Faecal Incontinence

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

A study using data from The Health Improvement Network , a UK primary care database, reported a rate of first diagnosis per 100,000 person years of 3.1 for men and 3.6 for women aged 60-89. For people with dementia, these figures increased by a factor of at least 4.[1] 

By virtue of the nature of the condition, faecal incontinence remains largely a hidden problem. Active but sensitive case finding may be required, particularly in high-risk groups:[2]

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Risk groups

  • Any patients with diarrhoea.
  • Patients with anal problems:
    • Women with third- and fourth-degree obstetric injury.
    • Patients with rectal or pelvic organ prolapse.
    • Patients with pelvic radiotherapy or colonic resection.
    • Patients with perianal itching, soreness or pain or anal surgery.
  • Patients with urinary incontinence.
  • Frail elderly patients.
  • Patients with neurological problems or spinal disease (eg, CVE, MS, spina bifida or spinal injury).
  • Patients with severe cognitive impairment or learning difficulties.

When asking questions, always be aware of the physical and emotional impact that faecal incontinence can have on patients and carers.

Be aware that faecal incontinence is a symptom or sign rather than a disease and that there are often multiple contributory factors.[2] One study found that nearly 40% of men with faecal incontinence report it in the absence of a definable functional or structural sphincter abnormality.[3] Professionals should not concentrate on one specific diagnosis to the total exclusion of all other factors.

A baseline assessment should include relevant medical history, a general examination, an anorectal examination and an assessment of cognitive function if appropriate.

Recognised associations with faecal incontinence include:

Childbirth

Incontinence is common after the use of forceps, a large baby, occipitoposterior position and a long second stage of labour.[4] One in five women develop incontinence after vaginal delivery and 30% have structural damage as evidenced by anal endosonography.[5] A systematic review reported that after repair anal incontinence persisted in 15-59% of women and anal urgency affected a further 6-28%.[6] 

Surgery

This is the most common cause after obstetric trauma.[4] Incontinence may be inevitable after complex anal fistula surgery, or may occur as an unexpected complication after haemorrhoidectomy or surgery for chronic anal fissure.[7] The incidence is reducing with advances in surgical techniques.[8][9]

Degeneration of the internal anal sphincter

After structural damage, this is the most common cause of sphincter dysfunction. Most cases are due to primary isolated degeneration of the smooth muscle of the internal anal sphincter. The condition is most common in middle age and affects both men and women.[4] 

Endosonography is a useful investigation to identify surgically correctable sphincter defects.[10] It often shows that the anal sphincter is fibrotic and thin and resting anal pressure is low.

Degeneration is occasionally seen secondary to:

  • Progressive systemic sclerosis.[11] 
  • Radiotherapy for cervical or other pelvic neoplasms.[7] 
  • Chronic idiopathic intestinal pseudo-obstruction.[12] .

Neurological disease

Faecal incontinence is a feature of many neurological diseases and may be aggravated by non-neurological factors such as the side-effects of drugs or childbirth. It can also be a feature of MS and diabetic autonomic neuropathy.[6][13]

Congenital disorders

90% of spina bifida patients report faecal incontinence.[14] It can also occur as a consequence of surgery for congenital disorders. Faecal incontinence is a major problem in patients treated for anal atresia and one study of 68 patients with Hirschprung's disease identified that 82% subsequently had severe soiling.[15][16] 

More recent studies suggested that persistence of incontinence after surgery in patients with Hirschprung's disease may be related to poor technique.[16]

Miscellaneous

Children with a normal sphincter can pass stools inappropriately as part of a behavioural disorder (encopresis) or can suffer from faecal impaction with overflow.[17][18] In some children the condition is due to a poorly defined neuromuscular disorder of the distal gut which can persist into adulthood.[19] 

Other conditions that can be associated with faecal incontinence include rectal prolapse, inflammatory bowel disease (IBD) and unwanted anal penetration.[20][21] 

Person-centred care

Management should be tailored to the needs of the individual. Information should be provided in a format which they can understand, so that they can participate in decisions about their care. Family and carers should be involved in this process, unless the individual deems this inappropriate.

Condition-specific interventions

The following potentially reversible conditions should be excluded and, if present, treated with condition-specific interventions before other initial management is instituted:

  • Faecal loading.
  • Potentially treatable causes of diarrhoea - for example, infective, IBD and irritable bowel syndrome (IBS).
  • Warning signs for lower gastrointestinal cancer.[23]
  • Rectal prolapse or third-degree haemorrhoids.
  • Acute anal sphincter injury including obstetric and other trauma.
  • Acute disc prolapse/cauda equina syndrome (CES).

Basic initial interventions

Interventions should promote ideal stool consistency and predictable bowel emptying.

Diet

  • Existing therapeutic diets should be taken into account.
  • Overall nutrient intake should be balanced.
  • A food and fluid diary might be helpful.
  • Advise patients to modify one food at a time.
  • Patients with hard stools and/or dehydration should be encouraged to aim for intake of at least 1.5 litres of fluid per day (unless contra-indicated).
  • Consider screening for malnutrition or risk of malnutrition.

Bowel and toileting habits

  • Bowel emptying should be encouraged after a meal.
  • Toilet facilities should be private, comfortable and used safely with sufficient time allowed.
  • The patient should adopt a sitting or squatting position to avoid straining.
  • Locations of toilets should be made clear and any equipment or help needed to access the toilet provided.
  • Advice should be offered on easily removable clothing.
  • Refer for home and mobility assessment if appropriate.

Medication

  • Consider alternatives to drugs contributing to faecal incontinence.
  • Antidiarrhoeal drugs should be prescribed, in accordance with the summary of product characteristics, for people with loose stools and associated incontinence once other causes have been excluded.
  • Loperamide hydrochloride should be first drug of choice. Consider loperamide hydrochloride syrup for doses less than 2 mg.
  • Codeine phosphate or co-phenotrope may be tried for those unable to tolerate loperamide hydrochloride.
  • Loperamide hydrochloride should not be offered to people with hard or infrequent stools, acute diarrhoea without a diagnosed cause, or an acute flare-up of ulcerative colitis.
  • Loperamide hydrochloride should be introduced at a very low dose and increased as tolerated until desired stool consistency is reached. Subsequent doses can be adjusted according to stool consistency and lifestyle.

Coping strategies
People with faecal incontinence should be offered advice on:

  • Continence products.
  • Emotional and psychological support.
  • Talking to friends and family.
  • Planning travel and carrying a toilet access card or RADAR key.
  • Disposable body-worn pads and disposable bed pads.
  • Anal plugs.
  • Skin-care, odour control and laundry advice.
  • Disposable gloves.
  • Reusable absorbent products - these are not generally recommended.

Specific groups

People with faecal loading

  • Offer a rectally administered treatment to clear the bowel satisfactorily, or a potent oral laxative if this is not appropriate. Often treatment will need to be repeated daily for a few days.
  • Recommend a combination of initial management options to reduce recurrence (see 'Specialist management', below).
  • Consider the use of orally administered laxatives if rectal treatments fail.

People with limited mobility

  • Consider a combination of oral or rectal laxatives and/or constipating agents.
  • Review toilet access.
  • Advise concerning appropriate disposable products (see 'Coping strategies', above).
  • Advise re timing of toileting - ie stool needs to be in the rectum at the time of the planned bowel action.

People using enteral tube feeding and reporting faecal incontinence

  • Modify the type and timing of feed on an individual basis to establish the most effective way to manage faecal incontinence.

People with severe cognitive impairment

  • Refer for a behavioural and functional analysis to determine if there is any behavioural reason for faecal incontinence.
  • If behavioural aspects are identified that contribute to faecal incontinence, offer cause-specific interventions founded on structured goal planning that aim to resolve them.
  • In cases of severe cognitive impairment, further specialist management of faecal incontinence may be inappropriate.

People with neurological or spinal disease/injury

  • Offer, until satisfactory bowel habit is established, a bowel management programme which:
    • Ascertains the person's preferences and premorbid bowel habit.
    • Maximises the person's understanding of normal bowel function and how it has been altered.
    • Modifies diet and/or administers rectal evacuants and/or oral laxatives, adjusted to individual response, to establish a predictable pattern of bowel evacuation.
    • Considers digital anorectal stimulation for people with spinal cord injuries or other neurogenic bowel disorders.
    • Considers manual/digital removal of faeces, particularly for people with a lower spinal injury.[24]
  • For those unable to achieve reliable bowel continence after a neurological bowel management programme offer:
    • Coping and long-term management strategies (see 'Coping strategies' above and 'Long-term strategies', below).
    • Rectal irrigation.
    • Electrical stimulation of the sacral roots has been used with some success in patients with partial CES.[25]
    • Other surgical options (including stoma) if faecal incontinence or the time taken for bowel emptying imposes major limits on their lifestyle.

People with learning disabilities

  • It is essential that these people follow the same initial care pathway as other people with faecal incontinence, regardless of when their faecal incontinence started.

Severely or terminally ill people

  • Consider a faecal collection device.

Specialist management

This should be considered for people who continue to have episodes of faecal incontinence despite initial management. Such management may include:

  • Pelvic floor muscle training.
  • Bowel retraining.
  • Specialist dietary assessment and management.
  • Biofeedback.
  • Electrical stimulation.
  • Rectal irrigation.
  • The use of anal bulking agent injections, which has met with variable success. A Cochrane review found that the use of silicone or ceramic microspheres of calcium hydroxylapatite achieved the best results.[26] 
  • Surgery - the benefits and limitations should be discussed, as follows:
    • Sphincter repair should be considered for people with a full-length external anal sphincter defect that is 90° or greater and faecal incontinence that restricts quality of life. The effectiveness of the procedure decreased in people with internal sphincter defects, pudendal nerve neuropathy, multiple defects, external sphincter atrophy, loose stools or IBS.[2] 
  • One ten-year follow-up study found a gradual deterioration in continence, especially people who were older at the time of surgery or who had more than two births.[27]
  • People undergoing anal sphincter repair should not:
    • Routinely receive a temporary defunctioning stoma.
    • Receive constipating agents in the postoperative period.
  • Consider a trial of temporary sacral nerve stimulation if sphincter surgery is inappropriate and proceed to implantation if successful.
  • Consider a neosphincter (stimulated graciloplasty or an artificial anal sphincter) if a trial of sacral nerve stimulation is unsuccessful.[28][29][30] Advise patients that they may experience evacuatory disorders and/or serious infection, which may necessitate removal of the device.
  • Antegrade irrigation via appendicostomy, neo-appendicostomy or continent colonic conduit should be offered to selected people with constipation and colonic motility disorders associated with faecal incontinence.[31] 
  • A stoma for people with faecal incontinence that severely restricts lifestyle should only be considered once all appropriate non-surgical and surgical options, including those at specialist centres, have been considered. Refer to a stoma care service.

Long-term strategies

Symptomatic people, who do not want to persevere with active treatment or who have intractable faecal incontinence, should be offered:

  • Advice on preservation of dignity and, where possible, independence.
  • At least six-monthly review of symptoms.
  • Discussion of other management options (including specialist referral).
  • Contact details for relevant support groups.
  • Advice on coping strategies and skin care.

Further reading & references

  • Faecal incontinence, NICE Quality Standards (Feb 2014)
  • Nurko S, Scott SM; Coexistence of constipation and incontinence in children and adults. Best Pract Res Clin Gastroenterol. 2011 Feb;25(1):29-41. doi: 10.1016/j.bpg.2010.12.002.
  • Rao SS; Advances in diagnostic assessment of fecal incontinence and dyssynergic defecation. Clin Gastroenterol Hepatol. 2010 Nov;8(11):910-9. doi: 10.1016/j.cgh.2010.06.004. Epub 2010 Jun 25.
  1. Grant RL, Drennan VM, Rait G, et al; First diagnosis and management of incontinence in older people with and without dementia in primary care: a cohort study using The Health Improvement Network primary care database. PLoS Med. 2013 Aug;10(8):e1001505. doi: 10.1371/journal.pmed.1001505. Epub 2013 Aug 27.
  2. Faecal incontinence; NICE Clinical Guideline (2007)
  3. Maeda Y, Vaizey CJ, Hollington P, et al; Physiological, psychological and behavioural characteristics of men and women with faecal incontinence. Colorectal Dis. 2009 Nov;11(9):927-32. Epub 2008 Oct 21.
  4. Kamm MA; Faecal incontinence. BMJ. 2003 Dec 6;327(7427):1299-300.
  5. Goetz LH, Lowry AC; Overlapping sphincteroplasty: is it the standard of care? Clin Colon Rectal Surg. 2005 Feb;18(1):22-31. doi: 10.1055/s-2005-864072.
  6. Mostwin J et al; Pathophysiology of Urinary Incontinence, Fecal Incontinence, and Pelvic Organ Prolapse, 2008.
  7. Lunniss PJ, Gladman MA, Hetzer FH, et al; Risk factors in acquired faecal incontinence. J R Soc Med. 2004 Mar;97(3):111-6.
  8. Tocchi A, Mazzoni G, Miccini M, et al; Total lateral sphincterotomy for anal fissure. Int J Colorectal Dis. 2004 May;19(3):245-9. Epub 2003 Sep 9.
  9. Mousavi SR, Sharifi M, Mehdikhah Z; A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg. 2009 Jul;13(7):1279-82. Epub 2009 May 5.
  10. Pinsk I, Brown J, Phang PT; Assessment of sonographic quality of anal sphincter muscles in patients with faecal incontinence. Colorectal Dis. 2009 Nov;11(9):933-40. Epub 2008 Oct 31.
  11. Fynne L, Luft F, Gregersen H, et al; Distensibility of the anal canal in patients with systemic sclerosis: a study with the functional lumen imaging probe. Colorectal Dis. 2013 Jan;15(1):e40-7. doi: 10.1111/codi.12063.
  12. Cojocaru M, Cojocaru IM, Silosi I, et al; Gastrointestinal manifestations in systemic autoimmune diseases. Maedica (Buchar). 2011 Jan;6(1):45-51.
  13. Vinik AI, Maser RE, Mitchell BD, et al; Diabetic autonomic neuropathy. Diabetes Care. 2003 May;26(5):1553-79.
  14. Kamrath KR; Chiropractic management of a 5-year-old boy with urinary and bowel incontinence. J Chiropr Med. 2010 Mar;9(1):28-31. doi: 10.1016/j.jcm.2009.12.003.
  15. Schmiedeke E, Busch M, Stamatopoulos E, et al; Multidisciplinary behavioural treatment of fecal incontinence and constipation after correction of anorectal malformation. World J Pediatr. 2008 Aug;4(3):206-10. doi: 10.1007/s12519-008-0038-2.
  16. Levitt MA, Martin CA, Olesevich M, et al; Hirschsprung disease and fecal incontinence: diagnostic and management strategies. J Pediatr Surg. 2009 Jan;44(1):271-7; discussion 277.
  17. Reid H, Bahar RJ; Treatment of encopresis and chronic constipation in young children: clinical results from interactive parent-child guidance. Clin Pediatr (Phila). 2006 Mar;45(2):157-64.
  18. Nurko S, Scott SM; Coexistence of constipation and incontinence in children and adults. Best Pract Res Clin Gastroenterol. 2011 Feb;25(1):29-41. doi: 10.1016/j.bpg.2010.12.002.
  19. Koch KL, Bitar KN, Fortunato JE; Tissue engineering for neuromuscular disorders of the gastrointestinal tract. World J Gastroenterol. 2012 Dec 21;18(47):6918-25. doi: 10.3748/wjg.v18.i47.6918.
  20. Lundgren P, Carr LA; Effects of anisomycin and CNS stimulants on brain catecholamine synthesis. Pharmacol Biochem Behav. 1978 Oct;9(4):559-61.
  21. Klot JF, Auerbach JD, Veronese F, et al; Greentree white paper: sexual violence, genitoanal injury, and HIV: priorities for research, policy, and practice. AIDS Res Hum Retroviruses. 2012 Nov;28(11):1379-88. doi: 10.1089/AID.2012.0273.
  22. Costilla VC, Foxx-Orenstein AE, Mayer AP, et al; Office-based management of fecal incontinence. Gastroenterol Hepatol (N Y). 2013 Jul;9(7):423-33.
  23. Referral for suspected cancer; NICE Clinical Guideline (2005)
  24. Vande Velde S, Van Biervliet S, Van Renterghem K, et al; Achieving fecal continence in patients with spina bifida: a descriptive cohort study. J Urol. 2007 Dec;178(6):2640-4; discussion 2644. Epub 2007 Oct 22.
  25. Gstaltner K, Rosen H, Hufgard J, et al; Sacral nerve stimulation as an option for the treatment of faecal incontinence in patients suffering from cauda equina syndrome. Spinal Cord. 2008 Sep;46(9):644-7. Epub 2008 Mar 4.
  26. Hussain ZI, Lim M, Stojkovic SG; Systematic review of perianal implants in the treatment of faecal incontinence. Br J Surg. 2011 Nov;98(11):1526-36. doi: 10.1002/bjs.7645. Epub 2011 Aug 26.
  27. Zutshi M, Tracey TH, Bast J, et al; Ten-year outcome after anal sphincter repair for fecal incontinence. Dis Colon Rectum. 2009 Jun;52(6):1089-94.
  28. Stimulated graciloplasty for faecal incontinence; NICE (2006)
  29. Sacral nerve stimulation for faecal incontinence; NICE Interventional Procedure Guideline (2004)
  30. Artificial anal sphincter implantation; NICE Interventional Procedure Guideline (2004)
  31. Imai K, Shiroyanagi Y, Kim WJ, et al; Satisfaction after the Malone antegrade continence enema procedure in patients with spina bifida. Spinal Cord. 2013 Oct 1. doi: 10.1038/sc.2013.111.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Laurence Knott
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Last Checked:
13/01/2014
Document ID:
2131 (v23)
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