Copyright
©The Author(s) 2017.
World J Gastroenterol. Jan 7, 2017; 23(1): 11-24
Published online Jan 7, 2017. doi: 10.3748/wjg.v23.i1.11
Published online Jan 7, 2017. doi: 10.3748/wjg.v23.i1.11
Table 1 Causes of fecal incontinence
Category | Details |
Acquired structural abnormalities | Obstetric injury (vaginal delivery) |
Anorectal surgery (hemorrhoid, fistula, fissure, etc.) | |
Rectal intussusception/prolapse | |
Sphincter-sparing bowel resection | |
Trauma (e.g., pelvic fracture, Anal impalement) | |
Functional disorders | Chronic diarrhea |
Irritable bowel disease | |
Inflammatory bowel disease | |
Radiation proctitis | |
Malabsorption | |
Hypersecretory tumors | |
Fecal impaction (paradoxical diarrhea) | |
Physical disabilities | |
Psychiatric disorder | |
Neurological disorders | Pudendal neuropathy |
(radiation, diabetes, chemotherapy) | |
Spinal surgery | |
Multiple sclerosis | |
Dementia | |
CNS disorder: stroke, trauma, tumor, infection | |
Spina bifida | |
Congenital disorders | Imperforate anus |
Cloacal defect | |
Spina bifida (myelomeningocele, meningocele) |
Table 2 Cleveland Clinic Fecal Incontinence Score[12]
Parameter | Frequency | ||||
Never | Rarely | Sometimes | Usually | Always | |
(< 1/mo) | (< 1/wk but ≥ 1/mo) | (< 1/d but ≥ 1/wk) | (≥ 1/d) | ||
Incontinence to solid stool | 0 | 1 | 2 | 3 | 4 |
Incontinence to liquid/loose stool | 0 | 1 | 2 | 3 | 4 |
Incontinence to gas | 0 | 1 | 2 | 3 | 4 |
Wears pad | 0 | 1 | 2 | 3 | 4 |
Lifestyle alteration | 0 | 1 | 2 | 3 | 4 |
Table 3 Structured workup of patients with fecal incontinence
Assessment tool | Details |
History | Onset |
Quantitation: staining < soilage < seepage < accidents | |
Qualitative assessment: passive incontinence vs urge incontinence | |
Obstetrical history: pregnancies, vaginal deliveries | |
Previous surgeries: anorectal surgeries, hysterectomy, bladder surgeries, (colo)rectal surgeries, spinal surgeries | |
Underlying diseases (diabetes, stroke, etc.) | |
Bowel function and stool quality | |
Incomplete evacuation | |
Stool/gas passage through vagina | |
Medications | |
Scoring instruments | CCF incontinence score (“Wexner score”) |
Fecal Incontinence Quality of Life score | |
Fecal Incontinence Severity Index | |
St. Marks Incontinence Score | |
EORTEC SF-36 | |
Revised Fecal Incontinence Scale | |
Other scoring instruments | |
Physical exam | Inspection: patulous anus, folds, perineal body, keyhole, skin irritation, perineal descent, prolapse, cloaca, rectovaginal fistula (stool in vagina)? |
Digital exam: sphincter integrity, tone (rest/squeeze), compensatory contraction/discoordination, rectocele, mass? | |
Sensation/anal reflex | |
Instrumentation/visualization: rule out other pathologies (e.g., rectal tumor, proctitis) | |
Anophysiology testing | Anal ultrasound |
Anophysiology testing: | |
Manometry | |
Anorectal sensation and volume tolerance | |
Compliance measurement | |
Nerve studies: PNTML, occasionally EMG | |
Placement of SNS trial electrode (phase I) | |
Additional evaluations in select cases | Imaging: dynamic pelvic MRI |
Defecating proctogram | |
Evaluation by other specialties (Urogynecology, Urology, Gastroenterology, etc.) |
Table 4 Surgical strategies
Goal | Options |
Correction of morphological deformities | Prolapse |
Cloaca | |
Keyhole deformity | |
Perirectal fistula | |
Rectovaginal fistula | |
Tumor | |
Sphincter repair | Overlapping sphincteroplasty |
Enhancement of impaired sphincter function | Sacral nerve stimulation |
Radiofrequency energy administration (SECCA™) | |
Injection of bulking agents (NASHA/DX, beads etc.) | |
Sphincter replacement/support | Artificial bowel sphincter |
Implantation of magnetic anal sphincter (Fenix™) | |
Graciloplasty | |
Implantation of Thiersch | |
Implantation of pelvic sling system | |
Diversion | Colostomy |
Reduction of fecal load | Malone antegrade continence enema |
Table 5 Types of injectable/implantable materials
Category | Details |
Conventional | Carbon |
Teflon or silicon biomaterial beads | |
Collagen | |
Autologous fat | |
Newer | Non-animal stabilized hyaluronic acid/dextranomer |
Pilot | Self-expandable hyexpan (polyacrylonitrile) prosthesis |
Future | Stem cells |
Table 6 Overview of various surgical options with respective outcomes (as detailed in the text)
Interventions category | Specific technique | Efficacy rate (complete/> 50% improvement) | Complication rates | Grade |
Correction of morphological abnormalities | Depending on underlying condition: | N/A | N/A | N/A |
Prolapse, cloaca, keyhole deformity, perirectal fistula, rectovaginal fistula, tumor | ||||
Sphincter repair | Overlapping sphincteroplasty | 75%-85% (short term) | N/A | |
0-50% (after 5-10 yr) | ||||
Enhancement of sphincter function | Sacral nerve stimulation | 0%-56%/51-100% | lead displacement (15%), diarrhea (6%), pain (6-28%), bleeding 11%, infection (3%) | 1B |
Tibial nerve simulation | 0%-12% (-40%)/0%-67% | 59% (infection, mild gastrodynia, temporary leg numbness) | 2C | |
Radiofrequency energy administration | 0%/12%-38% (-84%) | 0%-52% (pain, bleeding, infection) | 2B | |
Injection of: | 0%/33%-90% | 10%-12% (pain, bleeding, infection) | 2A | |
conventional bulking agents | 6%/56%-61% | |||
NASHA/DX | ||||
Sphincter replacement | Artificial bowel sphincter | 61%-90%/31%-100% | 5%-10% infection rates, 30%-52% long-term failure 9 | 1B |
Implantation of magnetic ring (Fenix™) | NA/54% | 0%-7% obstruction, infection, erosion | 1C | |
Graciloplasty (dynamic/non-dynamic) | NA/72% | > 40% including urinary tract infection/retention, infections 76 | 2C | |
Implantation of Thiersch | N/A | N/A | N/A | |
Pelvic floor repairs/sling | 19%/69.1% | 17%-30% (pain, infection) | 2C | |
Fecal diversion | Ileostomy, loop colostomy, end colostomy | near 100% FI improvement | 5%-10% stoma outlet obstruction, stricture, prolapse, hernia | 1C |
Fecal load reduction | Malone antegrade continence enema | (0%)/33%-100% FI continence | 8%-50% stoma stenosis, leakage | 2C |
- Citation: Saldana Ruiz N, Kaiser AM. Fecal incontinence - Challenges and solutions. World J Gastroenterol 2017; 23(1): 11-24
- URL: https://www.wjgnet.com/1007-9327/full/v23/i1/11.htm
- DOI: https://dx.doi.org/10.3748/wjg.v23.i1.11