Fecal incontinence is the involuntary passage of feces resulting from loss or impairment of external anal sphincter control. It may be temporary or permanent and can result from gastrointestinal, neurologic, or psychological disorders, surgery, or drug effects.

Pathophysiology

Defecation is regulated by three neurologic mechanisms:

1. Intrinsic defecation reflex – peristalsis in the colon initiated by rectal distention.

2. Parasympathetic reflex – amplifies the intrinsic reflex via sacral spinal segments.

3. Voluntary control – contraction or relaxation of the external anal sphincter to permit or prevent defecation.Damage to any of these pathways can cause fecal incontinence.

Signs and Symptoms:

• Involuntary passage of feces

• Leakage around impacted stool

• Occasional nocturnal incontinence

• Associated symptoms depend on underlying cause (e.g., diarrhea, constipation, neurologic deficits)

Clinical Assessment

History:

• Onset, duration, and severity

• Stool consistency, frequency, and volume

• Associated GI, neurologic, or psychological disorders

• Prior surgery or drug use

• Family history of bowel disorders

Physical Examination:

• Abdominal inspection, auscultation, percussion, palpation

• Anal inspection for excoriation, infection, or impaction

• Complete neurologic assessment if CNS lesion suspected

Medical Causes of Fecal Incontinence

Other Causes:

• Drugs: Chronic laxative abuse reduces colonic reflex sensitivity.

• Surgery: Pelvic, prostate, or rectal surgery; colostomy/ileostomy may cause temporary or permanent incontinence.

Special Considerations:

• Meticulous hygiene and skin care

• Emotional support for embarrassment

• Kegel exercises to strengthen perirectal muscles

• Bowel retraining and individualized treatment based on cause

Patient Counseling:

• Teach bowel retraining and Kegel exercises

• Explain proper hygiene and management strategies

Pediatric Pointers:

• Normal in infants; may be stress-related in young children

• Encopresis in children >4 years with chronic constipation

• Consider neurologic causes such as myelomeningocele

Geriatric Pointers:

• Common in elderly due to smooth muscle changes and chronic diseases

• Evaluate for reversible pathology before attributing to age

References

1. Bongers ME, van Dijk M, Benninga MA, Grootenhuis MA. Health related quality of life in children with constipation associated fecal incontinence. J Pediatr. 2009;154:749–753.

2. Wald A, Sigurdsson L. Quality of life in children and adults with constipation. Best Pract Res Clin Gastroenterol. 2011;25:19–27.