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Faecal incontinence in adults

Nature Reviews Disease Primers volume 8, Article number: 53 (2022) Cite this article

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Abstract

Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.

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Fig. 1: Prevalence of FI.
Fig. 2: Neuromuscular innervation of the pelvic floor muscles and anal sphincter.
Fig. 3: Pathophysiology of FI.
Fig. 4: Diagnostic approach for FI.
Fig. 5: Treatment of FI.

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Acknowledgements

A.E.B. is supported by US Public Health Service National Institutes of Health grant R01DK78924.

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA

    Adil E. Bharucha & Nicholas Oblizajek

  2. Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK

    Charles H. Knowles & S. Mark Scott

  3. University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany

    Isabelle Mack & Paul Enck

  4. Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia

    Allison Malcolm

  5. Department of Gastroenterology, University of Georgia, Augusta, GA, USA

    Satish Rao

  6. Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA

    Andrea Shin

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  1. Adil E. Bharucha
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  3. Isabelle Mack
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  4. Allison Malcolm
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Contributions

Introduction (P.E. and A.E.B.); Epidemiology (P.E. and I.M.); Mechanisms/pathophysiology (A.M. and S.M.S.); Diagnosis, screening and prevention (S.R.); Management (C.H.K. and A.S.); Quality of life (N.O.); Outlook (A.E.B.); Overview of Primer (P.E. and A.E.B.).

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Correspondence to Adil E. Bharucha or Paul Enck.

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Competing interests

A.E.B. is a consultant for Allergan, Medical Insights Group and GI Supply; receives royalties from Medspira; has patents with Medtronic, Medspira, and Minnesota Medical Technologies; and is listed as an inventor on the following patents relating to anorectal devices: WO2011014530A2 (applicant: Mayo Clinic; status: issued); US201562239397 (applicant: Minnesota Medical Technologies; status: issued); WO2014/068560 (applicant: Mayo Clinic and Medtronic; status: issued). C.H.K. is a consultant for Medtronic, Coloplast, Cook Myosite, Saluda Medical, Motilent, Takeda, Enteromed, Exero Medical, Alimentary Health, Amber Therapeutics, and Enterika; is on the speaker board of Medtronic; has shared or receives royalties from Amber Therapeutics and Enterika; and is listed as an inventor on the following patents for a surgical instrument and a pudendal nerve stimulation device: US11058405B2 (applicant: Queen Mary University of London; status: issued), US application serial number 63/160,322 (applicant: Amber Therapeutics Ltd, London, UK; status: filed). A.M. is a consultant for Allergan. P.E. is a consultant for Alimentary Health, Aptiny, Arena, Cemet, Indigo, SymbioPharm, and 4DPharma and is on the speaker Board of Alimentary Health, Biocodex, Biogen, Indigo, MDC, Medice, Merz, and Sanofi. S.R. is a consultant for InTone MV, Allergan, Ironwood, Neurogut, and Laborie. S.M.S. is a consultant for Laborie. A.S., I.M. and N.O. declare no competing interests.

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Nature Reviews Disease Primers thanks A.-M. Leroi; S. Wexner; K. Staller; A. Chandra, who co-reviewed with P. Rajan; C. Kontovounisios; and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Flatus

Passing of bowel gas.

Rome criteria

A set of diagnostic criteria defining functional bowel disorders.

Faecal impaction

Accumulation of faeces in the colon, especially in the rectum, which may cause blockage.

Prolapse

A bulging or falling out of a body part, such as the rectum or vagina, that may occur because of weakened supportive tissues and/or excessive straining.

Biofeedback therapy

Training by visual or auditory feedback signal of muscle action.

Episiotomy

An incision made in the perineum — the tissue between the vaginal opening and the anus — during childbirth.

Rectocele

Bulging of the rectum into the vagina owing to weakening of the fibrous tissue that separates the rectum from the vagina.

Sarcopenia

Progressive loss of skeletal muscle mass.

Slow-twitch muscle fibres

A subtype of muscle fibres that contain more blood-carrying myoglobin and, therefore, have their own source of energy necessary to sustain force for an extended period of time; however, in general, they generate less force than fast-twitch fibres.

Cells of Cajal

Pacemaker cells in the intestinal smooth muscle.

Enterocele

Enterocele or small bowel prolapse occurs when the small intestine descends into the lower pelvic cavity and pushes at the top part of the vagina, creating a bulge.

Psyllium

A form of fibre made from the husks of the Plantago ovata plant seeds; also known as ispaghula.

Passive FI

Leakage of bowel content without noticing and/or without the ability to withhold. FI, faecal incontinence.

Cloaca

A common cavity at the end of the digestive tract for the release of digestive, excretory and genital products in vertebrates except for most mammals, including humans. In humans, a cloaca is a congenital abnormality, caused by disease or iatrogenic.

Gutter deformity

Deformity in the anal canal that prevents the canal from being closed at rest.

Somatization

A personality trait to respond with somatic symptoms to psychological stress.

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Bharucha, A.E., Knowles, C.H., Mack, I. et al. Faecal incontinence in adults. Nat Rev Dis Primers 8, 53 (2022). https://doi.org/10.1038/s41572-022-00381-7

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