Fecal incontinence

FI affects virtually all aspects of sufferers' lives, greatly diminishing physical and mental health, and affecting personal, social, and professional life. Emotional effects may include stress, fearfulness, anxiety, exhaustion, fear of public humiliation, feeling dirty, poor body image, reduced desire for sex, anger, humiliation, depression, isolation, secrecy, frustration, and embarrassment. Some patients cope by controlling their emotions or behavior. Physical symptoms such as skin soreness, pain and odor may also affect quality of life. Physical activity such as shopping or exercise is often affected. Travel may be affected, requiring careful planning. Working is also affected for most. Relationships, social activities and self-image likewise often suffer. Symptoms may worsen over time. == Causes ==

FI is a sign or a symptom, not a diagnosis, Deficits of individual functional components of the continence mechanism can be partially compensated for a certain period, until the compensating components themselves fail. For example, obstetric injury may precede onset by decades, but postmenopausal changes in the tissue strength reduce in turn the competence of the compensatory mechanisms. Diabetes mellitus is also known to be a cause, but the mechanism of this relationship is not well understood. Childbirth Vaginal delivery causes stretching of the pelvic muscles and the pudendal nerve. Obstetric injury is a leading cause of fecal incontinence. Obstetric injury may tear the anal sphincters, and some of these injuries may be occult (undetected). The risk of injury is greatest when labor has been especially difficult or prolonged, when forceps are used, with higher birth weights, or when a midline episiotomy is performed. Only when there is post-operative investigation of FI such as endoanal ultrasound is the injury discovered. The nerve is especially vulnerable to stretch damage during childbirth because of the course of the nerve, as it runs in close proximity to pelvic muscles (piriformis and coccygeus) and ligaments, before exiting and then re-entering the pelvic cavity. The damage is likely to occur at the exit from the pudendal canal, because the course of the nerve is relatively fixed at this point. Stretching occurs during delivery, especially from the child's head. 60% of females who sustained obstetric tears were demonstrated to also have pudendal nerve damage. Any damage to the pudendal nerve occurring during childbirth may not become fully apparent until years later, for example at the onset of menopause. Anal sphincter weakness The anal canal presents the final barrier to continence. The resting tone of the anal canal is not the only important factor; both the length of the high-pressure zone and its radial translation of force are required for continence. This means that even with normal anal canal pressure, focal defects such as the keyhole deformity can be the cause of substantial symptoms. External anal sphincter (EAS) dysfunction is associated with impaired voluntary control, whereas internal anal sphincter (IAS) dysfunction is associated with impaired fine-tuning of fecal control. The external anal sphincter is supplied by the pudendal nerve. Damage to the nerve supply of the external anal sphincter on one side may not result in severe symptoms because there is substantial overlap in innervation by the nerves on the other side. Disruption of the function of the internal anal sphincter results in reduced resting pressure in the anal canal. This is associated with passive leakage. Obstructed defecation (incomplete evacuation of stool) Normal evacuation of rectal contents is 90100%. Obstructed defecation is often due to anismus (paradoxical contraction or relaxation failure of the puborectalis). Rectal storage capacity (i.e. rectal volume + rectal compliance) may be affected in the following ways. Surgery involving the rectum (e.g. lower anterior resection, often performed for colorectal cancer), radiotherapy directed at the rectum, and inflammatory bowel disease can cause scarring, which may result in the walls of the rectum becoming stiff and inelastic, reducing compliance. Reduced rectal storage capacity may lead to urge incontinence, Pudendal neuropathy is one cause of rectal hyposensitivity and may lead to fecal loading or impaction, megarectum and overflow FI (see overflow incontinence). Overflow incontinence This may occur when there is a large mass of feces in the rectum (fecal loading), which may become hardened (fecal impaction). Liquid stool elements can pass around the obstruction, leading to incontinence. Megarectum (enlarged rectal volume) and rectal hyposensitivity are associated with overflow incontinence. Hospitalized patients and care home residents may develop FI via this mechanism, Central nervous system Continence requires conscious and subconscious networking of information from and to the anorectum. Defects or brain damage may affect the central nervous system focally (e.g. stroke, tumor, spinal cord lesions, trauma, multiple sclerosis) or diffusely (e.g. dementia, multiple sclerosis, infection, Parkinson's disease or drug-induced). FI (and urinary incontinence) may also occur during epileptic seizures. Dural ectasia is an example of a spinal cord lesion that may affect continence. Diarrhea Liquid stool is more difficult to control than formed, solid stool. Hence, FI can be exacerbated by diarrhea. Orlistat is an anti-obesity (weight loss) drug that blocks the absorption of fats. This may give side effects of FI, diarrhea, and steatorrhea. Radiation Irradiation may occur during radiotherapy, e.g. for prostate cancer. Radiation-induced FI may involve the anal canal as well as the rectum, when proctitis, anal fistula formation, and diminished function of internal and external sphincter occur. Most people casually engaging in anal sex do not experience subsequent fecal incontinence. However, some practices are more strongly associated with incontinence; including anal fisting, high frequency of anal sex, psychoactive drug use and BDSM. Females have lower anal canal pressures and less robust sphincters than males, which may make them more susceptible to incontinence, particularly if coercion is involved. Congenital defects Anorectal anomalies and spinal cord defects may be a cause in children. These are usually picked up and operated upon during early life, but continence is often imperfect thereafter. == Pathophysiology ==

around the bowel. This pulls the bowel forwards and forms the anorectal angle, the angle between the anal canal and the rectum. A-puborectalis, B-rectum, C-level of the anorectal ring and anorectal angle, D-anal canal, E-anal verge, F-representation of internal and external anal sphincters, G-coccyx & sacrum, H-pubic symphysis, I-Ischium, J-pubic bone. The mechanisms and factors contributing to normal continence are multiple and interrelated. The puborectalis sling, forming the anorectal angle (see diagram), is responsible for the gross continence of solid stool. The IAS is an involuntary muscle, contributing about 50–85% of the resting anal pressure. Together with the hemorrhoidal vascular cushions, the IAS maintains continence of flatus and liquid during rest. The EAS is a voluntary muscle, that doubles the pressure in the anal canal during contraction, which is possible for a short time. The rectoanal inhibitory reflex (RAIR) is an involuntary IAS relaxation in response to rectal distension, allowing some rectal contents to descend into the anal canal where it is brought into contact with specialized sensory mucosa to detect consistency. The rectoanal excitatory reflex (RAER) is an initial, semi-voluntary contraction of the EAS and puborectalis which in turn prevents incontinence following the RAIR. Other factors include the specialized anti-peristaltic function of the last part of the sigmoid colon, which keeps the rectum empty most of the time, sensation in the lining of the rectum and the anal canal to detect when there is stool present, its consistency and quantity, and the presence of normal rectoanal reflexes and defecation cycle which completely evacuates stool from the rectum and anal canal. Problems affecting any of these mechanisms and factors may be involved in the cause. == Diagnosis ==

Identification of the exact causes usually begins with a thorough medical history, including detailed questioning about symptoms, bowel habits, diet, medication, and other medical problems. Digital rectal examination is performed to assess resting pressure and voluntary contraction (maximum squeeze) of the sphincter complex and puborectalis. Anal sphincter defects, rectal prolapse, and abnormal perineal descent may be detected. Proctosigmoidoscopy involves the insertion of an endoscope (a long, thin, flexible tube with a camera) into the anal canal, rectum and sigmoid colon. The procedure allows for visualization of the interior of the gut and may detect signs of disease or other problems that could be a cause, such as inflammation, tumors, or scar tissue. Endoanal ultrasound, which some consider the gold standard for detection of anal canal lesions, evaluates the structure of the anal sphincters and may detect occult sphincter tears that otherwise would go unseen. Functional FI is common. The Rome process published diagnostic criteria for functional FI, which they defined as "recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least four years". The diagnostic criteria are, one or more of the following factors present for the last three months: abnormal functioning of normally innervated and structurally intact muscles, minor abnormalities of sphincter structure or innervation (nerve supply), normal or disordered bowel habits, (i.e., fecal retention or diarrhea), and psychological causes. Furthermore, exclusion criteria are given. These are factors that all must be excluded for a diagnosis of functional FI, and are abnormal innervation caused by lesion(s) within the brain (e.g., dementia), spinal cord (at or below T12), or sacral nerve roots, or mixed lesions (e.g., multiple sclerosis), or as part of a generalized peripheral or autonomic neuropathy (e.g., due to diabetes), anal sphincter abnormalities associated with a multisystem disease (e.g., scleroderma), and structural or neurogenic abnormalities that are the major cause. Definition There is no globally accepted definition, "Social continence" has been given various precise definitions for the purposes of research; however, generally it refers to symptoms being controlled to an extent that is acceptable to the individual in question, with no significant effect on their life. There is no consensus about the best way to classify FI, whereas fecal incontinence may be given the definition of involuntary loss of solid or liquid feces which may also be caused by enlarged skin tags, poor hygiene, hemorrhoids, rectal prolapse, and fistula in ano. It may occur together with incontinence of liquids or solids, or it may present in isolation. Flatus incontinence may be the first sign of FI. However, the term anal incontinence is also often used interchangeably as a synonym for FI generally, and use a wider definition for FI which includes uncontrolled passage of feces or gas. Fecal leakage, fecal soiling and fecal seepage are minor degrees of FI, and describe incontinence of liquid stool, mucus, or very small amounts of solid stool. They cover a spectrum of increasing symptom severity (staining, soiling, seepage, and accidents). The term pseudoincontinence is used when there is FI in children who have anatomical defects (e.g. enlarged sigmoid colon or anal stenosis). Clinical measurement Several severity scales exist. The Cleveland Clinic (Wexner) fecal incontinence score takes into account five parameters that are scored on a scale from zero (absent) to four (daily) frequency of incontinence to gas, liquid, solid, of need to wear pad, and of lifestyle changes. • those continent for solid and liquid stool and also for flatus • those continent for solid and liquid stool but incontinent for flatus (with or without urgency) • those continent for solid stool but incontinent for liquid stool or flatus • those incontinent to formed stool (complete incontinence) The fecal incontinence severity index is based on four types of leakage (gas, mucus, liquid stool, solid stool) and five frequencies (once to three times per month, once per week, twice per week, once per day, twice or more per day). Other severity scales include AMS, Pescatori, Williams score, Kirwan, Miller score, Saint Mark's score, and the Vaizey scale. Differential diagnosis FI may present with signs similar to rectal discharge (e.g. fistulae, proctitis, or rectal prolapse), pseudoincontinence, encopresis (with no organic cause), and irritable bowel syndrome. == Management ==

FI is generally treatable with conservative management, surgery, or both. Medication Pharmacological management may include anti-diarrheal or constipating agents and laxatives or stool bulking agents. Stopping or substituting any previous medication that causes diarrhea may be helpful in some (see table). There is no good evidence for the use of any medications, however. In people who have undergone gallbladder removal, the bile acid sequestrant cholestyramine may help minor degrees of FI. Bulking agents also absorb water, so may be helpful for those with diarrhea. A common side effect is bloating and flatulence. Topical agents to treat and prevent dermatitis may also be used, such as topical antifungals when there is evidence of perianal candidiasis or occasionally mild topical anti-inflammatory medication. Prevention of secondary lesions is carried out by perineal cleansing, moisturization, and the use of a skin protectant. Other measures Evacuation aids (suppositories or enemas) e.g. glycerine or bisacodyl suppositories may be prescribed. People may have a poor resting tone of the anal canal, and consequently may not be able to retain an enema, in which case transanal irrigation (retrograde anal irrigation) may be a better option, as this equipment utilizes an inflatable catheter to prevent loss of the irrigation tip and to provide a water tight seal during irrigation. A volume of lukewarm water is gently pumped into the colon via the anus. People can be taught how to perform this treatment in their own homes, but it does require special equipment. If the irrigation is efficient, the stool will not reach the rectum again for up to 48 hours. However, persistent leaking of residual irrigation fluid during the day may occur and make this option unhelpful, particularly in persons with obstructed defecation syndrome who may have an incomplete evacuation of any rectal contents. Consequently, the best time to carry out the irrigation is typically in the evening, allowing any residual liquid to be passed the next morning before leaving the home. Complications such as electrolyte imbalance and perforation are rare. The effect of transanal irrigation varies considerably. Some individuals experience complete control of incontinence, and others report little or no benefit. Biofeedback therapy varies in the way it is delivered, but it is unknown if one type has benefits over another. Rarely, skin reactions may occur where the electrodes are placed, but these issues typically resolve when the stimulation is stopped. Surgically implanted sacral nerve stimulation may be more effective than exercises, and electrical stimulation and biofeedback may be more effective than exercises or electrical stimulation by themselves. In a minority of people, anal plugs may be useful for either standalone therapy or in concert with other treatments. Anal plugs (sometimes termed tampons) aim to block the involuntary loss of fecal material, and they vary in design and composition. The surgical options can be considered in four categories: restoration and improvement of residual sphincter function (sphincteroplasty, sacral nerve stimulation, tibial nerve stimulation, correction of anorectal deformity), replacement and imitation of the sphincter or its function (anal encirclement, SECCA procedure, non-dynamic graciloplasty, perianal injectable bulking agents and implantable bulking agents), dynamic sphincter replacement (artificial bowel sphincter, dynamic graciloplasty), antegrade continence enema (Malone procedure), and finally fecal diversion (e.g. colostomy). A surgical treatment algorithm has been proposed. Isolated sphincter defects (IAS/EAS) may be initially treated with sphincteroplasty and if this fails, the person can be assessed for sacral nerve stimulation. Functional deficits of the EAS or IAS (i.e. where there is no structural defect, or only limited EAS structural defect, or with neurogenic incontinence) may be assessed for sacral nerve stimulation. If this fails, neosphincter with either dynamic graciloplasty or artificial anal sphincter may be indicated. Substantial muscular or neural defects may be treated with neosphincter initially. == Epidemiology ==

FI is thought to be very common, Females are more likely to develop it than males (63% of those with FI over 30 may be female). 45–50% of people with FI have severe physical or mental disabilities. Risk factors include age, female gender, urinary incontinence, history of vaginal delivery (non-Caesarean section childbirth), obesity, Traditionally, FI was thought to be an insignificant complication of surgery, but it is now known that a variety of different procedures are associated with this possible complication, and sometimes at high levels. Examples are midline internal sphincterotomy (8% risk), lateral internal sphincterotomy, fistulectomy, fistulotomy (1852%), hemorrhoidectomy (33%), ileo-anal reservoir reconstruction, lower anterior resection, total abdominal colectomy, ureterosigmoidostomy, Some authors consider obstetric trauma to be the most common cause. == History ==

While the first mention of urinary incontinence occurs in 1500 BC in the Ebers Papyrus, the first mention of FI in a medical context is unknown. For many centuries, colonic irrigation was the only treatment available. In 1975, Parks describes post anal repair, a technique to reinforce the pelvic floor and EAS to treat idiopathic cases. Endoanal ultrasound is invented in 1991, which starts to demonstrate the high number of occult sphincter tears following vaginal deliveries. In 1994, the use of an endoanal coil during pelvic MRI shows greater detail of the anal canal than previously. During the last 20 years, dynamic graciliplasty, sacral nerve stimulation, injectable perianal bulking agents and radiofrequency ablation have been devised, mainly due to the relatively poor success rates and high morbidity associated with the earlier procedures. == Society and culture ==

Persons with this symptom are frequently ridiculed and ostracized in public. It has been described as one of the most psychologically and socially debilitating conditions in an otherwise healthy individual. In older people, it is one of the most common reasons for admission into a care home. Persons who develop FI earlier in life are less likely to marry and obtain employment. Often, people will go to great lengths to keep their condition secret. It has been termed "the silent affliction" since many do not discuss the problem with their close family, employers, or clinicians. They may be subject to gossip, hostility, and other forms of social exclusion. The economic cost has not received much attention. Fecal incontinence while passing gas is known colloquially as a "shart" (a portmanteau of "shit" and "fart"). Netherlands In the Netherlands, a 2004 study estimated that total costs of patients with fecal incontinence were €2169 per patient per year. Over half of this was productivity loss in work. United States In the US, the average lifetime cost (treatment and follow-up) was $17,166 per person in 1996. The average hospital charge for sphincteroplasty was $8555 per procedure. Overall, in the US, the total charges associated with surgery increased from $34 million in 1998 to $57.5 million in 2003. Sacral nerve stimulation, dynamic graciloplasty, and colostomy were all shown to be cost-effective. Japan Some insults in Japan relate to incontinence, such as or and , though these have not been in common use since the 1980s. Law The case Hiltibran et al v. Levy et al in the United States District Court for the Western District of Missouri resulted in that court issuing an order in 2011. That order requires incontinence briefs funded by Medicaid to be given by the State of Missouri to adults who would be institutionalized without them. == See also ==