Fecal Incontinence

Overview
Fecal incontinence is the inability to control the release of gas or stool. In a 2010 survey of the U.S. population, 9% of adults have experienced one or more episodes of fecal incontinence in the past month. This increased to 17.5% for adults over the age of 70. In 2012 the average annual cost to patients with fecal incontinence was $4,110. Yet it is a silent epidemic. Most adults with fecal incontinence are too ashamed to mention their problem, even to their doctors, and therefore do not receive the help which is available.

What causes fecal incontinence?
Many cases of fecal incontinence are caused by injury to the sphincter muscle at the time of a vaginal delivery. Often the woman will compensate by using other muscles of her pelvic floor. For this reason, the injury may not become apparent until many years later, when the muscles of the pelvic floor weaken with age.

Other reasons for fecal incontinence may include prior surgery, abnormal stool consistency and volume or neurologic disorders leading to sphincter muscle weakness.

How is fecal incontinence evaluated?
Fecal incontinence is a symptom with multiple different causes.  A full history and physical examination in the office by a colon and rectal surgeon can help determine the cause of fecal incontinence. Based on the office visit, further studies including anal ultrasound, anal manometry, pudendal nerve terminal motor latency, and defecography may be ordered.

How is fecal incontinence treated?
Often fecal incontinence will respond to changes in diet. Increasing the amount of dietary fiber can improve continence by adding bulk and improving stool consistency. Frequently, a trial period and repeat evaluation of symptoms while on a high fiber diet will be requested. Depending on the severity of fecal incontinence, therapy to manage the incontinence with conservative measures, such as diet, fiber supplementation, anti-motility drugs and biofeedback, can be effective.  For those patients who continue to experience incontinence there are other therapeutic interventions.

  • Solesta is a minimally invasive, biocompatible tissue bulking agent, indicated for the treatment of fecal incontinence in patients 18 years and older who have failed conservative therapy.  It is administered as four injections in an office-based procedure via anoscopy.
  • InterStim, or sacral nerve stimulation is stimulation of the third sacral nerve root to improve bowel control.  The same technique has been approved by the FDA for use by urologists for management of urinary incontinence since 1997.  Sacral nerve stimulation has been available in Europe and Canada for the treatment of fecal incontinence for years, but only in the second half of 2011 gained FDA approval.
  • Overlapping sphincteroplasty is an operation performed to restore normal anal sphincter anatomy following an injury, or disruption, to the anal sphincter muscle that has lead to the development of fecal incontinence. The surgeon will reconnect the free ends of damaged muscle to re-establish the sphincter as a ring, leading to improved function. Sphincteroplasty has been used for decades in the treatment of fecal incontinence and is a very safe operation.

What is the prognosis for patients with fecal incontinence after treatment?
For years, overlapping sphincteroplasty was the only intervention available to patients suffering from fecal incontinence who had sustained an anal sphincter injury.  Dietary modification, anti-diarrheals and biofeedback were the remaining options for those with no sphincter defect. Additional techniques, such as implantation with an artificial bowel sphincter, has been fraught with complications, including infection and erosion of the implant, necessitating removal in up to 50% of patients. Overlapping sphincteroplasty has been shown to be initially successful in up to 75% of patients with severe fecal incontinence due to sphincter injury, and is necessary in cases where normal anatomy has been severely disturbed. However, there have also been discouraging reports about deterioration in function over time. Fortunately, we now have additional therapeutic interventions such as Solesta and InterStim, which are showing some encouraging results and are very well-tolerated.