Scott W. Smilen, MD Director, Division of

Urogynecology/Reconstructive

Pelvic Surgery NYU Langone Medical Center

New York, NY

Disclosure Statement

This activity has been planned and implemented in

accordance with the Essential Areas and policies of the

Accreditation Council for Continuing Medical Education

(ACCME) through the joint sponsorship of the Annenberg

Center for Health Sciences at Eisenhower and The Gi

Health Foundation. The Annenberg Center for Health

Sciences at Eisenhower is accredited by the ACCME to

provide continuing medical education for physicians.

Learning Objectives

• Describe the epidemiology and burden of illness,

pathophysiology, and diagnostic evaluation of fecal

incontinence (FI)

• Describe the current and future management of FI

• Discuss the pros and cons of medical vs. surgical

approaches for the management of patients with FI

• Formulate an appropriate treatment plan for fecal

incontinence, taking into account clinical

presentation and patient preference

Fecal Incontinence:

Epidemiology and

Burden of Illness

Prevalence of Fecal Incontinence:

Fast Facts

Overall prevalence of

fecal incontinence: 9.0%

Prevalence of fecal

incontinence occurring at

least once weekly: 1.1%

Prevalence in men: 7.4%

Prevalence in women: 9.1%

Prevalence in individuals

aged ≥70 years: 17.5% 0

2

4

6

8

10

2005/2006 2009/2010

Prevalence of FI

(≥1 time in previous month)*

Su

bje

cts

(%

)

*Data from NHANES 2005/2006 and 2009/2010 surveys. N=52,195.

Ditah I et al. Am J Gastroenterol. 2012;107:S717. Abstract 1762.

Fecal Incontinence is Associated

with High Economic Cost

Xu X et al. Dis Colon Rectum. 2012;55(5):586-598.

• Average annual cost to patients with FI is

$4,110

– Total costs range between $0 and $46,342

• Indirect costs resulting from lost productivity

at work and lost household productivity

average $1,549

• Direct medical and nonmedical costs

average $2,353

– Surgical costs up to $25,246

Fecal Incontinence Has a Profound

Impact on Quality of Life

1

2

3

4

Lifestyle Coping Depression Embarrassment

FI patients GI patients not affected by FI

P<.01

*Quality of life measured using the Fecal Incontinence Quality of Life Scale, a validated 4 scale, 29-item survey.

Rockwood TH et al. Dis Colon Rectum. 2000;43:9-16.

Sco

re*

What is Most Bothersome to

Patients With FI?

Rank Symptom

1 Urgency

2 Frequency

3 Mucous

4 Bothersome/embarrassment

5 Straining

6 Intestinal discomfort

7 Consistency

8 Volume

9 Gas

Heymen S et al. Digestive Disease Week 2014. Abstract no. Mo2024.

Pathophysiology of

Fecal Incontinence

Anatomy of the Anorectum

Welton ML et al. Anorectum. In: Doherty GM, ed. Current Diagnosis & Treatment Surgery. New York, NY: The McGraw-Hill

Companies, Inc.;2010:698-723.

Rao SSC. Gastroenterology. 2004;126:S14-S22.

Structural

Abnormalities

Functional

Abnormalities

Stool

Characteristics

Pathophysiology of

Fecal Incontinence

Structural Abnormalities

ANS=autonomic nervous system; CNS=central nervous system

Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.

Anatomic Structure Cause Mechanistic Effect

Anal sphincter muscle • Obstetric injury

• Hemorrhoidectomy, anal dilation,

secondary to neuropathy

Sphincter weakness

Loss of sampling reflex

Rectum • Inflammation

• IBD

• Radiation

• Rectal prolapse

• Aging

• IBS

Loss of accommodation

Loss of sensation

Hypersensitivity

Puborectalis muscle • Excessive perineal descent

• Aging

• Trauma

Obtuse anorectal angle

Sphincter weakness

Pudendal nerve • Obstetric or surgical injury

• Excessive straining/perineal descent

• Rectal prolapse

Sphincter weakness

Sensory loss, impaired

reflexes

CNS, spinal cord, ANS • Spinal cord, head injury

• Back surgery

• Multiple sclerosis, diabetes, stroke,

avulsion injury

Loss of sensation

Impaired reflexes

Secondary myopathy

Loss of accommodation

Functional Abnormalities

1. Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604; 2. Engel AF et al. Gut. 1994;35:857-859.

• Anorectal sensation impairment1

– May be caused by aging, neurologic damage, mental

impairment2

– Impairment in anorectal sensation may lead to:1

• Excessive accumulation of stool

• Fecal overflow

• Impairment of the sampling reflex

• Fecal impaction caused by dyssynergic defecation1

– May result in fecal retention with overflow and

leakage of liquid stool

Stool Characteristics

Rao SSC et al. Gastroenterology. 2004;126:S14-S22.

• Stool consistency, volume, and

presence of irritants in the stool

may contribute to fecal

incontinence

– Large-volume liquid stools require

intact sensation and unimpaired

sphincter function to be retained

• Stool characteristics may be

influenced by:

– Infection

– Inflammatory bowel disease

– Irritable bowel syndrome

– Medications

– Food intolerances

Other Mechanisms Underlying

Fecal Incontinence

Rao SSC et al. Gastroenterology. 2004;126:S14-S22.

• Limited physical mobility,

particularly among the

elderly and those with

neurologic diseases

• Decreased cognitive

function

• Willful soiling in patients

with psychosis

History, Physical Exam,

and Diagnostic Tests

Diagnosis of

Fecal Incontinence

Diagnostic Evaluation

Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.

• History

• Physical exam, including digital rectal exam

• Diagnostic tests

Adapted from Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.

A Detailed History is Critical When

Evaluating Patients With Suspected Fecal

Incontinence

1. Severity, duration, and timing

2. Obstetric history (eg, forceps, tears,

presentation, repair)

3. Assess diet and lifestyle

4. History of fecal impaction

5. Determine clinical subtype (passive

incontinence, urge incontinence, fecal

seepage)

23%

87%

0

20

40

60

80

100

Disclosed FI Disclosed UI

Pa

tie

nts

(%

)

Relative disclosure of UI and FI in

women with dual incontinence

UI=urinary incontinence.

Cichowski SB et al. Int Urogynecol J. 2014.

Patients are Far Less Likely to

Disclose FI than UI

1. Determine the Severity, Duration,

and Timing of Fecal Incontinence

*Other than none; †Higher scores indicate more severe incontinence

1. Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604; 2. Seong M-K et al. J Korean Surg Soc. 2011;81:326-331.

Frequency Type Impact Range†

Lowest* Highest Gas Liquid Solid Others Pad

usage

Lifestyle

alteration

Wexner <1/month >1/day + + + — + + 0-20

FISI 1-3/month >2/day + + + Mucus — — 0-61

Scoring Systems for Measuring the Severity of Fecal Incontinence2

1. Determine the Severity, Duration,

and Timing of Fecal Incontinence

• Severity can be formally quantified and tracked

during treatment using grading systems1,2

1. Determine the Severity, Duration,

and Timing of Fecal Incontinence

1. Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604; 2. Seong M-K et al. J Korean Surg Soc. 2011;81:326-331.

• A stool diary1 can be used to quantify frequency,

impact, subtype, and potential correlations2

2. Obstetric History

1. Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604; 2. Kamm MA. Lancet. 1994;344:730-733; 3. Engel AF et al.

Int J Colorectal Dis. 1995;10:152-155; 4. Gee AS, Durdley P. Br J Surg. 1995;1179-1182; 5. Hill J et al. Dis Colon Rectum.

1994;37:473-477.

• In adult women, obstetric trauma may increase risk for fecal

incontinence1-4

– ~35% of primiparous women show evidence of sphincter disruption

following normal vaginal delivery1

• Injury may involve:1

– External anal sphincter

– Internal anal sphincter

– Pudendal nerves

• Obstetric risk factors:1,5

– Forceps delivery

– Prolonged second stage of labor

– High birth weight

– Occipito-posterior presentation

3. Assess Diet, Medications,

and Lifestyle

Adapted from National Institute for Health and Clinical Excellence (NICE). CG49 Faecal incontinence: tables.

Available at: http://www.nice.org.uk/CG49Tables#table2. Accessed March 30, 2013.

Dietary components that may elicit or exacerbate fecal incontinence

Fiber Fiber supplements, whole-grain cereals or bread,

whole-wheat based cereals

Certain fruits and

vegetables Rhubarb, figs, prunes, plums, beans, cabbage, sprouts

Spices Chili powder

Alcohol Especially stouts, beers, or ales

Lactose/fructose Milk, other high-lactose or high-fructose foods

Caffeine Coffee, tea, sodas

Vitamin and mineral

supplements

Excessive vitamin C, magnesium, phosphorus, and/or

calcium

Olestra fat substitute Can cause loose stools

3. Assess Diet, Medications,

and Lifestyle

Adapted from National Institute for Health and Clinical Excellence (NICE). CG49 Faecal incontinence: tables.

Available at: http://www.nice.org.uk/CG49Tables#table2. Accessed March 30, 2013

Medications that may elicit or exacerbate fecal incontinence

Drugs that alter

sphincter tone

Nitrates, calcium channel antagonists, beta-blockers,

sildenafil, SSRIs

Broad-spectrum

antibiotics Cephalosporins, penicillins, erythromycin

Topical drugs applied

to anus

Glyceryl trinitrate ointment, diltiazem gel, bethancechol

cream, botulinum toxin A injection

Drugs causing

profuse loose stools

Laxatives, metformin, orlistat, SSRIs, magnesium-

containing antacids, digoxin

Tranquilizers or

hypnotics Benzodiazepines, SSRIs, antipsychotics

4. History of Fecal Impaction

Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.

• Fecal impaction:

– Results in prolonged

relaxation of internal

anal sphincter tone

– Allows liquid stool to

flow around

impacted stool and

escape through the

anal canal

5. Determine Clinical Subtype of

Fecal Incontinence

EAS=external anal sphincter; IAS=internal anal sphincter

1. Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604; 2. Rao SSC et al. Gastroenterology. 2004;126:S14-S22.

• Passive incontinence1,2

– Unaware of stool or gas passage; associated with

diseased or disrupted IAS

• Urge incontinence1,2

– Release of feces despite awareness and attempted

retention; 88% associated with EAS dysfunction

• Fecal seepage1,2

– Presence of small amount of fecal material on

undergarments; thought to be due to impaired rectal

sensation

The Physical Exam

Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.

• Inspect for presence of:

– Fecal matter

– Prolapsed hemorrhoids

– Dermatitis

– Scars

– Skin excoriation

– Absence of perianal creases

– Gaping anus

The Physical Exam (continued)

Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.

• Examine for excessive perineal descent or

rectal prolapse

– Ask patient to attempt defecation

– A bulge that exceeds 3 cm is usually defined as

excessive

• Check perianal sensation

– Gently stroke perianal skin with cotton bud in each

quadrant

– Normal response: brisk contraction of anal sphincter

– Impaired or absent anocutaneous reflex suggests

afferent or efferent neuronal injury

The Physical Exam

Wald A. N Engl J Med. 2007;356:1648-1655.

Position 1—Check Anal

Tone at Rest

Position 2—Insert Finger More Deeply

and Feel Puborectalis Muscle

Diagnostic Testing

Physiologic Test Measurements Evidence

Anorectal

manometry

Quantifies sphincter pressures,

sensation, rectal compliance and

recto-anal reflexes

Good

Endoanal

ultrasound

Assesses IAS and EAS

thickness, integrity Good

Needle EMG

Distinguishes between

neuropathy and myopathy Fair

Surface EMG

Provides information on normal

or weak tone Fair

Adapted from: Rao SSC. Clin Gastroenterol Hepatol. 2010;8:910-919.

Endoanal Ultrasound

Normal (Sphincters Intact) Abnormal (Sphincters Disrupted)

Subjective interpretation of ultrasound results may limit its value

E=external anal sphincter; I=internal anal sphincter

Rottenberg GT, Williams AB. Br J Radiol. 2002;75:428-488.

Management of

Fecal Incontinence Dietary, Lifestyle, Pharmacologic

Interventional/Surgical

Management of

Fecal Incontinence Surgical Modalities

Surgical Management of

Fecal Incontinence

Intervention Mechanism of

Action Side Effects Comments

Sacral nerve stimulation

Increases stool

consistency and

anal sphincter tone;

decrease urgency

Infection; lead fracture

or migration Relatively safe

Secca procedure

Healing of RF-

induced lesions

changes tone

Tissue damage Relatively safe

Artificial sphincter Restores anal

barrier

Device erosion, failure,

infection

High morbidity; seldom

used

Sphincteroplasty for

sphincter defects

Restores sphincter

integrity

Wound infection

delayed recurrent FI

Beneficial effects

decrease over time;

indicated for IAS defects

without denervation

Colostomy Reserved for

most severe

IAS=internal anal sphincter.

Female Pelvic Anatomy

Sphincter Repair

• Overlapping or end-to-end

• Recovery from surgery

– Bowel management

– Wound care

• Outcomes

Artificial Anal Sphincter

• Cuff placed around upper

anal canal

• Tubing from cuff is directed

along perineum and

connected to pump

implanted just below skin of

scrotum or labia

• Limited clinical experience

– In a post-hoc analysis (n=37),

normal continence for liquid

stool was 78.9%; normal

continence for gas was 63.1%

– ~12% failure rate

Michot F et al. Ann Surg. 2003;1:52-56.

Conclusions

• Fecal incontinence is multifactorial

• Physiological evaluation facilitates optimal

therapy

• Lifestyle measures

– Avoid coffee

– Lactose-free diet

• Biofeedback training main type of

conservative therapy

Conclusions

• Most parous women with FI have

anatomic sphincter defects

• Sphincter defects can be repaired

surgically, but continence will not always

be restored

• Newer modalities may be of benefit

(Solesta, magnetic sphincter)

Conclusions

Treatment Options for

Fecal Incontinence

Conservative

Therapies

Conservative

Therapies

Dextranomer

Microsphere

Injection

Dextranomer

Microsphere

Injection

Surgical

Therapies

Surgical

Therapies

• Generally safe

• Limited evidence

of benefit

• Generally safe

• Limited evidence

of benefit

• Generally safe

• Requires in-office

procedure

• Longer-term evidence for

benefit required

• Generally safe

• Requires in-office

procedure

• Longer-term evidence for

benefit required

• Invasive

• Potential safety issues

• Long-term benefit may

be limited

• Invasive

• Potential safety issues

• Long-term benefit may

be limited