is to restore continence and improve the quality of life, and this includes supportive and specific measures (Table 1).

Supportive Measures

First, one should address the underlying predisposing condition(s), such as fecal impaction, dementia, neurological problems, inflammatory bowel disease or dietary factors such as carbohydrates intolerance. In the institutionalized patient, timely recognition of soiling and immediate cleansing of the perianal skin is important (59). Barrier creams such as zinc oxide and calamine lotion may be useful in preventing the skin excoriation (59,60). More significantly, scheduled toileting on a commode at the bedside or bedpan and supportive measures to improve the general well-being and nutrition of the patient may all prove effective. Stool deodorants (Chlorophyl) can be useful for disguising the smell of faces.

Dietary modifications such as reducing caffeine or fiber intake may also be useful. Fiber supplements such as psyllium are often advocated in an attempt to increase stool bulk and reduce watery stools. However, there has been no published study to justify this approach. Fiber supplements can potentially worsen diarrhea by increasing colonic fermentation of unabsorbable fiber.

Specific Therapies

These include 1) Drugs; 2) Biofeedback therapy; 3) Surgery; 4) Plugs, sphincter bulkers and ancillary therapy. An algorithmic approach to the treatment of fecal incontinence is presented in Figure 2 above.

Drugs: Anti-diarrheal drugs, such as loperamide hydrochloride or diphenoxylate/ atropine sulphate, are commonly used. A placebo-controlled study showed that loperamide 4 mg t.i.d. reduced the stool frequency and urgency, increased colonic transit time (24), reduced stool weight (61) and increased anal resting sphincter pressure (62). Clinical improvement was also reported with diphenoxylate/ atropine (Lomotil), but objective improvement was lacking (63). Diphenoxylate/ atropine may cause dryness of mouth. Although most patients benefit temporarily, many report crampy lower abdominal pain or difficulty with evacuation on anti-diarrheals. Hence, careful titration is required. Patients with diarrhea and fecal incontinence secondary to bile salt malabsorption may benefit with an ion exchange resins such as cholestyramine or colestipol. A serotonin (5-HT3) antagonist, alosetron is currently available under a restricted use program, and may be useful in patients with severe diarrhea, especially when symptoms do not respond to other agents, but this has not been tested.

Biofeedback Therapy: Behavioral therapy using “operant conditioning,” techniques has been shown to improve bowel function and incontinence (64). The goals of biofeedback therapy in a patient with fecal incontinence are 1) to improve the strength of the anal sphincter muscles; 2) to improve the coordination between the abdominal, gluteal and anal sphincter muscles during voluntary squeeze and following rectal perception; and 3) to enhance sensory perception. The treatment protocol should be customized for each patient based upon the underlying pathophysiologic mechanism(s). Biofeedback training is performed using visual, auditory or verbal feedback techniques (64). The instrument used to provide feedback can either be a manometry probe or an EMG electrode that is inserted into the anorectum. The pressure or EMG signals are displayed on a monitor or chart recorder (17,64). Patients are taught how to selectively squeeze their anal muscles without increasing the intra-abdominal pressure or inappropriately contracting their thigh muscles (65).

In a study of 100 patients with fecal incontinence, 2/3rds improved at the end of treatment, and those with urge incontinence alone faired better than those with passive incontinence (55% vs. 23%) (66). The same center recently reported that change in manometric findings after biofeedback does not correlate with success or failure of biofeedback treatment (67).

The mechanism of improvement from biofeedback therapy is not clearly known. The beneficial results of biofeedback therapy may be due to the motivation of the patient and the enthusiasm of the therapist rather than to the technical aspects of therapy (64,68,69). One RCT, biofeedback was compared with conservative standard care or standard care with Kegal exercises. Both the biofeedback and specialist nurse care that included advice on diet, fluids, technique to improve evacuation and bowel training produced 50% or more improvement in patients with fecal incontinence and there was no difference between treatments (67). Anal ultrasound or manometric findings did not predict outcome. Why patients who received advice only without sphincter exercises or training showed improvement remains unclear. Also, only 50% of patients underwent repeat testing and more than 25% were lost for follow up. In another recent study, nearly 2/3rds of patients with medically refractory fecal incontinence showed subjective and objective improvement of anorectal function, both short term and at one year (70).

Biofeedback therapy should be offered to all patients before reconstructive surgery for fecal incontinence and to those who have failed supportive measures, especially older patients, those with comorbid illnesses, or pudendal neuropathy.

Surgery: Surgical treatment for fecal incontinence should be considered in patients who do not respond to medical or biofeedback treatment (70) or have well documented sphincter defect.

In 80% of patients with obstetrical damage, anterior overlap repair of the external anal sphincter resolves symptoms (71). In patients with incontinence due to a weak, but intact anal sphincter, post anal repair has been tried (72). Over time success of sphincter repair seems to wear off and less than one-third of patients are continent to liquid or solid stool after 5 years (73,74).

If the anal sphincter is irreparably damaged, reconstruction of the sphincter may be required. Striated muscles, gracilis or gluteus can be surgically wrapped around the anal canal to increase resting pressure (52,75). The technique of stimulated gracilis muscle transposition (dynamic gracioplasty) has been most frequently tried (76). Continuous electrical stimulation with an implantable pulse generator helps to maintain muscle contraction (77). This technique uses the principle that a fast twitch, fatigable skeletal muscle when stimulated over a long term can be transformed into a slow twitch, non-fatigable muscle that can provide a sustained, sphincter-like muscle response. Clinical improvement (success) rates have ranged between 38-90% (52,78). A recent systematic review showed that dynamic gracioplasty is associated with 2% mortality and a significant risk of re-operation (79). Another surgical approach has been to implant an artificial bowel sphincter. A multicenter, prospective study evaluated the safety and efficacy of the artificial bowl sphincter; 115 patients were implanted, and a successful outcome was achieved in 85% of patients with functioning device and with an intention to treat analysis, the success rate was 53%. However, 384 device-related adverse events were reported in 99 patients, and 46% of patients required revisonal operation, 37% had their device completely explanted (80).

Plugs, Procon incontinence device, Sphincter Bulkers: Innovative disposable anal plugs have been designed to temporarily occlude the anal canal (82). These plugs may be useful for patients with impaired anal canal sensation, those with neurological disease and those who are institutionalized or immobilized. In some patients with fecal seepage, insertion of an anal plug made up of cotton wool may prove beneficial (82).

Radio Frequency Stimulation

“Secca procedure” was developed to deliver radiofrequency energy to all quadrants of the anal canal muscles in patients with fecal incontinence. A multicenter study of 50 patients demonstrated that radiofrequency energy can be safely delivered to the lower rectum and anal canal and it significantly improved fecal incontinence and overall quality of life (83). In a single center study of 10 patients, this procedure resulted in an improvement in symptoms and quality of life, which persisted for two years after treatment (84). The proposed mechanism of action is heat-induced tissue contraction and remodeling of the anal canal and distal rectum. These data are preliminary and carefully conducted clinical controlled trials are required before advocating this treatment.

Sacral nerve stimulation

This approach is less invasive and has the advantage that a temporary procedure can be done to assess outcome. This technique is well established in the treatment of urinary incontinence. Temporary electrodes are placed percutaneously through the sacral foramina. If the test period of 2-3 weeks shows satisfactory continence, the permanent electrode is placed and a neurostimulator is implanted. In one study that assessed the short-term effects (85), continence was restored in 8 of 9 patients. Another study analyzed the medium term results of permanent sacral nerve stimulation in 15 patients and reported improvement in all patients up to 5 years (86).

Other procedures

The Malone or ante-grade continent enema procedure (87) consists of fashioning a caceostomy button or appedicostomy (88,89) which allows ante-grade wash out of the colon and may be suitable for children and patients with neurological lesions (90). In the long term, fibrosis of the stoma site may lead to a loss of response but overall success rate of 61% has been reported at a mean follow up of 3.25 years (91).

If none of these techniques are suitable or have failed, a colostomy is a safe option, although aesthetically less preferable (92). It is particularly suitable for patients with spinal cord injury, those immobilized with skin problems or other complications (92,93). A colostomy should not be regarded as a failure of medical or surgical treatment (92). In many, the restoration of a normal quality of life and ameliorization of symptoms can be very rewarding. The use of laparoscopic-assisted approach, Trephine colostomy may help to fashion a stoma with minimal morbidity for the patient (94).

Summary

Fecal incontinence is a symptom based diagnosis with complex etiology and pathogenesis. A detailed history and examination will facilitate diagnosis. If conservative management fails, further investigations should be performed. Physiological and morphological tests help in the evaluation of functional abnormalities and assessment of anatomical sphincter defects. These tests guide clinical management of fecal incontinence. Behavioral therapy is successful in most patients. Surgical treatment of fecal incontinence improves symptoms and function in the medium term but does not cure and the outcome may deteriorate with time. Several experimental approaches, including bulking of the anal sphincter, sacral nerve stimulation and the delivery of radiofrequency energy to the anal canal are currently being assessed.

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