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Fecal incontinence" is defined as the involuntary loss of stool at any time of life after toilet training. It is a socially and psychologically devastating condition for patients and their families, and a topic which both patients and physicians are reluctant to approach. Although the true prevalence of
fecal incontinence is unknown, studies have reported it to be as high
as 2. 2% in the general population, with significantly higher rates among
nursing home residents and hospitalized elderly. Risk factors include advancing age, female gender and multiparity. An understanding of pelvic floor anatomy and physiology is required to appreciate how diverse medical conditions can affect mechanisms involved in normal continence. The rectum serves as a storage reservoir until elimination can take place at a socially acceptable time and place. The pelvic floor muscles help to regulate the defecatory process and maintain continence. These muscles include the internal anal sphincter, the external anal sphincter and the puborectalis muscle. Each muscle contributes to normal continence, although the relative importance of each is controversial. Neurologic integrity and sensation are also key factors. Conditions associated with
fecal incontinence include diarrheal states,
fecal impaction, idiopathic neurologic
injury, surgical and obstetric injury, pelvic
trauma,
collagen vascular disease, and neurologic impairment related to
stroke, diabetes, or
multiple sclerosis. Evaluation of the patient with
fecal incontinence includes a directed history and physical examination, with particular attention paid to integrity of the perineum and rectum, and a complete neurologic evaluation. Diagnostic tools such as stool studies, anorectal manometry, defecography, electromyography, pudendal nerve conduction, and endoanal ultrasound may be employed in an outpatient setting.
Fecal incontinence may be treated conservatively by employing such methods as
dietary restriction, stool bulking agents, and
biofeedback. Surgery may be the best option for cases refractory to medical treatment, or for those patients with
rectocele or obstetrical injury. In this article, we review the presentation, epidemiology, pathophysiology, and etiology of
fecal incontinence. Evaluation, including key components of directed history and physical examination, and the appropriate use of diagnostic studies and indications for treatment options are also addressed.