Fecal Incontinence in Women: Causes and Treatment

Ashima Makol; Madhusudan Grover; William E Whitehead

Women's Health. 2008;4(5):517-528.

Case Definition

Fecal incontinence refers to the involuntary loss of fecal matter from the anal canal.^[7] There is no consensus on whether the definition should include involuntary loss of flatus versus being restricted to involuntary loss of solid or liquid stool or mucus. Patients often report that the involuntary loss of flatus should be included in the definition because it is very embarrassing and has an adverse impact on QOL,^[8] and some epidemiological studies^[9] and assessment scales^[10] include flatus in their definition. However, the involuntary loss of flatus occurs very commonly in healthy individuals, making it difficult to discriminate health from disease; for this reason, many physicians prefer to exclude flatus from the definition. There is an evolving consensus to use the term FI to refer only to involuntary loss of solid or liquid stool or mucus and to use the term anal incontinence to include flatus as well as solid or liquid stool and mucus.^[11] Clinicians often distinguish among three subtypes of FI that appear to have different etiologies and different treatments:

Passive incontinence – refers to the involuntary discharge of stool or gas without awareness;
Urge incontinence – refers to the discharge of fecal matter in spite of active attempts to retain bowel contents;
Fecal soiling – is the staining of underwear without loss of significant amounts of fecal material.^[12]

The severity of FI is related to:

The frequency of incontinence
The type of fecal material lost
The volume of stool lost^[10,13]

The impact of FI on QOL is directly related to these three factors.

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Sidebar: Executive Summary

Fecal Incontinence (FI) is a common medical condition affecting up to 15% of women.

It significantly impairs the lifestyle of women and has a tremendous negative impact on social interactions and self-image, resulting in poor quality of life, work absenteeism and self-imposed isolation and depression.

The physiological mechanisms that maintain continence are adequate strength in the pelvic floor muscles to hold back a bowel movement, adequate compliance of the rectum to be able to store stool between bowel movements, ability to sense rectal filling and normal stool consistency. Deficits in any of these may contribute to FI and, in any given patient, the etiology may be multifactorial.

Risk factors that are unique to women include obstetric trauma (instrumental vaginal delivery, prolonged second stage of labor, large neonatal birthweight and occipito-posterior presentation) and hysterectomy. Other risk factors common to both men and women include chronic diarrhea or urgency, obesity and older age. Systemic diseases that increase the risk of FI are irritable bowel syndrome and diabetes, and many neurological disorders increase the risk of FI. Urinary incontinence is a frequently associated condition.

Primary prevention strategies include reducing the incidence of diarrheal diseases through public health measures, discouraging routine use of episiotomies and internal anal sphincter myectomies, encouraging the use of pelvic floor exercises immediately after childbirth and decreasing obesity. Secondary prevention hinges on increasing the willingness of patients to consult their doctors about FI and the willingness of physicians to screen for FI. Conservative treatment measures that are effective are already available.

The role of elective cesarean section to prevent FI is controversial.

Treatments range from education and conservative medical management to biofeedback and surgery. Conservative treatment emphasizes normalization of stool consistency with antidiarrheal drugs or laxatives and encouragement of pelvic floor exercises. Biofeedback aims to strengthen pelvic floor muscles and improve perception of rectal sensations. The most common surgical options are sphincteroplasty, injection of bulking agents to improve resting pressure in the anal canal and colostomy. Sacral nerve stimulation is an experimental approach that appears promising.

It is important to sensitize general practitioners to this under-recognized condition with a high prevalence. Since effective therapies are available, clinicians who care for postpartum and elderly women should routinely screen for FI and offer evaluation and treatment to women with FI.

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