Sage Journals: Discover world-class research

Abstract

Keywords

biofeedback epidemiology fecal incontinence health-related quality of life prevention treatment

Fecal incontinence is a common problem in women, which often enforces life changes owing to embarrassment and social stigma. It is frequently not reported or diagnosed. Age, obstetric trauma, pelvic surgery, chronic diarrhea, obesity and other medical conditions, such as diabetes and stroke, increase the risk of fecal incontinence. Preventive strategies include avoiding diarrheal triggers, discouraging the routine use of episiotomies, early recognition and management of obstetric injuries and possibly pelvic floor muscle exercises after childbirth. Treatment options are available and should be discussed with the patient. These, in order of progression, are education and medications for diarrhea or constipation, supportive care, biofeedback training and surgery.

Fecal incontinence (FI) is a very common complaint; it affects up to 15% of community-living women [1,2] and approximately half of the women in nursing homes [3,4]. It is widely believed to be more common in women than in men [5], as women are exposed to a unique set of risk factors during pregnancy and childbirth. However, population-based studies that include subjects of all ages fail to find a significant difference between women and men [6]. The most likely explanation for this disparity is that FI has multiple causes and, when all ages are included, the contribution of obstetrical injuries is diluted. Reproductive hormones do not appear to have a direct impact on FI since age-related increases in the prevalence of FI are observed in both men and women [6].

This article will focus on FI in community-dwelling women because the risk factors associated with FI and the approaches to its prevention and management are very different from those in institutional settings. We will review the definition and prevalence of FI, its impact on quality of life (QOL), the physiological mechanisms that are responsible for maintaining continence, risk factors (especially those that differentially affect women), approaches for prevention and treatment options. This is not a comprehensive systematic review or a meta-analysis; however, it is an overview that reflects the opinions of the authors. We sought to make this overview understandable to patients and healthcare providers from a variety of disciplines.

This is an opportune time to review FI in women because there has been an explosion of new research findings on FI in the past 5 years, and there is a new emphasis on prevention reflected in the sponsorship by the NIH of the State of the Science Conference on the prevention of FI and urinary incontinence (UI) in December 2007 [5].

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.

Prevalence

Prior to the year 2000, there were almost no published data on the prevalence of FI. Since then, there have been a number of reports from population-based samples [9,14,15] as well as clinical samples [16,17], and there are now systematic reviews [2,18,19] and a meta-analysis [6]. Nevertheless, the reported prevalence estimates still vary in a wide range. Factors contributing to this variability include differences in case definition (anal incontinence vs FI), differences in the population studied, especially the age of the sample [20], and whether nursing home residents are included. Reports of the prevalence of FI from population-based studies of community-dwelling adults range from 3 to 17% [14,15] depending on the age of the cohort, with prevalence in women increasing from 6% in those younger than 40 years to 15% in women older than 65 years [5]. The female:male ratio is estimated to be 3:2 [9].

The prevalence of FI may be underestimated – less than a third of people who identify themselves as having FI in surveys say they have reported this to their doctor [16] and, therefore, it is possible that some people might be reluctant to report FI in surveys as well.

Impact of fecal incontinence on quality of life

Although not a life-threatening symptom, FI can significantly impair a woman's lifestyle [8]. Severe FI has a devastating impact on social interactions and self-image [13,14]. Women who have FI may feel ashamed, embarrassed or humiliated, and some do not want to leave their homes out of the fear of having an ‘accident’ in public. Some remain tethered to the toilet in an attempt to minimize incontinence [21] while others learn the location of all the public toilets in any area where they plan to go and carefully plan each trip to be within reach of a toilet. This can result in work absenteeism, self-imposed isolation and depression [22 –25].

Little objective data exist on the effect of incontinence on the quality of relationships with family members and sexual partners. There is some evidence suggesting impaired sexual relationships in individuals with incontinence [26]. However, when women are frail and are dependent on family members or other caregivers for assistance with toileting, FI may be a significant source of stress owing to the physical and mental effort needed for some of the tasks and the unpleasantness of dealing with incontinence [27]. When caregivers can no longer cope with the additional burden imposed by incontinence, the likelihood of transfer to a nursing home increases.

Economic impact of fecal incontinence

Very little data are available on the direct and indirect healthcare costs associated with FI, since the few studies that have looked at healthcare costs for incontinence have not distinguished between UI and FI. The largest known direct healthcare cost is the cost of nursing home admission; since FI and UI rank as the second leading causes of nursing home admission, this is a considerable but poorly defined cost to society [28]. For women living in the community who have FI, the principal direct healthcare costs are for supplies e.g., (diapers, absorbent pads and panties) and antidiarrheal drugs. Approximately US$400 million/year are spent on adult diapers [29,30], and these costs are usually not reimbursed by insurance companies. The costs for medical, behavioral or surgical treatment have not been systematically studied [5]. A study by a surgical group estimated the average cost for evaluation and treatment of FI to be $17,166 per patient [31].

Indirect costs include lost wages by individuals with FI as well as family members who may miss work to help care for them. With the progressive aging of the population, and with incontinence being a major caregiver burden and predictor of institutional placement, the role and responsibility of spousal caregivers further increases. This is becoming more important because the government is restraining expenditures for institutional healthcare.

Pathophysiology & diagnostic tests

Fecal incontinence results when the pressure in the rectum exceeds anal sphincter pressure. Coughing or lifting can transiently increase intra-abdominal pressure and result in stool leakage if the sphincter is weak, and obesity may cause a chronic increase in intrarectal pressure. Forceful propulsion of stool into the rectum and/or loose stools may also overwhelm weak sphincter muscles as a result of infectious diarrhea or chronic conditions, such as irritable bowel syndrome (IBS). The strength of pelvic floor muscles can be affected by injuries to pelvic floor muscles, such as those sustained during childbirth, or by neurological disorders, such as diabetic neuropathy or spinal cord injury that affect the innervation of pelvic floor muscles. In addition, loss of the ability to perceive any increases in rectal pressure can result in a failure to contract pelvic floor muscles at appropriate times to prevent incontinence.

To state these pathophysiological observations more generally and in a way that provides a guide to diagnostic assessment, continence for stools depends on four main factors: rectal sensation, rectal storage capacity, anal sphincter strength and stool consistency. If any of these is compromised, FI can occur [7]. The first three factors are dependent on the structural integrity and innervation of the rectum, anus and adjoining pelvic floor muscles, whereas stool consistency is determined by the motility (contractions) of the colon. In any one patient, multiple mechanisms may be involved [7] so diagnostic evaluation should take all of these factors into account.

Standard diagnostic tests include anorectal manometry (pressure measurements in the anal canal and rectum) to assess pelvic floor muscle strength, rectal sensation and rectal compliance, and anal canal ultrasound to assess structural defects in the anal sphincters. Other diagnostic tests that may complement these standard tests include needle electromyography (EMG) [32] or surface EMG of the anal canal [33], or pudendal nerve latency studies (pudendal nerve terminal motor latency) [34] to assess the integrity of pudendal nerves innervating the pelvic floor. Pelvic MRI is sometimes substituted for anal canal ultrasound [35]. These tests permit objective assessment and help to plan focused therapy [36]. More detailed descriptions of the physiological mechanisms responsible for the maintenance of continence and the diagnostic tests used to determine which factors are important in a specific patient are available elsewhere [7,37].

Risk factors

Several risk factors for FI have been identified in epidemiological studies or clinical case series. We will first discuss those risk factors that are unique to women.

Obstetric trauma is a major predisposing factor [38]. The injury may involve either the external anal sphincter, internal anal sphincter or the pudendal nerves, or all three. Prospective studies demonstrate that nearly 35% of primiparous women have evidence of sphincter disruption following vaginal delivery [38 –40], and between a third to two-thirds of women who sustain a recognized third-degree tear during delivery subsequently suffer from FI [41 –43]. More severe fourth-degree sphincter tears convey a greater risk of FI than smaller third-degree tears [44,45]. FI is known to be more prevalent in women who deliver vaginally and have recognized anal sphincter tears (17%) compared with those who deliver vaginally without such tears (8%) [46]. Other important obstetrical risk factors for both sphincter laceration and FI are a cumulative number of vaginal deliveries [47], vacuum extraction, forceps delivery, prolonged second stage of labor, large birthweight and occipito-posterior presentation [48 –51]. Some studies suggest that cesarean delivery is associated with lower rates of sphincter laceration and FI compared with vaginal delivery [52], but other studies find no significant difference [53,54]. When an obstetrical injury does occur, rates of FI are greatest in the immediate postpartum period and decline by 6 months [55]. However, FI can also occur or recur many years later [56]. It has been difficult to evaluate the long-term impact of sphincter laceration on FI because there is a strong tendency for the prevalence of FI to increase with age, independent of obstetric history [1]. However, it has been shown that women with a history of third- or fourth-degree sphincter laceration are at increased risk of sphincter laceration and incontinence during subsequent vaginal deliveries [45].

Episiotomy is an obstetric technique in which the external sphincter is intentionally cut in the belief that this prevents uncontrolled tears on the perineum and sphincter during vaginal childbirth. This was once standard practice and is still performed in some places. However, large case series have demonstrated that episiotomy does not reduce the severity of sphincter lacerations or the risk of FI, but instead exacerbates it [57,58]. Midline episiotomies are associated with higher rates of sphincter laceration compared with mediolateral episiotomy [59].

Hysterectomy is also a risk factor for FI in women, and the association is stronger if the hysterectomy is combined with oophorectomy [14]. The mechanism for this is unknown; it does not appear to be due to the loss of estrogen, since no differences in prevalence have been found between women on HRT and those not on it [14].

Hemorrhoids are more common in women than in men and often develop for the first time during straining with childbirth [60]. Overall, 48–63% of patients with grade 3 or 4 hemorrhoids (requiring manual reduction), report soiling of underwear [61,62]. Moreover, surgical treatment of hemorrhoids sometimes includes a myectomy of the internal anal sphincter to reduce anal canal pressure (and, hence, reduce straining), and this is associated with an increased incidence of FI. In a large case series at the Mayo Clinic (Rochester, MN, USA), myectomy was shown to result in some degree of FI in 45% of individuals postoperatively and was found to be significantly higher in women [63].

There is a higher incidence of obstetrical injury in Asian compared with Caucasian women [64]. A postal survey carried out in 7879 women who delivered babies during the same year at three hospitals showed a higher incidence of FI in Asian women than in Caucasians (OR = 3.2) [52]. However, another study reported a nonsignificant tendency for fewer Asian women to report FI compared with Caucasian women (21 vs 29%) [65]. In the Childbirth and Pelvic Symptoms study [46], there was indirect evidence to suggest that African–American women were less likely to sustain a third- or fourth-degree laceration (this was shown by the fact that they were less frequent in the control group without tears) and, among women with sphincter tears, African–Americans made up most (59%) of the ‘other races’ category that were significantly less likely than Caucasians to report FI in the postpartum period. These differences may be related to anthropometric differences in pelvic anatomy.

Age is significantly associated with the prevalence of FI in both men and women [46,66], although the physiological mechanisms that account for the increased risk of FI in older people are unknown. Age at childbirth is also associated with increased risk of obstetrical complications leading to an increased risk of FI [46].

Diarrhea is consistently found to be a risk factor for FI in both men and women with odds ratios (ORs) generally above 4 [14,67]. There is an interaction between stool consistency and structural defects to the sphincter – in women with third- or fourth-degree sphincter lacerations sustained during childbirth, the likelihood of FI is greater in women with frequent loose stools as compared to those with formed stools [68]. The relationship between diarrhea and FI is probably causative, as liquid stool is more difficult to control than solid stool. The symptom of urgency (having to rush to the toilet) has also been associated with FI. Two population-based surveys found urgency to be a strong risk factor (OR = 5) that is independent of diarrhea and other risk factors [56,67].

Since pathophysiological mechanisms overlap for UI and FI, an association between the two would be expected. Population-based studies have demonstrated that up to 50% of patients with FI also have UI (double incontinence) and the risk of FI in individuals with UI may be increased by up to sixfold [69 –72]. However, UI is probably not a contributing cause of FI; it serves only as a marker variable to alert the clinician to screen for FI.

Obesity is a risk factor for both FI and UI [73]. The mechanism for this may be that obesity increases the intra-abdominal pressure on the pelvis, rendering the continence mechanism less efficient. It is not known whether weight loss in the obese incontinent patient results in an improvement in FI.

Population-based studies have demonstrated an excess incidence of FI in patients with IBS (OR = 2–8) [66,74], and IBS is more common in women than in men by approximately 2:1 [75]. Inflammatory bowel disease (ulcerative colitis and Crohn's disease) is also associated with a higher prevalence of FI [76].

Many neurological disorders place patients at increased risk of FI. Diabetes mellitus (DM) was associated with a 40% increase in the risk of FI in one study [66]. In a large, population-based study, the proportion of patients reporting FI to occur at least several times was 12.8% for DM patients versus 3.8% in non-DM patients, while those reporting FI to occur often was 2.6 versus 0.8% in DM and non-DM patients, respectively; the OR was estimated to be 2.7 [77]. Microvascular complications associated with DM may damage the innervation of the rectum and pelvic floor musculature and this is presumed to be the mechanism for the increased risk of FI in DM patients [78]. Other neurological diseases, including stroke, multiple sclerosis, dementia, traumatic spinal cord and brain injury, have been associated with FI. These can affect continence by interfering with sensory perception or motor function, or both. In the Copenhagen Stroke Study investigating 935 consecutive admissions for stroke, FI was transiently present in the majority of patients and the prevalence of FI remained elevated compared with population norms at 1 year [79]. A total of 30–50% of patients with multiple sclerosis are reported to have FI [80]. Idiopathic pudendal neuropathy is another common cause of FI, particularly in older women, and frequently occurs in association with a sphincter defect [81].

In addition to its association with specific diseases and injuries affecting the pelvic floor, FI is also associated with a high overall burden of illness. Goode and colleagues found that poor self-perceived general health status was a risk factor for FI, with an OR measuring 1.9 among women with FI versus those without it [14]. There are also reports that childhood sexual or physical abuse and adult sexual abuse increase the risk of FI [5]. The mechanism for this is unknown.

The ability to determine risk factors for FI is limited by the way in which most studies have been designed and analyzed. The majority of studies on FI have been cross-sectional in design, which helps identify associations with FI but not causality. An example is UI, which is strongly associated with FI but is unlikely to be a cause of FI. Therefore, it is not known if changing a particular risk factor will reduce or eliminate FI. More prospective studies are needed to identify modifiable risk factors.

Prevention

Preventive measures can be categorized into primary and secondary prevention, as depicted in Box 1. Primary prevention refers to eliminating or ameliorating risk factors before FI develops in order to delay or prevent its occurrence. Secondary prevention refers to screening and detection of disease at an early stage, when FI is more amenable to treatment and before progression to a point that has severe adverse effects on health and QOL. Both primary and secondary prevention are important goals in FI.

Primary prevention

Modifiable risk factors for FI include diarrhea, obesity and surgical/obstetrical practices. The prevention and treatment of diarrhea and obesity are established societal goals independent of their association with FI, and there is a large body of literature devoted to the management of both. However, obstetrical and surgical practices are areas in which improvements can be made.

In the past, episiotomy was routinely carried out at delivery, based on the belief that this would control and, therefore, minimize sphincter tears. However, recent evidence demonstrates that episiotomy does not prevent sphincter laceration but, instead, tends to make it worse [57]. The use of routine episiotomy can cause morbidity in women who would have otherwise had an intact perineum [58]. In fact, the risk of anal sphincter injury from a nonextending midline episiotomy is triple that compared with a spontaneous laceration [57]. On the strength of this evidence, many obstetricians have abandoned episiotomy, and this decrease in the use of episiotomy has been associated with a substantial reduction in the incidence of sphincter lacerations [51]. Nevertheless, some obstetricians continue to employ episiotomy. Practice guidelines now recommend that the routine use of episiotomy should be avoided [5].

There is some evidence that cesarean delivery may protect against sphincter lacerations during childbirth [52], although studies are inconclusive [53,54]. This has sparked debate about offering elective cesarean delivery to all women or at least to women judged to be at high risk for sphincter lacerations, as a means of reducing the risk of obstetrical injury and possible FI [5]. Although it is difficult to predict anal sphincter injury before delivery or identify the women at risk, certain parameters, such as estimated neonatal birthweight of above 4 kg, occipito-posterior presentation, prolonged second stage of labor, previous history of sphincter trauma and connective tissue disease and obesity [82], are known to increase the propensity to sustain perineal injury and poor wound healing and, thus, increase the likelihood of subsequent FI [83]. However, cesarean delivery does not completely protect the pelvic floor, and rates of FI are noted to be higher among women who have undergone elective cesarean deliveries when compared with nulliparous controls [54]. Current guidelines recommend that elective cesarean delivery be considered only in those at high risk of sphincter trauma from vaginal delivery and in those who have had previous FI symptoms or evidence of anal sphincter injury [84 –86]. Although the evidence for a protective effect is disputed, the worldwide incidence of cesarean delivery is increasing; it accounts for 29% of all deliveries in the USA [201].

Box 1.

Preventive measures for fecal incontinence.

Primary prevention

Encourage and support public hygiene measures to reduce diarrheal diseases.

Discourage routine use of episiotomy except in limited circumstances.

Discourage use of internal anal sphincter myectomy for treatment of anal fissures and hemorrhoids.

Encourage debate and research on cesarean section for preventing sphincter laceration.

Secondary prevention

Physicians should include questions about fecal incontinence in routine review of systems.

Recognize high-risk patients: postpartum, those with diarrhea or urgency, irritable bowel syndrome, diabetes mellitus or neurological disorders.

Effective management of these conditions that increase the risk of fecal incontinence.

Early recognition and management after high-risk surgical interventions, such as instrumented vaginal delivery or internal anal sphincterotomy.

Encourage pelvic floor muscle exercises.

There is some evidence that pelvic floor muscle training (also known as Kegel exercises) are effective in preventing and reversing childbirth-related FI for the first year after delivery, and that these exercises have short-term effectiveness in preventing and reversing FI in older women [87]. One study demonstrated that when younger subjects were instructed in pelvic floor muscle exercises 3 months postnatally, they reported less frequent FI at 12-month follow-up [88]. However, further studies are needed before any conclusive recommendation can be made.

Secondary prevention

The greatest challenge to secondary prevention, specifically, preventing the progression of FI, is that most physicians do not screen for it. Surveys repeatedly demonstrate that fewer than 25% of patients with FI have discussed this with their physician [67,89,90]. There may be barriers, such as embarrassment and social stigma, which prevent patients from seeking medical help for this condition, but there is also a need for physicians to incorporate questions on FI into their routine review of symptoms. “If you don't ask, they won't tell” [91]. Increasing awareness of what can be done to treat FI may encourage more screening. Early endoanal ultrasound can help detect missed sphincter defects in those suspected to have a second-degree tear during delivery [41]. The presence of other risk factors should also alert the physician to screen for FI. These include diarrhea, urgency, IBS, DM and any neurological disorders.

Treatment

The goal of treatment for patients with FI is to restore, or at least improve, continence and minimize the impact of FI on QOL. Complete continence may not be achievable, depending on the etiology, but amelioration is possible for almost every patient. Treatment progresses through a series of steps that are progressively more aggressive and costly until adequate relief is achieved. These steps are education and medical management of stool consistency, pelvic floor muscle exercises and lifestyle adjustments, biofeedback or behavior modification and surgery. Pads and containment devices are an important adjunct to all these treatments, since they help the patient to avoid embarrassing accidents while undergoing treatment. The brief discussion of treatment that follows is prescriptive and not entirely evidence based. The authors acknowledge that some of these recommendations are their own opinions rather than the consensus of professional societies.

Medical management

Conservative medical management involves four techniques:

Educating the patient about the causes of FI and suggesting behavioral strategies for minimizing FI;

Teaching pelvic floor exercises during digital examination of the rectum and encouraging the patient to practice 100 squeezes/day;

Using antidiarrheal drugs or laxatives (as appropriate) to normalize stool consistency;

Recommendations regarding the use of pads and skin hygiene measures.

Education

Anatomical drawings are used to explain to patients how continence is normally maintained and how their own injury or disease affects this mechanism. This is combined with behavioral suggestions to adopt a regular bowel habit, such as attempting to have a bowel movement after the same meal each day, and to prepare for coughing or lifting by first contracting pelvic floor muscles. Advice about avoiding foods such as caffeine that may cause loose stools may also be helpful [12].

Pelvic floor exercises

These exercises are intended to strengthen weak pelvic floor muscles through daily exercise. There is evidence that they are effective, when taught correctly, at reducing FI [92,93]. Some studies suggest they may be as effective as biofeedback [94].

Drugs

Antidiarrheal agents, such as loperamide hydrochloride (Imodium®, Janssen Pharmaceutical, Titusville, NJ, USA) or diphenoxylate/atropine sulphate (Lomotil®, Searle, Chicago, IL, USA) are the mainstay of drug treatment for diarrhea-related FI. Placebo-controlled studies have demonstrated reduction in the frequency of FI, improvement in stool urgency, increase in colonic transit time as well as increase in the resting anal sphincter pressure [94 –96]. Codeine phosphate is also effective, but has significant systemic side effects and addiction potential. Ion-exchange resins, such as cholestyramine or colestipol, may be tried in patients with idiopathic bile salt malabsorption underlying their diarrhea and FI [97]. Most patients require low doses and titration is important to produce the desired result. One study has demonstrated that increasing dietary fiber is also helpful for reducing diarrhea-associated FI [98]. Enemas and suppositories play a role in the treatment of FI patients with incomplete rectal evacuation or postdefecation seepage [99]. Laxatives can also be used for constipation-associated FI, which is more commonly observed in children and the institutionalized elderly [12].

Pads & supportive measures

Pads should not be seen as an alternative to treatment, but as an adjunct to ongoing treatment; they provide a measure of security against embarrassment. These pads come in a variety of sizes, shapes and materials. With guidance from a nurse or physician, patients will be able to select the type of pad that is most appropriate for them. In addition, medical management should include advice on skin hygiene [12]. Timely recognition of soiling and immediate cleansing of the perianal skin is important. Use of a moist cloth or tissue is better for cleaning than using dry toilet paper. Barrier creams, such as zinc oxide and calamine lotion, may be useful in preventing skin excoriation. Topical antifungals may be used to treat infection where needed. Stool deodorants can help disguise smell.

Biofeedback

Biofeedback therapy is a form of motor skills learning. When learning a new motor skill, such as throwing a basketball, one tries repeatedly and learns from success and failure how to improve one's skill. However, when success is difficult to perceive, such as contraction of a weak anal sphincter muscle, it may be necessary to use machines to amplify weak contractions and display them in a form that the subject can use to facilitate learning. In addition to strengthening weak muscles, biofeedback is used to improve a subject's ability to perceive important physiological signals, such as the faint distensions of the rectum, which tell us when to contract the sphincters to avoid incontinence. This sensory training is accomplished by distending a rectal balloon with progressively smaller amounts of air and training the subject to attend to and to recognize weaker sensations than previously. Biofeedback training for FI involves both strength training and sensory training [100 –102].

Our laboratory carried out a randomized, controlled trial in which patients with symptoms of FI occurring at least once a week were first treated with conservative medical management to eliminate those who did not need biofeedback training [93]. The remaining patients were randomly assigned to receive either biofeedback or pelvic floor exercises alone for six biweekly sessions. A higher proportion of patients reported adequate relief after biofeedback training than after pelvic floor exercises (76 vs 41%, respectively), suggesting that biofeedback is superior to pelvic floor exercises and conservative management. However, the research team at St Marks Hospital in London, UK, did not find any difference between biofeedback and conservative management with pelvic floor exercises [92]. They believe that when patients are taught to perform pelvic floor exercises during a physical examination, with the therapist giving the patient verbal feedback based on the contractions they detect with their finger, the outcomes are as good as with instrumented biofeedback. Additional studies will be needed to resolve this important issue. It is clear, however, that intensive training by an experienced therapist can improve continence outcomes more than the use of conservative management.

Surgical management

The most commonly employed surgical treatments for FI are sphincteroplasty (plicating the separated ends of a torn sphincter muscle), injection of collagen or other bulking agents around the sphincter to increase anal canal resting pressure and colostomy or ileostomy. Obstetrical injury is the most common reason for performing a sphincteroplasty, and the short-term success rate is reported to be between 70 and 80% [103]. However, damage to the pudendal nerve is associated with a poorer outcome and by 5 years, fewer than 25% of women with a sphincteroplasty are still continent [104].

The injection of collagen or other bulking agents into the sphincter walls may be indicated if there is decreased resting pressure in the anal canal and passive leakage from the rectum [105]. A recent variation is to implant expandable microballoons in the submucosa of the anal canal. This can be performed as an outpatient procedure and has shown, at short-term follow-up, to improve incontinence scores with minimal adverse events [106]. However, it remains experimental, pending future work in a larger sample of patients followed over a longer period of time.

Colostomy or ileostomy involves bringing the colon or ileum to the surface of the abdominal wall where fecal material can be collected in a bag. This is something that both patients and surgeons regard as a last resort, but it does produce social continence and may improve QOL.

Among the experimental approaches to treating FI, the most promising is sacral nerve stimulation [107,108]. In this procedure, the surgeon uses a needle to insert electrodes into the sacral nerve plexus and explores to identify a site at which stimulation causes the external anal sphincter to contract. If such sites are found, the patient is provided with a temporary stimulator for approximately 2 weeks. If the 2-week trial is successful, the stimulator can be permanently implanted. Large clinical trials have now been carried out, which demonstrate improvements in 80–90% and full continence in approximately half of patients who are implanted [108,109]. There are a significant number of complications, including infections, device failures and migration of electrodes, but the overall experience has been positive [107,109,110].

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.

Conclusion & future perspective

Fecal incontinence is a common disorder affecting up to 15% of women, and it may have a devastating impact on QOL. Most patients do not seek treatment, apparently because of social stigma and pessimism that symptoms can be improved, and most physicians do not screen for it for similar reasons. However, it is treatable; most patients with FI can be substantially improved or cured through medical management, biofeedback or surgery. We recommend that appropriate professional societies make it a priority to:

Reduce the social stigma associated with FI so that more patients seek treatment

Educate primary-care physicians about treatment options and encourage screening

Develop and test prevention strategies

The major barriers to helping women with incontinence appear to not be the lack of research, but the social and professional barriers to diagnosing and treating this disorder.

Footnotes

The authors were supported by grants R24 DK067674 and RO1 DK57048. W Whitehead receives grant support from McNeil Pharmaceuticals, the makers of loperamide. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

References

Bharucha

Zinsmeister

Locke

: Prevalence and burden of fecal incontinence: a population-based study in women. Gastroenterology 129, 42–49 (2005).

Macmillan

Merrie

Marshall

Parry

: The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature. Dis. Colon Rectum 47, 1341–1349 (2004).

Dey

: Characteristics of elderly nursing home residents: data from the 1995 National Nursing Home Survey. Adv. Data 289, 1–8 (1997).

Nelson

Furner

Jesudason

: Fecal incontinence in Wisconsin nursing homes: prevalence and associations. Dis. Colon Rectum 41, 1226–1229 (1998).

Landefeld

Bowers

Feld

: National Institutes of Health State-of-the-Science Statement: prevention of fecal and urinary incontinence in adults. Ann. Intern. Med. 148(6), 449–458 (2008).

Pretlove

Radley

Toozs-Hobson

Thompson

Coomarasamy

Khan

: Prevalence of anal incontinence according to age and gender: a systematic review and meta-regression analysis. Int. Urogynecol. J. Pelvic Floor Dysfunct. 17, 407–417 (2006).

Bharucha

Wald

Enck

Rao

: Functional anorectal disorders. Gastroenterology 130, 1510–1518 (2006).

Norton

: The perspective of the patient. Gastroenterology 126, S175–S179 (2004).

Nelson

Norton

Cautley

Furner

: Community-based prevalence of anal incontinence. JAMA 274, 559–561 (1995).

10.

Rockwood

Church

Fleshman

: Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis. Colon Rectum 42, 1525–1532 (1999).

11.

Norton

Christiansen

Butler

: Anal incontinence. In: Incontinence Management (Volume 2). 2nd International Consultation on Incontinence. Abrams

Cardozo

Khoury

Wein

(Eds). Health Books, Plymouth, Plymbridge, UK, 985–1043 (2002).

12.

Rao

: Diagnosis and management of fecal incontinence. American College of Gastroenterology Practice Parameters Committee. Am. J. Gastroenterol. 99, 1585–1604 (2004).

13.

Bharucha

Zinsmeister

Locke

Schleck

McKeon

Melton

: Symptoms and quality of life in community women with fecal incontinence. Clin. Gastroenterol. Hepatol. 4, 1004–1009 (2006).

14.

Goode

Burgio

Halli

: Prevalence and correlates of fecal incontinence in community-dwelling older adults. J. Am. Geriatr. Soc. 53, 629–635 (2005).

15.

Edwards

Jones

: The prevalence of faecal incontinence in older people living at home. Age Ageing 30, 503–507 (2001).

16.

Johanson

Lafferty

: Epidemiology of fecal incontinence: the silent affliction. Am. J. Gastroenterol. 91, 33–36 (1996).

17.

Khullar

Damiano

Toozs-Hobson

Cardozo

: Prevalence of faecal incontinence among women with urinary incontinence. Br. J. Obstet. Gynaecol. 105, 1211–1213 (1998).

18.

Norton

Whitehead

Bliss

Metsola

Tries

: Conservative and pharmacological management of faecal incontinence in adults. In: Incontinence Management (Volume 2). Abrams

Cardozo

Khoury

Wein

(Eds). Health Publications Ltd, Paris, France, 1521–1563 (2005).

19.

Nelson

: Epidemiology of fecal incontinence. Gastroenterology 126, S3–S7 (2004).

20.

Perry

Shaw

McGrother

: Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut 50, 480–484 (2002).

21.

Miner

Jr : Economic and personal impact of fecal and urinary incontinence. Gastroenterology 126, S8–S13 (2004).

22.

Rockwood

Church

Fleshman

: Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis. Colon Rectum 43, 9–16 (2000).

23.

Talley

Young

Bytzer

: Impact of chronic gastrointestinal symptoms in diabetes mellitus on health-related quality of life. Am. J. Gastroenterol. 96, 71–76 (2001).

24.

Smallegan

: There was nothing else to do: needs for care before nursing home admission. Gerontologist 25, 364–369 (1985).

25.

Byrne

Pager

Rex

Roberts

Solomon

: Assessment of quality of life in the treatment of patients with neuropathic fecal incontinence. Dis. Colon Rectum 45, 1431–1436 (2002).

26.

Roe

May

: Incontinence and sexuality: findings from a qualitative perspective. J. Adv. Nurs. 30, 573–579 (1999).

27.

Cassells

Watt

: The impact of incontinence on older spousal caregivers. J. Adv. Nurs. 42, 607–616 (2003).

28.

Green

Smoker

Moore

: Urinary incontinence in subacute care – a retrospective analysis of clinical outcomes and costs. Med. J. Aust. 178, 550–553 (2003).

29.

Tariq

: Fecal incontinence in older adults. Clin. Geriatr. Med. 23, 857–869, vii (2007).

30.

Lahr

: Evaluation and treatment of incontinence. Pract. Gastroenterol. 12, 27–35 (1988).

31.

Mellgren

Jensen

Zetterstrom

Wong

Hofmeister

Lowry

: Long-term cost of fecal incontinence secondary to obstetric injuries. Dis. Colon Rectum 42, 857–865 (1999).

32.

Wiesner

Jost

: EMG of the external anal sphincter: needle is superior to surface electrode. Dis. Colon Rectum 43, 116–118 (2000).

33.

Thomas

Lefaucheur

Galula

de Parades

Bourguignon

Atienza

: Respective value of pudendal nerve terminal motor latency and anal sphincter electromyography in neurogenic fecal incontinence. Neurophysiol. Clin. 32, 85–90 (2002).

34.

Vernava

III Longo

Daniel

: Pudendal neuropathy and the importance of EMG evaluation of fecal incontinence. Dis. Colon Rectum 36, 23–27 (1993).

35.

Fletcher

Busse

Riederer

: Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders. Am. J. Gastroenterol. 98, 399–411 (2003).

36.

Jorge

Wexner

: Etiology and management of fecal incontinence. Dis. Colon Rectum 36, 77–97 (1993).

37.

Rao

: Pathophysiology of adult fecal incontinence. Gastroenterology 126, S14–S22 (2004).

38.

Kamm

: Obstetric damage and faecal incontinence. Lancet 344, 730–733 (1994).

39.

Sultan

Kamm

Hudson

Bartram

: Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. Br. Med. J. 308, 887–891 (1994).

40.

Sultan

Kamm

Hudson

Thomas

Bartram

: Anal-sphincter disruption during vaginal delivery. N. Engl. J. Med. 329, 1905–1911 (1993).

41.

Dudding

Vaizey

Kamm

: Obstetric anal sphincter injury: incidence, risk factors, and management. Ann. Surg. 247, 224–237 (2008).

42.

Norderval

Oian

Revhaug

Vonen

: Anal incontinence after obstetric sphincter tears: outcome of anatomic primary repairs. Dis. Colon Rectum 48, 1055–1061 (2005).

43.

Nichols

Nam

Ramakrishnan

Lamb

Currie

: Anal sphincter defects and bowel symptoms in women with and without recognized anal sphincter trauma. Am. J. Obstet. Gynecol. 194, 1450–1454 (2006).

44.

Nichols

Lamb

Ramakrishnan

: Differences in outcomes after third- versus fourth-degree perineal laceration repair: a prospective study. Am. J. Obstet. Gynecol. 193, 530–534 (2005).

45.

Sangalli

Floris

Faltin

Weil

: Anal incontinence in women with third or fourth degree perineal tears and subsequent vaginal deliveries. Aust. NZ J. Obstet. Gynaecol. 40, 244–248 (2000).

46.

Burgio

Borello-France

Richter

: Risk factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study. Am. J. Gastroenterol. 102, 1998–2004 (2007).

47.

Ballester

Minguez

Herreros

Hernandez

Sanchiz

Benages

: Prevalence of silent fecal and urinary incontinence in women from the town of Teruel. Rev. Esp. Enferm. Dig. 97, 78–86 (2005).

48.

Engel

Kamm

Bartram

Nicholls

: Relationship of symptoms in faecal incontinence to specific sphincter abnormalities. Int. J. Colorectal Dis. 10, 152–155 (1995).

49.

Gee

Durdey

: Urge incontinence of faeces is a marker of severe external anal sphincter dysfunction. Br. J. Surg. 82, 1179–1182 (1995).

50.

Hill

Corson

Brandon

Redford

Faragher

Kiff

: History and examination in the assessment of patients with idiopathic fecal incontinence. Dis. Colon Rectum 37, 473–477 (1994).

51.

Kudish

Sokol

Kruger

: Trends in major modifiable risk factors for severe perineal trauma, 1996–2006. Int. J. Gynaecol. Obstet. (2008) (Epub ahead of print).

52.

MacArthur

Glazener

Wilson

: Obstetric practice and faecal incontinence three months after delivery. BJOG 108, 678–683 (2001).

53.

Hannah

Hodnett

: Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial. JAMA 287, 1822–1831 (2002).

54.

Lal

Mann

Callender

Radley

: Does cesarean delivery prevent anal incontinence? Obstet. Gynecol. 101, 305–312 (2003).

55.

Borello-France

Burgio

Richter

: Fecal and urinary incontinence in primiparous women. Obstet. Gynecol. 108, 863–872 (2006).

56.

Bharucha

Zinsmeister

Locke

: Risk factors for fecal incontinence: a population-based study in women. Am. J. Gastroenterol. 101, 1305–1312 (2006).

57.

Signorello

Harlow

Chekos

Repke

: Midline episiotomy and anal incontinence: retrospective cohort study. Br. Med. J. 320, 86–90 (2000).

58.

Hartmann

Viswanathan

Palmieri

Gartlehner

Thorp

Jr Lohr

: Outcomes of routine episiotomy: a systematic review. JAMA 293, 2141–2148 (2005).

59.

Angioli

Gomez-Marin

Cantuaria

O'Sullivan

: Severe perineal lacerations during vaginal delivery: the University of Miami experience. Am. J. Obstet. Gynecol. 182, 1083–1085 (2000).

60.

Abramowitz

Sobhani

Benifla

: Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis. Colon Rectum 45, 650–655 (2002).

61.

Murie

Sim

Mackenzie

: The importance of pain, pruritus and soiling as symptoms of haemorrhoids and their response to haemorrhoidectomy or rubber band ligation. Br. J. Surg. 68, 247–249 (1981).

62.

Johannsson

Graf

Pahlman

: Bowel habits in hemorrhoid patients and normal subjects. Am. J. Gastroenterol. 100, 401–406 (2005).

63.

Nyam

Pemberton

: Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis. Colon Rectum 42, 1306–1310 (1999).

64.

Combs

Robertson

Laros

Jr : Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries. Am. J. Obstet. Gynecol. 163, 100–104 (1990).

65.

Huang

Thom

Kanaya

: Urinary incontinence and pelvic floor dysfunction in Asian–American women. Am. J. Obstet. Gynecol. 195, 1331–1337 (2006).

66.

Varma

Brown

Creasman

: Fecal incontinence in females older than aged 40 years: who is at risk? Dis. Colon Rectum 49, 841–851 (2006).

67.

Kalantar

Howell

Talley

: Prevalence of faecal incontinence and associated risk factors; an underdiagnosed problem in the Australian community? Med. J. Aust. 176, 54–57 (2002).

68.

Whitehead

: Fecal incontinence following obstetrical anal sphincter laceration is associated with frequent loose stools. Neurogastroenterol. Motil. 18(8), 680 (2006).

69.

Roberts

Jacobsen

Reilly

Pemberton

Lieber

Talley

: Prevalence of combined fecal and urinary incontinence: a community-based study. J. Am. Geriatr. Soc. 47, 837–841 (1999).

70.

Uustal

Wingren

Kjolhede

: Factors associated with pelvic floor dysfunction with emphasis on urinary and fecal incontinence and genital prolapse: an epidemiological study. Acta Obstet. Gynecol. Scand. 83, 383–389 (2004).

71.

Jelovsek

Barber

Paraiso

Walters

: Functional bowel and anorectal disorders in patients with pelvic organ prolapse and incontinence. Am. J. Obstet. Gynecol. 193, 2105–2111 (2005).

72.

Manning

Eyers

Korda

Benness

Solomon

: Is there an association between fecal incontinence and lower urinary dysfunction? Dis. Colon Rectum 44, 790–798 (2001).

73.

Richter

Burgio

Clements

Goode

Redden

Varner

: Urinary and anal incontinence in morbidly obese women considering weight loss surgery. Obstet. Gynecol. 10, 1272–1277 (2005).

74.

O'Keefe

Talley

Zinsmeister

Jacobsen

: Bowel disorders impair functional status and quality of life in the elderly: a population-based study. J. Gerontol. A Biol. Sci. Med. Sci. 50, M184–M189 (1995).

75.

Drossman

Camilleri

Mayer

Whitehead

: AGA technical review on irritable bowel syndrome. Gastroenterology 123, 2108–2131 (2002).

76.

Farrokhyar

Marshall

Easterbrook

Irvine

: Functional gastrointestinal disorders and mood disorders in patients with inactive inflammatory bowel disease: prevalence and impact on health. Inflamm. Bowel Dis. 12, 38–46 (2006).

77.

Bytzer

Talley

Leemon

Young

Jones

Horowitz

: Prevalence of gastrointestinal symptoms associated with diabetes mellitus: a population-based survey of 15,000 adults. Arch. Intern. Med. 161, 1989–1996 (2001).

78.

Russo

Botten

Kong

: Effects of acute hyperglycaemia on anorectal motor and sensory function in diabetes mellitus. Diabet. Med. 21, 176–182 (2004).

79.

Nakayama

Jorgensen

Pedersen

Raaschou

Olsen

: Prevalence and risk factors of incontinence after stroke. The Copenhagen Stroke Study. Stroke 28, 58–62 (1997).

80.

Caruana

Wald

Hinds

Eidelman

: Anorectal sensory and motor function in neurogenic fecal incontinence. Comparison between multiple sclerosis and diabetes mellitus. Gastroenterology 100, 465–470 (1991).

81.

Roig

Villoslada

Lledo

: Prevalence of pudendal neuropathy in fecal incontinence. Results of a prospective study. Dis. Colon Rectum 38, 952–958 (1995).

82.

Lind

Wallenburg

: Pregnancy and the Ehlers–Danlos syndrome: a retrospective study in a Dutch population. Acta Obstet. Gynecol. Scand. 81, 293–300 (2002).

83.

Chaliha

Kalia

Stanton

Monga

Sultan

: Antenatal prediction of postpartum urinary and fecal incontinence. Obstet. Gynecol. 94, 689–694 (1999).

84.

Sultan

Stanton

: Preserving the pelvic floor and perineum during childbirth – elective caesarean section? Br. J. Obstet. Gynaecol. 103, 731–734 (1996).

85.

Minkoff

Chervenak

: Elective primary cesarean delivery. N. Engl. J. Med. 348, 946–950 (2003).

86.

McKenna

Ester

Fischer

: Elective cesarean delivery for women with a previous anal sphincter rupture. Am. J. Obstet. Gynecol. 189, 1251–1256 (2003).

87.

Fernandez-Fraga

Azpiroz

Malagelada

: Significance of pelvic floor muscles in anal incontinence. Gastroenterology 123, 1441–1450 (2002).

88.

Chen

Lin

: Prevalence and correlations of anal incontinence and constipation in Taiwanese women. Neurourol. Urodyn. 22, 664–669 (2003).

89.

Faltin

Sangalli

Curtin

Morabia

Weil

: Prevalence of anal incontinence and other anorectal symptoms in women. Int. Urogynecol. J. Pelvic Floor Dysfunct. 12, 117–120 (2001).

90.

MacArthur

Bick

Keighley

: Faecal incontinence after childbirth. Br. J. Obstet. Gynaecol. 104, 46–50 (1997).

91.

Whitehead

: Diagnosing and managing fecal incontinence: if you don't ask, they won't tell. Gastroenterology 129, 6 (2005).

92.

Norton

Chelvanayagam

Wilson-Barnett

Redfern

Kamm

: Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology 125, 1320–1329 (2003).

93.

Heymen

Scarlett

Jones

Ringel

Drossman

Whitehead

: Randomized controlled trial shows biofeedback to be superior to alternative treatments for patients with fecal incontinence. Dis. Colon Rectum 50, 132 (2007).

94.

Sun

Read

Verlinden

: Effects of loperamide oxide on gastrointestinal transit time and anorectal function in patients with chronic diarrhoea and faecal incontinence. Scand. J. Gastroenterol. 32, 34–38 (1997).

95.

Hallgren

Fasth

Delbro

Nordgren

Oresland

Hulten

: Loperamide improves anal sphincter function and continence after restorative proctocolectomy. Dig. Dis. Sci. 39, 2612–2618 (1994).

96.

Herbst

Kamm

Nicholls

: Effects of loperamide on ileoanal pouch function. Br. J. Surg. 85, 1428–1432 (1998).

97.

Remes-Troche

Ozturk

Philips

Stessman

Rao

: Cholestyramine – a useful adjunct for the treatment of patients with fecal incontinence. Int. J. Colorectal Dis. 23, 189–194 (2008).

98.

Bliss

Jung

Savik

: Supplementation with dietary fiber improves fecal incontinence. Nurs. Res. 50, 203–213 (2001).

99.

Chassagne

Jego

Gloc

: Does treatment of constipation improve faecal incontinence in institutionalized elderly patients? Age Ageing 29, 159–164 (2000).

100.

Whitehead

Thompson

: Motility as a therapeutic modality: biofeedback. In: Atlas of Gastrointestinal Motility in Health and Disease. Schuster

(Ed.).Williams & Wilkins, Baltimore, MD, USA, 300–316 (1993).

101.

Palsson

Heymen

Whitehead

: Biofeedback treatment for functional anorectal disorders: a comprehensive efficacy review. Appl. Psychophysiol. Biofeedback 29, 153–174 (2004).

102.

Rao

: The technical aspects of biofeedback therapy for defecation disorders. Gastroenterologist 6, 96–103 (1998).

103.

Madoff

: Surgical treatment options for fecal incontinence. Gastroenterology 126, S48–S54 (2004).

104.

Weber

: The perspective of a gynecologist on treatment-related research for fecal incontinence in women. Gastroenterology 126, S169–S171 (2004).

105.

Tjandra

Lim

Hiscock

Rajendra

: Injectable silicone biomaterial for fecal incontinence caused by internal anal sphincter dysfunction is effective. Dis. Colon Rectum 47, 2138–2146 (2004).

106.

Feretis

Benakis

Dailianas

: Implantation of microballoons in the management of fecal incontinence. Dis. Colon Rectum 44, 1605–1609 (2001).

107.

Matzel

Stadelmaier

Hohenfellner

Hohenberger

: Chronic sacral spinal nerve stimulation for fecal incontinence: long-term results with foramen and cuff electrodes. Dis. Colon Rectum 44, 59–66 (2001).

108.

Tjandra

Chan

Yeh

Murray-Green

: Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis. Colon Rectum 51, 494–502 (2008).

109.

Leroi

Michot

Grise

Denis

: Effect of sacral nerve stimulation in patients with fecal and urinary incontinence. Dis. Colon Rectum 44, 779–789 (2001).

110.

Rosen

Urbarz

Holzer

Novi

Schiessel

: Sacral nerve stimulation as a treatment for fecal incontinence. Gastroenterology 121, 536–541 (2001).

111.

National Center for Health Statistics: 2006. www.cdc.gov/nchs

Fecal Incontinence in Women: Causes and Treatment

Abstract

Keywords

Case definition

Prevalence

Impact of fecal incontinence on quality of life

Economic impact of fecal incontinence

Pathophysiology & diagnostic tests

Risk factors

Prevention

Primary prevention

Secondary prevention

Treatment

Medical management

Education

Pelvic floor exercises

Drugs

Pads & supportive measures

Biofeedback

Surgical management

Conclusion & future perspective

Footnotes

References