Physical assessment should include a general neurologic exam as well as a perineal exam, to look for prolapsing tissue and evidence of scars from prior surgery or obstetrical trauma. Check the anocutaneous reflex by stroking the perianal skin. Absence of the anal wink in a younger patient is likely associated with nerve damage; in an older patient, it may simply indicate muscle weakness. Perform a digital rectal exam to assess for normal resting tone and augmentation with squeeze, regardless of the patient’s age.
Use tools to assess the severity
Anal incontinence can be broadly characterized as complete or partial. Numerous other systems have been proposed for classifying severity, the simplest of which has the following 4 components:
A: Continent of solid, liquid, and flatus (complete continence)
B: Continent of solid and liquid, but not flatus
C: Continent of solid, but not liquid or flatus
D: Continued fecal leakage (complete incontinence).22
Although this classification system may be helpful, it yields little information about the significance of the problem from the patient’s perspective.23 Thus, scales that take into account both the frequency of incontinence episodes and the extent of both the mental and physical impact are used more frequently.
One of the most widely used scales is the Cleveland Clinic Fecal Incontinence Score (TABLE),24 which quantifies both the frequency and type of incontinence and scores the level of severity. Fecal incontinence quality of life scales are available, as well, and include questions about the impact on the patient’s lifestyle, coping behavior, mood, and level of embarrassment.25
Even without a quality of life scale, a couple of targeted questions—(eg, Are you ever afraid to go out? Do you worry about others smelling stool on you?)—will give you an idea of how great an impact fecal incontinence is having on your patient’s life. Asking patients to keep bowel diaries can also be helpful in assessing the extent of the problem and the effect of treatment.
Next steps: Start with modifiable risks
While there are numerous diagnostic tests for fecal incontinence (more about these in a bit), none is necessary for initial treatment, which starts with modifiable risks. Chief among them is smoking.
Smoking cessation. Nicotine is believed to have a direct effect on colonic transit and rectal compliance.26 Thus, smoking is associated with an increased risk for fecal incontinence, independent of chronic cough or chronic obstructive pulmonary disease. Patients should be advised to quit smoking and referred to a smoking cessation program.
Dietary fiber. Diet may be a factor in fecal incontinence, as well. Ask patients to record everything they eat, and advise those with a low intake of dietary fiber to eat more fruits, vegetables, whole grains, and other high-fiber food. Recommend that they avoid caffeine and alcohol, as well.
Some medications may also affect stool form and frequency, and precipitate fecal incontinence. Common offenders, in addition to laxatives and antacids, include antibiotics, proton pump inhibitors, and senna-based colon cleansers.27 Consider a switch to another drug class. A trial with a drug thought to improve bowel continence is recommended, as well.
Prescribe pharmacologic treatment
Kaolin, pectin, bulking agents, bismuth salts, anticholinergics, opium derivatives, diphenoxylate/atropine, and loperamide have all been used to treat fecal incontinence, with variable success. Loperamide, the drug most extensively studied for this purpose, has been found to increase resting anal pressure and improve anal sphincter function and continence by acting directly on the circular and longitudinal muscles of the bowel.28
Amitriptyline has also been used empirically, with some success. It is believed to work by decreasing the frequency and amplitude of rectal motor complexes.29 Clonidine in the form of a transdermal patch has been shown to increase the number of problem-free days and overall quality of life for patients with fecal incontinence.30
Consider biofeedback
Biofeedback training is often the next step after pharmacologic treatment. It has been investigated for the treatment of fecal incontinence, and many patients—particularly if they are highly motivated—have reported improvement.31 Therapy generally has 3 components: exercising the external sphincter complex, training in the discrimination of rectal sensations, and developing synchrony of the internal and external sphincter responses during rectal distension.
The goal is for the patient to learn to contract the sphincter in response to small amounts of rectal distension.
But a significant time commitment on the part of the patient and sophisticated apparatus are necessary to carry out such therapy, and only a few randomized controlled trials (RCTs) have evaluated the effect. The largest RCT had 4 arms: a standard care group; standard care plus instruction on sphincter exercises; standard care with sphincter exercises and biofeedback; and standard care with sphincter exercises, biofeedback, and training at home.32