Diagnosis of Fecal Incontinence

Anamnesis
Anamnesis is very important to define the etiology and specific risk factors for incontinence,
characterize the duration and severity of primary symptoms, and detect secondary problems.
Also, physician can direct and prompt a more focused examination based on informations
gathered during anamnesis. 1
Many patients come to the physician complaining diarrhea or urgency. Thus, the steps of
evaluation are to establish a rapport with the patient, to confirm the existence of fecal
incontinence, and to characterize the condition further. During the anamnesis, there are
several important informations that should be elicited:13
a. Onset and precipitating event(s)
b. Duration, severity, and timing
c. Stool consistency and urgency
d. Coexisting problems such as diabetes mellitus, obesity, chronic diarrhea, pelvic

radiation, neurological problems, previous anorectal surgery, urinary incontinence,

and back injury
e. Obstetric history such as forceps, tears, presentation, repair
f.

Drugs that may exacerbate fecal incontinence, such as nitrates, beta-blockers,

cephalosporins, ditiazem gel, laxatives, loperamide, metformin, and SSRIs.

g. Foods that may exacerbate fecal incontinence, such as fibre supplements, plums, chili,

alcohol, lactose, caffeine, and excessive vitamin C.

h. Lifestyle which may precede fecal incontinence, such as smoking and limited physical

activity.
i.

Clinical subtypes
a. Passive incontinence, which is the involuntary discharge of fecal matter or
flatus without any awareness. This condition is likely due to a loss of
perception and/or impaired rectoanal dysfunction with or without sphincter
dysfunction.
b. Urge incontinence, which is the discharge of fecal matter or flatus even the
patient tried to hold the discharge. This condition suggests a sphincter
dysfunction or disruption of rectal capacity.
c. Fecal seepage, which is undesired leakage of stool (often after a bowel
movement) with otherwise normal continence and evacuation. Here, there is a
predominant disruption in stool evacuation and/or rectal sensation.

j.

Clinical grading of severity (including quality of life assessment). Fecal incontinence

severity has been assessed most commonly with the Fecal Incontinence Severity
Index, St. Marks Incontinence Score, and Cleveland Clinic Florida Fecal Incontinence

Score (CCF). Patients with more severe symptoms or worse quality of life are
appropriate for more aggressive therapies
k. History of fecal impaction

Beside those key points, a prospective stool diary may also be very helpful.

Picture 1. An example of prospective stool diary.2

Clinical features alone cannot sufficiently define the patophysiology of fecal incontinence
and therefore more objective testing is essential.
PHYSICAL EXAMINATION
A detailed physical and neurological examination of the back and lower limbs is indicated,
because systemic or neurological disorder is often preceeding the fecal incontinence.
Upon inspection, physician may find fecal matter, prolapsed hemorrhoids, skin anomalies,
absence of perianal creases, thickness of perineal body, or a gaping anus. These features
suggest sphincter weakness or chronic skin issitation and will give hints on possible etiology.
Physician should also ask the patient to attempt defecation. If an outward bulge that exceeds
3 cm is detected, it usually means an excessive perineal descent or rectal prolapse is present.
Physician should perform an anocutaneous reflex test to examine the reflex arc between the
skin and sensory nerves, the intermediate neurons in spinal cord segments S2-S4, and motor
innervation of the external anal sphincter. This test is performed by using a cotton bud to
stroke the perianal skin in all quadrants. In normal conditions, the external anal sphincter will
contract after stimulation.
Digital rectal examination is used to assess the resting sphincter tone, the length of anal canal,
the integrity of puborectalis sling, the anorectal angle, the presence of rectocele or impacted
stools, the strength of anal muscle, and the elevation of perineum during voluntary squeeze.

Furthermore, it can detect the presence of a rectal mass, stricture, or fecal impaction, which
would suggest other mechanisms for incontinence. Physician should aware that the findings
of digital rectal examination is not very reliable, influenced by patients cooperation, and
prone to interobserver differences.1,2
SUPPORTING EXAMINATIONS
The first step is to identify if the fecal incontinence is secondary to diarrhea using endoscopy,
stool tests, and breath tests. Specific and complementary tests that can define the underlying
mechanisms are available.4 The results from an examination is to be interpreted along with
patients symptoms and other examinations. For a diagnosis to be made, good clinical
judgement is required.
1. Flexible sigmoidoscopy or colonoscopy.
This test may be performed if diarrhea is coexisting. It can detect colonic mucosal
inflammation, rectal mass, scar tissue, or stricture. Beside that, this test is performed
in the presence of specific symptoms such as bleeding, urgency, tenesmus, or mucus
drainage to capture the possibility of serious colorectal pathology that might require
priority attention (e.g. colorectal cancer).1,2,5
2. Stool studies
Stool studies, including infection screening, stool volume, osmolality, and electrolytes
may be performed for diarrhea diagnosis.2
3. Biochemical test
Biochemical test could reveal a thyroid disorder, diabetes mellitus, or other metabolic
disorders that may coexist with fecal incontinence.2
4. Breath test
Breath test may reveal lactose intolerance or bacterial overgrowth.2
5. Anorectal manometry and sensory testing
Anorectal manometry uses a narrow, flexible tube (probe) which is inserted into the
patients anus and rectum. The probe is connected to a pressure-recording device.
Anorectal manometry with sensory testing provides an objective assessment to define
the function of external and internal anal sphincter, assess rectal sensation and
reflexes, and measure rectal compliance. Unfortunately, there are no standard
technique or equipment to perform anorectal manometry.
The resting anal sphincter pressure represents the smooth muscle activity of internal
anal sphincter, which is tonically active. The voluntary squeeze anal pressure
represents external anal sphincter function and reflect combined cognitive, neural and
muscle components. Patients with incontinence usually have low resting and low
squeeze sphincter pressures. The duration of sustained voluntary squeeze will provide
a hint about sphincter muscle fatigue. 2,6
The anocutaneous reflex represents the response to pin prick stimulation of the
perianal skin evoking a reflex contraction of the external anal sphincter. It tests the

integrity of somatic sensory nerves and the pudendal motor nerves. The contraction
reflex ability of external anal sphincter is represented by the increase of anal sphincter
pressure during abrupt increases of intraabdominal pressure (such as when coughing).
In patients with lesions above the conus medullaris, the reflex response is present but
voluntary squeeze is absent. In patients with lesions in cauda equina or sacral plexus,
both the reflex response and voluntary squeeze
Rectal balloon distention can be used to assess the sensory responses and rectal
compliance. The thresholds for first perception, first desire, and urgent desire can be
measured by distending the balloon inside the rectum. A higher threshold suggests a
diminished rectal sensation. Incontinent patients may exhibit rectal hyposensitivity or
hypersensitivity. The balloon volume required to partially or completely inhibit the
anal sphincter can be assessed. In incontinent patients, the balloon volume
requirement decrease. Rectal compliance is assessed by measuring the changes of
intrarectal pressure when the rectal balloon is distending. Rectal compliance is
reduced in patients with colitis, low spinal cord lesions, and diabetics with
incontinence but is increased in subjects with high spinal cord lesions.2,4
6. Imaging modalities
a. Anal endosonography
This test is traditionally performed using a 7 mHz rotating transducer with a focal
length of 1-4 cm inserted into the anus and rectum. This allows a real time video
assessment of the thickness and structural integrity of the external and internal
anal sphincter as well as detecting the presence of scarring, muscle loss, and other
local pahologies. More recently, 3-D ultrasound imaging has become available
which provides better delineation of anal sphincters and puborectalis and
surrounding structures This test cannot reliably demonstrate the etiology of fecal
incontinence.2,46
b. Magnetic resonance imaging (MRI)
MRI is particularly useful to provide additional information where anal
endosonography is unavailable. Endoanal MRI provides superior imaging with
better spatial resolution, particularly for defining the anatomy of the external anal
sphincter. Dynamic pelvic MRI or MRI colpocystography with the patient
evacuating ultrasound gel (as contact agent) may define anorectal anatomy more
precisely. The use of an endo-anal coil significantly enhances the resolution and
allows more precise definition of sphincter muscles.1,2
c. Defecography/proctography
A contrast material is inserted into the rectum and the patient is asked to squeeze,
cough, or expel the material. This process is recorded with X-ray video images or
MRI. This method is beneficial to assess anorectal angle, pelvic floor descent,
length of anal canal, rectocele, rectal prolapse, or mucosal intussusception. This
test can also evaluate the amount of stool the rectum can hold and how the stool is
expelled. However, some abnormalities that detected using this method may
appear in asymptomatic individuals.2,5,7

7. Balloon expulsion test

This test uses a 50 ml water-filled balloon or a silicon-artificial stool that is inserted
into the rectum. The length of time it takes to expel the balloon is recorded. All
normal patients and most patient with fecal incontinence can expel the balloon from
the rectum in one minute. However, patients with fecal seepage and elderly patients
with fecal incontinence secondary to fecal impaction usually will have difficulty to
evacuate this balloon.2,5
8. Neurophysiologic testing of anorectal function
a. Electromyography (EMG)
EMG can identify sphincter injury as well as denervation-reinnervation potentials
that indicate neuropathy. It occurs in patients with fecal incontinence following
pudendal nerve injury or cauda equina syndrome.4
b. Pudendal nerve terminal motor latency (PNTML)
This test measures neuromuscular integrity between the terminal portion of the
pudendal nerve and the anal sphincter. Pudendal nerve injury will lead to
denervation of anal sphincter muscles and muscle weakness. PNTML can
distinguish a weak sphincter muscle due to muscle injury or nerve injury. A
prolonged nerve latency time will suggest a nerve injury. However, a normal result
does not exclude pudendal neuropathy and physician should always consider the
possibility of mixed injury if the result is positive. This test has a limited impact to
diagnosis and management, therefore the use of PNTML is optional.1,2
9. Motor evoked potentials
Electrical or magnetic stimulation of the lumbosacral nerve roots facilitates
measurements of the conduction time within the cauda equina and diagnosis of sacral
motor radiculopathy as a possible cause of fecal incontinence.4
10. Saline infusion test
With the patient lying on the bed, a tube is placed inside the rectum. Next, 800 ml or
1.500 ml warm saline is infused into the rectum at a rate of 60 ml/minute. The patient
is instructed to hold the liquid as long as possible. This test is useful in assesing
clinical outcome after therapy.2

Reference
1.

Paquette I, Varma M, Kaiser A, Steele SR, Rafferty MD. The American Society of
Colon and Rectal Surgeons Clinical Practice Guideline for the Treatment of Fecal
Incontinence. 2015;62336.

2.

Rao SSC. Diagnosis and Management of Fecal Incontinence. Am J Gastroenterol.

2004;1585604.

3.

National Collaborating Centre for Acute Care. The Management of Faecal

INcontinence in Adult. London: National Collaborating Centre for Acute Care; 2007.

1-146 p.
4.

Rao SSC. Advances in diagnostic assessment of fecal incontinence and dyssynergic

defecation. Clin Gastroenterol Hepatol. 2010;8(11):9109.

5.

Fecal Incontinence [Internet]. Mayo Clinic. 2015 [cited 2016 Jun 28]. Available from:
http://www.mayoclinic.org/diseases-conditions/fecal-incontinence/diagnosistreatment/diagnosis/dxc-20166900

6.

Lazarescu A, Turnbull GK, Vanner S. Investigating and treating fecal incontinence:

When and how. Can J Gastroenterol ogy. 2009;23(4):3018.

7.

Kim AY. How to Interpret a Functional or Motility Test - Defecography. J

Neurogastroenterol Motil. 2011;17(4):41620.