Abstract
PURPOSE: Fecal incontinence is a socially devastating disorder which affects at least 2.2 percent of community dwelling adults and 45 percent of nursing home residents. Most incontinent patients can be helped, but physicians are poorly informed about treatment options. The aim of this study was to develop a consensus on treatment options by convening a conference of surgeons, gastroenterologists, nurses, psychologists, and patient advocates. METHOD: A 1–1/2 day conference was held in April, 1999. Experts from different disciplines gave overviews, followed by extended discussions. Consensus statements were developed at the end of the conference. This summary statement was drafted, circulated to all participants, and revised based on their input. CONCLUSIONS: 1) Diarrhea is the most common aggravating factor for fecal incontinence, and antidiarrheal medications such as loperamide and diphenoxylate or bile acid binders may help. Fecal impaction, a common cause of fecal incontinence in children and elderly patients, responds to combinations of laxatives, education, and habit training in approximately 60 percent. These causes of fecal incontinence can usually be identified by history and physical examination alone. 2) In patients who fail medical management or have evidence of sphincter weakness, anorectal manometry and endoanal ultrasound are recommended as helpful in differentiating simple morphologic defects from afferent and efferent nerve injuries and from combined structural and neurologic injuries. 3) Biofeedback is a harmless and inexpensive treatment which benefits approximately 75 percent of patients but cures only about 50 percent. It may be most appropriate when there is neurologic injury (i.e., partial denervation), but it has been reported to also benefit incontinent patients with minor structural defects. 4) External anal sphincter plication with or without pelvic floor repair is indicated when there is a known, repairable structural defect without significant neurologic injury. It is effective in approximately 68 percent. 5) Salvage operations are reserved for patients who can not benefit from biofeedback or levator-sphincteroplasty. These include electrically stimulated gracilis muscle transpositions and colostomy. 6) Antegrade enemas delivered through stomas in the cecum or descending colon reduce or eliminate soiling in approximately 78 percent of children with myelomeningocele; this operation may come to be more widely applied. 7) Investigational treatments include implanted nerve stimulators, artificial sphincters, and anal plugs. 8) Patient characteristics which influence choice of treatment include mental status, mobility impairment, and typical bowel habits. 9) Additional research is needed to better define the mechanisms responsible for fecal incontinence, to assess the efficacy of these treatments, to develop better treatments for nursing home residents, and to identify predictors of outcome.
Similar content being viewed by others
References
Nelson R, Norton N, Cautley E, Furner S. Community based prevalence of anal incontinence. JAMA 1995;274:559–61.
Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SS. Functional disorders of the anus and rectum. Gut 1999;45(Suppl II):II55–9.
Mavrantonis C, Wexner SD. A clinical approach to fecal incontinence. J Clin Gastroenterol 1998;27:108–21.
Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut 1999;44:77–80.
Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36:77–97.
Pescatori M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence: evaluation of 335 patients. Dis Colon Rectum 1992;35:482–7.
American Medical Systems. Fecal incontinence scoring system. Minnetonka, Minnesota: American Medical Systems, 1997.
Rockwood TH, Church JM, Fleshman JW,et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum 1999;42:1525–32.
Nelson R, Furner S, Jesudason V. Fecal incontinence in Wisconsin nursing homes: prevalence and associations. Dis Colon Rectum 1998;41:1226–9.
Drossman DA, Li Z, Andruzzi E,et al. U.S. Householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact. Dig Dis Sci 1993;38:1569–80.
Talley NJ, O'Keefe EA, Zinsmeister AR,et al. Prevalence of gastrointestinal symptoms in the elderly: a population-based study. Gastroenterology 1992;102:895–901.
Reilly WT, Talley NJ, Pemberton JH. Fecal incontinence: prevalence and risk factors in the community [Abstract]. Gastroenterology 1995;108:A32.
Dey AN. Characteristics of elderly nursing home residents: data from the 1995 National Nursing Home Survey. Advance data from vital and health statistics; no. 289. Hyattsville, Maryland: National Center for Health Statistics 1997.
Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol 1996;91:33–6.
Okamoto GA, Lamers JV, Shurtleff DB. Skin breakdown in patients with myelomeningocele. Arch Phys Med Rehab 1983;64:20–3.
Menter R, Weitzenkamp D, Cooper D, Bingley J, Charlifue S, Whiteneck G. Bowel management outcomes in individuals with long-term spinal cord injuries. Spinal Cord 1997;35:608–12.
Krogh K, Nielsen J, Djurhuus JC, Mosdal C, Sabroe S, Laurberg S. Colorectal function in patients with spinal cord lesions. Dis Colon Rectum 1997;40:1233–9.
Harari D, Sarkarati M, Gurwitz JH, McGlinchey-Berroth G, Minaker KL. Constipation-related symptoms and bowel program concerning individuals with spinal cord injury. Spinal Cord 1997;35:394–401.
Hinds JP, Eidelman BH, Wald A. Prevalence of bowel dysfunction in multiple sclerosis. A population survey. Gastroenterology 1990;98:1538–42
Feldman M, Schiller LR. Disorders of gastrointestinal motility associated with diabetes mellitus. Ann Int Med 1983;98:378–84.
Drossman DA, Sandler RS, Broom CM, McKee DC. Urgency and fecal soiling in people with bowel dysfunction. Dig Dis Sci 1986;31:1221–5.
Wagner TH, Hu T-W. Economic costs of urinary incontinence in 1995. Urology 1998;51:355–61.
Rockwood TH, Church JM, Fleshman JW,et al. Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 2000;43:9–17.
O'Keefe EA, Talley NJ, Zinsmeister AR, Jacobsen SJ. Bowel disorders impair functional status and quality of life in the elderly: a population-based study. J Gerontol Series A, Biological Sciences & Medical Sciences 1995;50:M184–9.
Burnett C, Whitehead WE, Drossman D. Psychological distress and impaired quality of life in patients with functional anorectal disorders [abstract]. Gastroenterology 1998;114:A729.
Crowell MD, Schettler-Duncan VA, Brookhart K, Barofsky I. Fecal incontinence: impact on psychosocial function and health-related quality of life [abstract]. Gastroenterology 1998;114:A738.
Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SS. Functional disorders of the anus and rectum. In: Drossman DA, Corazziari E, Talley NJ, Thompson WG, Whitehead WE, eds. Rome II: the functional gastrointestinal disorders. 2nd ed. McLean, VA: Degnon Associates, 2000:483–532.
Sagar PM, Pemberton JH. Anorectal and pelvic floor function. Relevance to continence, incontinence, and constipation. Gastroenterol Clin North Am 1996;25:163–82.
Keating JP, Stewart PJ, Eyes AA, Warner D, Bokey EL. Are special investigations of value in the management of patients with fecal incontinence? Dis Colon Rectum 1997;40:896–901.
Diamant NE, Kamm MA, Wald A, Whitehead WE. AGA technical review on anorectal testing techniques. Gastroenterology 1999;116:735–60.
Cheong DM, Vaccaro CA, Salanga VD, Wexner SD, Phillips RC, Hanson MR. Electrodiagnostic evaluation of fecal incontinence. Muscle Nerve 1995;18:612–9.
Wexner SD, Marchetti F, Salanga VD, Corredor C, Jagelman DG. Neurophysiologic assessment of the anal sphincters. Dis Colon Rectum 1991;34:606–12.
Vernava AM III, Longo WE, Daniel GL. Pudendal neuropathy and the importance of EMG evaluation of fecal incontinence. Dis Colon Rectum 1993;36:23–7.
Laurberg S, Swash M, Henry MM. Delayed external sphincter repair for obstetric tear. Br J Surg 1988;75:786–8.
Gilliland R, Altomare DF, Moreira H Jr, Oliveira L, Gilliland JE, Wexner SD. Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty. Dis Colon Rectum 1998;41:1516–22.
Engel AF, Kamm MA, Sultan AH, Bartram CI, Nicholls RJ. Anterior anal sphincter repair in patients with obstetric trauma. Br J Surg 1994;81:1231–4.
Ternent CA, Shashidharan M, Blatchford GJ, Christensen MA, Thorson AG, Sentovich SM. Transanal ultrasound and anorectal physiology findings affecting continence after sphincteroplasty. Dis Colon Rectum 1997;40:462–7.
Levine MD. Children with encopresis: a descriptive analysis. Pediatrics 1975;56:412–6.
Lowery SP, Srour JW, Whitehead WE, Schuster MM. Habit training as treatment of encopresis secondary to chronic constipation. J Pediatric Gastroenterol Nutr 1985;4:397–401.
Read NW, Celik AF, Katsinelos P. Constipation and incontinence in the elderly. J Clin Gastroenterol 1995;20:61–70.
Loening-Baucke V. Chronic constipation in children. Gastroenterology 1993;105:1557–64.
Loening-Baucke V. Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis. J Pediatr 1990;116:214–22.
Wald A, Chandra R, Gabel S, Chiponis D. Evaluation of biofeedback in childhood encopresis. J Pediatric Gastroenterol Nutr 1987;6:554–8.
Van der Plas RN, Benninga MA, Bueller HA,et al. Biofeedback training in treatment of childhood constipation: a randomized controlled study. Lancet 1996;348:776–80.
Van der Plas RN, Benninga MA, Redekop WK, Taminiau JA, Buller HA. Randomised trial of biofeedback training for encopresis. Arch Dis Child 1996;75:367–74.
Palmer KR, Corbett CL, Holdsworth CD. Double-blind cross-over study comparing loperamide, codeine and diphenoxylate in the treatment of chronic diarrhea. Gastroenterology 1980;79:1272–5.
Read M, Read NW, Barber DC, Duthie HL. Effects of loperamide on anal sphincter function in patients complaining of chronic diarrhea with fecal incontinence and urgency. Dig Dis Sci 1982;27:807–14.
Sun WM, Read NW, Verlinden M. Effects of loperamide oxide on gastrointestinal transit time and anorectal function in patients with chronic diarrhoea and faecal incontinence. Scand J Gastroenterol 1997;32:34–8.
Cerulli MA, Nikoomanesh P, Schuster MM. Progress in biofeedback conditioning for fecal incontinence. Gastroenterology 1979;76:742–6.
Whitehead WE, Burgio KL, Engel BT. Biofeedback treatment of fecal incontinence in geriatric patients. J Am Geriatr Soc 1985;33:320–4.
Whitehead WE, Parker L, Bosmajian L,et al. Treatment of fecal incontinence in children with spina bifida: comparison of biofeedback and behavior modification. Arch Phys Med Rehab 1986;67:218–24.
Sangwan YP, Coller JA, Barrett RC, Roberts PL, Murray JJ, Schoetz DJ Jr. Can manometric parameters predict response to biofeedback therapy in fecal incontinence? Dis Colon Rectum 1995;38:1021–5.
Engel BT, Nikoomanesh P, Schuster MM. Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence. N Engl J Med 1974;290:646–9.
Glia A, Gylin M, Akerlund JE, Lindfors U, Lindberg G. Biofeedback training in patients with fecal incontinence. Dis Colon Rectum 1998;41:359–64.
MacLeod JH. Biofeedback in the management of partial anal incontinence. Dis Colon Rectum 1983;26:244–6.
Rieger NA, Wattchow DA, Sarre RG,et al. Prospective trial of pelvic floor retraining in patients with fecal incontinence. Dis Colon Rectum 1997;40:821–6.
Latimer PR, Campbell D, Kasperski J. A components analysis of biofeedback in the treatment of fecal incontinence. Biofeedback Self Regul 1984;9:311–24.
Miner PB, Donnelly TC, Read NW. Investigation of mode of action of biofeedback in treatment of fecal incontinence. Dig Dis Sci 1990;35:1291–8.
Enck P. Biofeedback training in disordered defecation: a critical review. Dig Dis Sci 1993;38:1953–60.
Rao SS, Enck P, Loening-Baucke V. Biofeedback therapy for defecation disorders. Dig Dis 1997;15(Suppl 1):78–92.
Norton C, Hosker G, Brazzelli M. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. (Cochrane Review). In: The Cochrane Library, Issue 3, Oxford: Update Software, 2000.
Oliveira L, Pfeifer J, Wexner SD. Physiological and clinical outcome of anterior sphincteroplasty. Br J Surg 1996;83:502–5.
Orkin BA. Fecal incontinence: evaluation. In: Smith LE, ed. A practical guide to anorectal testing. 2nd ed. New York: Igaku-Shoin, 1995:301–18.
Nikiteas N, Korsgen S, Kumar D, Keighley MR. Audit of sphincter repair: factors associated with poor outcome. Dis Colon Rectum 1996;39:1164–70.
Genadry R, Nichols D. Recurrent anal incontinence. In: Nichols D, ed. Reoperative gynecologic and obstetrical surgery. 2nd ed. St Louis: Mosby, 1997:240.
Nyam D, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 1999;42:1306–10.
Bachoo P, Brazzelli M, Grant A. Surgery for faecal incontinence in adults (Cochrane Review). In: The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
Jensen LL, Lowry AC. Biofeedback improves functional outcome after sphincteroplasty. Dis Colon Rectum 1997;40:197–200.
Baeten CG, Geerdes BP, Adang EM,et al. Anal dynamic graciloplasty in the treatment of intractable fecal incontinence. N Engl J Med 1995;332:1600–5.
Williams NS, Patel J, George BD, Hallan RI, Watkins ES. Development of an electrically stimulated neoanal sphincter. Lancet 1991;338:1166–9.
Madoff RD, Rosen HR, Baeten CG,et al. Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial. Gastroenterology 1999;116:549–56.
Lehur P-A, Michot F, Denis P,et al. Results of artificial sphincter in severe anal incontinence: report of 14 consecutive implantations. Dis Colon Rectum 1996;39:1352–5.
Wong WD, Jensen LL, Bartolo DC, Rothenberger DA. Artificial anal sphincter. Dis Colon Rectum 1996;39:1345–51.
Vaizey CJ, Kamm MA, Gold DM, Bartram CI, Halligan S, Nicholls RJ. Clinical, physiological, and radiological study of a new purpose-designed artificial bowel sphincter. Lancet 1998;352:105–9.
MacDonagh RP, Sun WM, Smallwood R, Forster D, Read NW. Control of defecation in patients with spinal injuries by stimulation of sacral anterior nerve roots. BMJ 1990;300:1494–97.
Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP. Electrical stimulation of sacral spinal nerves for treatment of fecal incontinence. Lancet 1995;346:1124–7.
Vaizey CJ, Kamm MA, Turner IC, Nicholls RJ, Woloszko J. Sacral nerve stimulation for faecal incontinence: evaluation of short term efficacy and effect on anorectal function [Abstract]. Gastroenterology 1997;112:A842.
Mills PM, Deakin M, Kiff ES. Percutaneous electrical stimulation for ano-rectal incontinence. Physiotherapy 1990;76:433–8.
Pescatori M, Pavesio R, Anastasio G, Daini S. Transanal electrostimulation for fecal incontinence: clinical, psychologic, and manometric prospective study. Dis Colon Rectum 1991;34:540–5.
Binnie NR, Kawimbe BM, Papachrysostomou M, Smith AN. Use of the pudendo-anal reflex in the treatment of neurogenic faecal incontinence. Gut 1990;31:1051–5.
Scheuer M, Kuijpers HC, Bleijenberg G. Effect of electrostimulation on sphincter function in neurogenic fecal continence. Dis Colon Rectum 1994;37:590–4.
Malone PS, Wheeler RA, Williams JE. Continence in patients with spina bifida: long term results. Arch Dis Child 1994;70:107–10.
Kalidasan V, Elgabroun MA, Guiney EJ. Button caecostomy in the management of faecal incontinence. Br J Surgery 1997;84:694–7.
Fukunaga K, Kimura K, Lawrence JP, Soper RT, Phearman LA. Button device for antegrade enema in the treatment of incontinence and constipation. J Pediatr Surg 1996;31:1038–9.
Curry JI, Osborne A, Malone PS. The MACE procedure: experience in the United Kingdom. J Pediatr Surg 1999;34:338–40.
Gerharz EW, Vik V, Webb G, Leaver R, Shah PJ, Woodhouse CR. The value of the MACE (Malone antegrade colonic enema) procedure in adult patients. J Am Coll Surg 1997;185:544–7.
Pearl RK, Prasad ML, Orsay CP, Abcarian H, Tan AB, Melzl MT. Early local complications from intestinal stomas. Arch Surg 1985;120:1145–7.
Shirran E, Brazzelli M. Absorbant products for the containment of urinary and/or faecal incontinence in adults (Cochrane Review). In: The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
Kamm MA. Fortnightly review: faecal incontinence. BMJ 1998;316:528–32.
Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905–11.
Ryhammer AM, Laurberg S, Hermann AP. Long-term effect of vaginal deliveries on anorectal function in normal perimenopausal women. Dis Colon Rectum 1996;39:852–9.
Snooks SJ, Swash M, Henry MM, Setchel M. Risk factors in childbirth causing damage to the pelvic floor innervation. Int J Colorectal Dis 1986;1:20–4.
Author information
Authors and Affiliations
Additional information
This article is a summary of the Consensus Conference on Treatment Options in Fecal Incontinence, Milwaukee, Wisconsin, April 20 to 21, 1999, sponsored by International Foundation for Functional Gastrointestinal Disorders, and Office of Continuing Medical Education, University of Wisconsin Medical School, with support from American College of Gastroenterology, American Society of Colon and Rectal Surgeons, American Medical Systems, Ana-Tech, Meditronics Synectics, Sandhill Scientific Instruments, and G&W Labs.
About this article
Cite this article
Whitehead, W.E., Wald, A. & Norton, N.J. Treatment options for fecal incontinence. Dis Colon Rectum 44, 131–142 (2001). https://doi.org/10.1007/BF02234835
Issue Date:
DOI: https://doi.org/10.1007/BF02234835