Fecal incontinence

Disease Description (Causes and Symptoms)

• Definition: Fecal incontinence is a condition that interferes with daily life in which stool is passed without the person’s awareness (passive fecal incontinence) or bowel movements occur because the urgency to defecate cannot be restrained (urge fecal incontinence). In people aged 4 years or older, fecal incontinence is considered when impaired bowel control persists for 3 months or longer.
• Main causes
  • Anal sphincter damage (injury during childbirth, anal/rectal surgery, trauma)
  • Damage to the sphincter or pelvic floor nerves (peripheral neuropathy, pudendal nerve lesions, diabetes, stroke, dementia, etc.)
  • Reduced rectal sensation or impaired rectal storage function (fecal impaction, rectal prolapse, etc.)
  • Stool consistency (soiling caused by severe diarrhea or chronic constipation)
  • Lesions around the anus and rectum, such as tumors, fistulas, and abscesses
• Pathophysiology (briefly): A combination of reduced sphincter contraction strength; abnormalities in rectal sensation and storage function; damage to central and peripheral neural circuits; and abnormal stool consistency (diarrhea or spasmodic stools) results in an inability to control bowel movements.
• Main symptoms: Soiling of underwear (gas, liquid, or solid stool), bowel urgency, nighttime incontinence, pad use, and social and psychological withdrawal. Symptoms are classified as passive incontinence (insensate leakage) or urge incontinence (being unable to hold it).

Treatment Methods (Standard Treatment · Medication · Procedures/Surgery · Lifestyle Management · Precautions)

• First-line nonsurgical treatment (try first)
  • Lifestyle and dietary therapy: Keep a record of foods consumed (to identify foods that trigger symptoms), increase fiber (e.g., psyllium) to bulk and stabilize stools, limit drinks and foods that trigger diarrhea (caffeine, alcohol, dairy products, products containing sorbitol or xylitol, etc.), eat small amounts frequently, and drink sufficient fluids.
  • Medication: Adjust frequency and stool consistency with antidiarrheal medications (e.g., loperamide), use bulking agents (fiber supplements), and adjust stool softeners or laxatives as needed (in cases of constipation-related impaction).
  • Bowel habit modification: Keep a bowel diary and encourage regular bowel movements (such as attempting to defecate after meals).
  • Pelvic floor muscle strengthening (Kegel exercises) and biofeedback therapy: Improve function by teaching anal sphincter function visually and through sensory feedback.
  • Electrical stimulation therapy (rectal or perineal electrical stimulation): May help restore muscle strength and sensation.
• Interventional and procedural treatment
  • Injectable agents (injectable bulking agents): Minimally invasive improvement may be attempted by injecting medication into the anal canal (indications and effectiveness are limited).
  • Neuromodulation (e.g., sacral nerve stimulation, sacral neuromodulation): A reversible electrical modulation procedure considered when there is no response to medication or rehabilitation.
• Surgical treatment (for structural defects or failure of conservative treatment)
  • Primary sphincter repair (in cases of recent injury, such as childbirth)
  • Sphincteroplasty (an overlapping technique, overlapping sphincteroplasty)
  • Functional improvement surgeries such as postanal repair
  • Artificial anal sphincter implantation (an option for severe sphincter defects; risk of infection exists)
• Precautions and complications
  • Possible postoperative infection, surgical failure or recurrence, and changes in bowel or urinary function
  • If left untreated chronically, may cause skin irritation, dermatitis, urinary tract infections, depression, and social isolation
  • Treatment effectiveness may be limited when nerve damage is severe or systemic diseases (dementia, severe neurological disorders) are present
• Prognosis: Varies depending on the cause, severity, and suitability of treatment. Many cases improve with conservative treatment, but surgical treatment is necessary when there is structural sphincter damage, and outcomes vary according to the patient’s condition.

Checklist Before an Outpatient Visit (Items to Bring · Records to Prepare · Information to Tell the Medical Staff in Advance)

• Items to bring

  • List of medications and supplements currently being taken (including dosage and administration times)
  • History of previous surgeries and childbirth (number of deliveries, whether forceps delivery or episiotomy was performed), and whether anal or rectal surgery was performed
  • Underlying diseases (diabetes, neurological diseases, dementia, stroke, etc.) and medical records/referral letter (if available)
  • Copies of recent test results, if already obtained (anal ultrasound, anorectal manometry, MRI, blood tests, etc.)

• What to record before the appointment (recommended)

  • Bowel diary (2–4 weeks): frequency of leakage, type of leakage (gas/liquid/solid), time of day (night/day), and triggering situations (coughing, exercise, meals, etc.)
  • Stool form (recording according to the Bristol Stool Scale is recommended), and whether diarrhea or constipation is present
  • Frequency and details of pad use (number of pads per day, changing times)
  • Time of symptom onset and progression, and impact on quality of life (social activities, work, sleep)

• Information that must be reported to the medical staff during the appointment

  • Whether warning symptoms such as bloody stool, weight loss, fever, or severe anal pain are present
  • Previous treatments attempted (medication, physical therapy, surgery) and their effects or side effects

• Examples of questions the doctor may ask during the appointment (preparing in advance may be helpful)

  • "Please describe specifically when stool leakage occurs (when, how often, and in what situations)."
  • "Have you recently started or stopped any medications (such as laxatives, antibiotics, or antidepressants)?"

Examples of General Questions to Ask the Doctor

• What is the most likely cause of fecal incontinence in my case?
• What additional tests should I undergo (anal ultrasound, anorectal manometry, MRI, etc.)? What can be learned from each test?
• How much improvement can I expect from nonsurgical treatment (diet, medication, biofeedback), and how long will it take?
• If surgery is necessary, which procedure is appropriate, and what are the success rate and risk of complications?
• What precautions or restrictions should I implement immediately in daily life?

Examples of Disease-Specific Questions

• In cases of fecal incontinence that developed after childbirth, if sphincter damage is confirmed by anal ultrasound, by when (at what point) should surgical repair be considered?
• For how many weeks or months should biofeedback and pelvic floor rehabilitation be performed before their effectiveness can be assessed, and what are the criteria for indications for the next treatment (neuromodulation or surgery) if they are ineffective?