Fecal incontinence

Fecal incontinence, the involuntary passage of feces, follows any loss or impairment of external anal sphincter control. It can result from various GI, neurologic, and psychological disorders; the effects of drugs; or surgery. In some patients, it may even be a purposeful manipulative behavior.

Fecal incontinence may be temporary or permanent; its onset may be gradual, as in dementia, or sudden, as in spinal cord trauma. Although usually not a sign of severe illness, it can greatly affect the patient’s physical and psychological well-being.

History and physical examination

Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, at night or with diarrhea. Note the frequency, consistency, and volume of stools passed within the last 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.

Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation, page 334.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.

Medical causes

Dementia

Any chronic degenerative brain disease can produce fecal as well as urinary incontinence. Associated signs and symptoms include impaired judgment and abstract thinking, amnesia, emotional lability, hyperactive deep tendon reflexes (DTRs), aphasia or dysarthria and, possibly, diffuse choreoathetoid movements.

Gastroenteritis

Severe gastroenteritis may result in temporary fecal incontinence manifested by explosive diarrhea. Nausea, vomiting, and colicky, peristaltic abdominal pain are typical. Other findings include headache, myalgia, and hyperactive bowel sounds.

Head trauma

Disruption of the neurologic pathways that control defecation can cause fecal incontinence. Additional findings depend on the location and severity of the injury and may include decreased level of consciousness, seizures, vomiting, and a wide range of motor and sensory impairments.

Inflammatory bowel disease

Nocturnal fecal incontinence occurs occasionally with diarrhea. Related findings include abdominal pain, anorexia, weight loss, blood in the stool, and hyperactive bowel sounds.

Multiple sclerosis

Fecal incontinence occasionally appears as one of this disorder’s extremely variable signs. Other effects depend on the area of demyelination and may include muscle weakness, ataxia, and paralysis; gait disturbances; sensory impairment, such as paresthesia and genital anesthesia; visual blurring, diplopia, or nystagmus; urinary disturbances; and emotional lability.

Rectovaginal fistula

Fecal incontinence occurs in tandem with uninhibited passage of flatus.

Spinal cord lesion

Any lesion that causes compression or transsection of sensorimotor spinal tracts can lead to fecal incontinence. Incontinence may be permanent, especially with severe lesions of the sacral segments. Other signs and symptoms reflect motor and sensory disturbances below the level of the lesion, such as urinary incontinence, weakness or paralysis, paresthesia, analgesia, and thermanesthesia.

Stroke

Temporary fecal incontinence occasionally occurs in a stroke patient but usually disappears when muscle tone and DTRs are restored. Persistent fecal incontinence may reflect extensive neurologic damage. Other findings depend on the location and extent of damage and may include urinary incontinence, hemiplegia, dysarthria, aphasia, sensory losses, reflex changes, and visual field deficits. Typical generalized signs and symptoms include headache, vomiting, nuchal rigidity, fever, disorientation, mental impairment, seizures, and coma.

Tabes dorsalis

This late sign of syphilis occasionally results in fecal incontinence. It also produces urinary incontinence, ataxic gait, paresthesia, loss of DTRs and temperature sensation, severe flashing pain, Charcot’s joints, Argyll Robertson pupils, and possibly impotence.

Other causes

Drugs

Chronic laxative abuse may cause insensitivity to a fecal mass or loss of the colonic defecation reflex.

Surgery

Pelvic, prostate, or rectal surgery occasionally produces temporary fecal incontinence. A colostomy or an ileostomy causes permanent or temporary fecal incontinence.

Special considerations

Maintain proper hygienic care, including control of foul odors. Also, provide emotional support for the patient because he may feel deep embarrassment. For the patient with intermittent or temporary fecal incontinence, encourage Kegel exercises to strengthen abdominal and perirectal muscles. (See How to do Kegel exercises, page 264.) For the neurologically capable patient with chronic incontinence, provide bowel retraining. (See Bowel retraining tips.)

Pediatric pointers

Fecal incontinence is normal in infants and may occur temporarily in young children who experience stress-related psychological regression or a physical illness associated with diarrhea. Pediatric fecal incontinence can also result from myelomeningocele.

Geriatric pointers

Fecal incontinence is an important factor when long-term care is considered for an elderly patient. Leakage of liquid fecal material is especially common in males. Age-related changes affecting smooth-muscle cells of the colonmay change GI motility and lead to fecal incontinence. Before age is determined to be the cause, however, any pathology must be ruled out.

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Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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