**Childhood Encopresis — Pathophysiology, Evaluation and Treatment**

C. Coffey and A.G. Catto-Smith

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/57071

#### **1. Introduction**

Encopresis is defined as persistent faecal incontinence without associated anatomic abnor‐ mality. It is a common, disabling condition of children often associated with functional defaecation disorders potentially open to nonsurgical treatments. It is considered to be primarily a disorder associated with chronic constipation, with stool retention in 96% of children over the age of four years presenting with faecal incontinence. [1]

The symptom of constipation is defined broadly as difficulty or delay in defaecation [2], often associated with large calibre stools and the presence of stool in the rectal ampulla. [3-5] Anecdotal evidence from parents often shows a transition from early simple constipation to chronic constipation, faecal retention and soiling. [6]

Constipation may not be easy to identify on history. Barr et al. noted that 45 percent of children when asked the most commonly used screening question for constipation relating to frequency of bowel motions gave an answer within the normal range. [5] These children were obviously constipated based on other criteria. Some children with encopresis have daily bowel motions but apparently incomplete evacuation as evidenced by periodic passage of very large amounts of stool. [7] Conversely, infrequent defaecation alone may not indicate constipation as this may simply represent the lower limit of normality. [8] In the literature the terms 'constipation' and 'faecal retention' are used interchangeably.

A period of continence is often defined as a period of at least one month without faecal incontinence. However, the frequency of soiling episodes does not necessarily correlate with severity of constipation. [9] Soiling in childhood encopresis is variable in quantity and frequency and may occur in the range of monthly to many times a day. It can occur at night but rarely exclusively so. [10] Children may have always soiled (primary) or may have

commenced soiling after a period of continence (secondary) with a third to half of children presenting with primary encopresis. [11, 12]

Of the 46% controls who responded to the questionnaire, 5% indicated they experienced faecal soiling. It was suggested that either the doctor might be reluctant to treat the problem, or alternatively that they regarded it as a minor symptom. Therefore assessment of the recovery rate of children with encopresis by comparison of reported prevalences is open to gross inaccuracies. It seems likely that the same bias occurs in paediatric reporting. In their study of 176 consecutively referred children with constipation, Arhan et al. [29] reported a referral diagnosis of encopresis in 8% but in fact 68% of the 176 children suffered from this symptom. There are functional differences in continence mechanisms between normal adult men and women. These include greater activity of both sphincters in men and a lower rectal volume to reach the threshold for desire to defaecate in women. [30-32] There are dangers inherent in extrapolation from the physiology of adults to children but it has suggested that gender differences also exist in paediatric anorectal function which might explain the greater propor‐ tion of boys with anorectal dysfunction. To date most studies which have included a compar‐ ison group of control children have not found evidence to support this suggestion. Corazziari did study 78 healthy children as a comparison group for 63 chronically constipated children and found no gender difference in stool frequency or total gastrointestinal transit time. [24] Only 25 (13 boys) children had manometric studies and there were no gender differences identified. Similarly, Meunier et al. found no significant gender differences in two control

Childhood Encopresis — Pathophysiology, Evaluation and Treatment

http://dx.doi.org/10.5772/57071

5

In order to investigate continence and defaecation disorders it is first necessary to understand these processes in a normal person. Unfortunately the literature only provides detailed studies of normal adults and so we are in the position of having to extrapolate these findings to

Stool frequency in Western communities decreases in the first years of life and then appears to plateau, but there is some evidence that this is not the case in developing communities for which there are no significant age-related differences. [34] Corazziari [24] observed that bowel frequency was significantly higher in children younger than three years than those of 3 to 12 years but found no difference in total gastrointestinal transit time. Normal frequency in the older age group was considered to be between 4 and 9 bowel actions per week. In young adults 5 to 12 bowel actions per week can be considered to be normal with males defaecating

Continence is maintained by the physical resistance to the passage of faeces moving from the rectosigmoid into the rectum and thence through the anal canal. [36] Stool transfer into the rectum usually occurs as a result of colonic high-amplitude propagated contractions, which are more likely to occur after wakening and meals. The rectum is generally collapsed before the arrival of faeces, which then result in distension, rectal contraction, a sensation of urgency, reflex relaxation of the internal anal sphincter and semi-voluntary relaxations of pelvic floor muscles. If defaecation does not occur, rectal contractions and the sense of urgency slowly

groups of normal children (n= 32 and 31). [23, 33]

significantly more frequently than females. [35]

children.

**3. Physiology of normal continence and defaecation**

The underlying pathologies resulting in childhood faecal retention remain relatively poorly understood. Colonic motility, large gut innervation, cyclic anal activity, bowel sensation and evacuation release, as well as behavioural factors may all contribute in varying degrees to the condition known generically as constipation with secondary encopresis. Encopresis involving soiling without evidence of stool accumulation and in the absence of any obvious anatomic abnormality does occur but there are no studies which have specifically and usefully examined functional disorders in this group.

Some authors attribute soiling and the generally associated faecal retention solely or predom‐ inantly to psychogenic causes. Halpern [13] reviewed the child rearing practices and person‐ ality types said to precipitate encopresis, but pointed to the lack of firm evidence associating inadequate parenting with soiling. Children with encopresis have been found to have a higher incidence of maladjustment than the normal population, but this is far from universal and more importantly has been observed to improve with symptomatic remission. [11, 14-16] It is likely therefore that the symptom of encopresis is at least contributing to the behaviour problems rather than the reverse. The stress on the child, his/her family, friends and teachers resulting from prolonged faecal incontinence is obvious but it should not distract from the need to identify and correct any functional abnormality that may exist. [16]

#### **2. Epidemiology and natural history**

Boys are far more prone to encopresis than girls, with the prevalence of encopresis amongst 7 to 8 year old boys 2.3 percent and amongst girls of 0.7 percent in the classic study from Stockholm. [17] The Isle of Wight survey found that 1.3 percent of 11 year old boys and 0.3 percent of girls were incontinent of stool [18], and similar data has recently been reported from the Netherlands. [19]

Approximately 70 to 80% of children presenting with encopresis are boys. [10, 11, 20, 21] The proportion of boys in studies of children with chronic constipation is approximately 60 percent. [3, 22-24]

In adults the picture is reversed with women being more inclined to suffer from constipation8, [25] and incontinence. [26, 27] However, in the clinical group of 276 patients described by Speakman and Henry, if men and women who had had previous surgery or trauma and the women who had a history of difficult vaginal delivery were discounted then the remaining patients consisted of 6 women and 4 men. Obviously when comparing childhood and adult prevalence of any disorder it is necessary to discount adult conditions for which there is no paediatric equivalent.

Faecal incontinence tends to be underreported in medical histories, [28] likely leading to systematic underestimation of its incidence and prevalence in adults. In one study, only 5% of patients with self-reported faecal incontinence had this recorded in their medical history. [28] Of the 46% controls who responded to the questionnaire, 5% indicated they experienced faecal soiling. It was suggested that either the doctor might be reluctant to treat the problem, or alternatively that they regarded it as a minor symptom. Therefore assessment of the recovery rate of children with encopresis by comparison of reported prevalences is open to gross inaccuracies. It seems likely that the same bias occurs in paediatric reporting. In their study of 176 consecutively referred children with constipation, Arhan et al. [29] reported a referral diagnosis of encopresis in 8% but in fact 68% of the 176 children suffered from this symptom.

There are functional differences in continence mechanisms between normal adult men and women. These include greater activity of both sphincters in men and a lower rectal volume to reach the threshold for desire to defaecate in women. [30-32] There are dangers inherent in extrapolation from the physiology of adults to children but it has suggested that gender differences also exist in paediatric anorectal function which might explain the greater propor‐ tion of boys with anorectal dysfunction. To date most studies which have included a compar‐ ison group of control children have not found evidence to support this suggestion. Corazziari did study 78 healthy children as a comparison group for 63 chronically constipated children and found no gender difference in stool frequency or total gastrointestinal transit time. [24] Only 25 (13 boys) children had manometric studies and there were no gender differences identified. Similarly, Meunier et al. found no significant gender differences in two control groups of normal children (n= 32 and 31). [23, 33]

#### **3. Physiology of normal continence and defaecation**

commenced soiling after a period of continence (secondary) with a third to half of children

The underlying pathologies resulting in childhood faecal retention remain relatively poorly understood. Colonic motility, large gut innervation, cyclic anal activity, bowel sensation and evacuation release, as well as behavioural factors may all contribute in varying degrees to the condition known generically as constipation with secondary encopresis. Encopresis involving soiling without evidence of stool accumulation and in the absence of any obvious anatomic abnormality does occur but there are no studies which have specifically and usefully examined

Some authors attribute soiling and the generally associated faecal retention solely or predom‐ inantly to psychogenic causes. Halpern [13] reviewed the child rearing practices and person‐ ality types said to precipitate encopresis, but pointed to the lack of firm evidence associating inadequate parenting with soiling. Children with encopresis have been found to have a higher incidence of maladjustment than the normal population, but this is far from universal and more importantly has been observed to improve with symptomatic remission. [11, 14-16] It is likely therefore that the symptom of encopresis is at least contributing to the behaviour problems rather than the reverse. The stress on the child, his/her family, friends and teachers resulting from prolonged faecal incontinence is obvious but it should not distract from the

Boys are far more prone to encopresis than girls, with the prevalence of encopresis amongst 7 to 8 year old boys 2.3 percent and amongst girls of 0.7 percent in the classic study from Stockholm. [17] The Isle of Wight survey found that 1.3 percent of 11 year old boys and 0.3 percent of girls were incontinent of stool [18], and similar data has recently been reported from

Approximately 70 to 80% of children presenting with encopresis are boys. [10, 11, 20, 21] The proportion of boys in studies of children with chronic constipation is approximately

In adults the picture is reversed with women being more inclined to suffer from constipation8, [25] and incontinence. [26, 27] However, in the clinical group of 276 patients described by Speakman and Henry, if men and women who had had previous surgery or trauma and the women who had a history of difficult vaginal delivery were discounted then the remaining patients consisted of 6 women and 4 men. Obviously when comparing childhood and adult prevalence of any disorder it is necessary to discount adult conditions for which there is no

Faecal incontinence tends to be underreported in medical histories, [28] likely leading to systematic underestimation of its incidence and prevalence in adults. In one study, only 5% of patients with self-reported faecal incontinence had this recorded in their medical history. [28]

need to identify and correct any functional abnormality that may exist. [16]

presenting with primary encopresis. [11, 12]

4 Fecal Incontinence - Causes, Management and Outcome

**2. Epidemiology and natural history**

the Netherlands. [19]

60 percent. [3, 22-24]

paediatric equivalent.

functional disorders in this group.

In order to investigate continence and defaecation disorders it is first necessary to understand these processes in a normal person. Unfortunately the literature only provides detailed studies of normal adults and so we are in the position of having to extrapolate these findings to children.

Stool frequency in Western communities decreases in the first years of life and then appears to plateau, but there is some evidence that this is not the case in developing communities for which there are no significant age-related differences. [34] Corazziari [24] observed that bowel frequency was significantly higher in children younger than three years than those of 3 to 12 years but found no difference in total gastrointestinal transit time. Normal frequency in the older age group was considered to be between 4 and 9 bowel actions per week. In young adults 5 to 12 bowel actions per week can be considered to be normal with males defaecating significantly more frequently than females. [35]

Continence is maintained by the physical resistance to the passage of faeces moving from the rectosigmoid into the rectum and thence through the anal canal. [36] Stool transfer into the rectum usually occurs as a result of colonic high-amplitude propagated contractions, which are more likely to occur after wakening and meals. The rectum is generally collapsed before the arrival of faeces, which then result in distension, rectal contraction, a sensation of urgency, reflex relaxation of the internal anal sphincter and semi-voluntary relaxations of pelvic floor muscles. If defaecation does not occur, rectal contractions and the sense of urgency slowly subside with the rectum accommodating to continuing distension. Resistance to the movement of stool into the rectum allows its accumulation in the distal colon.

and there is a sustained relaxation. Parallel to this the contraction of the EAS increases in strength and duration, maintaining continence. Prior to sustained relaxation of the IAS during the resting phases, Frenckner [45] determined that the IAS is responsible for just

Childhood Encopresis — Pathophysiology, Evaluation and Treatment

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7

The progression from mild to acute urgency generally occurs with the attainment of sustained increase in rectal tone and dilatation of the IAS. The sense of urgency is likely due to activation of stretch receptors in the proximal rectum or sigmoid colon. [43] There is disagreement about whether acute urgency and sustained relaxation of the IAS always occur together in normal children [4, 16, 46] while in adults Sun et al. [43] found no evidence

There are significant differences between age groups in normal children in both the maximal tolerable rectal volume, and the threshold volume required to elicit rectal contractions (rectorectal reflex). [33] The thresholds for these increased and decreased respectively with

Although some component of the EAS response to the inhibitory reflex is spinal (as it is observed to an extent in paraplegic patients) [47] depending on the level of the lesion it is susceptible to conscious control and therefore must be modulated by CNS involvement. [48] During sleep there is no diminution of the IAS response but there is a significant reduction in

Very high levels of rectal distension can be associated with reflex abolition of both EAS and IAS activity causing a profound reduction in anal pressure [41] resulting in automatic defae‐ cation. [49] This has been noted in normal children [4, 50] and adults. [51] This reflex is present in paraplegic patients with intact peripheral nerves and distal spinal reflexes so it is probably

The sensory receptors are complex in that not only the presence but also the nature of rectal contents are perceived, and the sensation due to IAS relaxation is felt differently from that due to rectal distension. [52] Receptors exist in the anal canal and may exist in the rectum and the muscles of the pelvic floor. There is disagreement about the origins of rectal sensation, whether mediated by receptors in the pelvic floor and not in the rectum, or whether as Sun [43] and Loening-Baucke [53] have postulated there are at least two types of rectal receptors: rapidly adapting mucosal receptors and slowly adapting mechanoreceptors in or on the rectal wall,

Sun [41] found that the duration of IAS relaxation and sensation in adults were not correlated although the former was always shorter than the latter. However, a strong association was found between the durations of EAS contraction and sensation. Transient sensation was not generally perceived if rectal contractions were not elicited and the EAS did not contract unless perception occurred. [30] Buser et al. [52] found that some adults with faecal incontinence did experience sensation at a time when EAS contraction was absent, so postulated that the EAS contracts as the result of rather than the cause of sensation. Read and Read [54] have suggested that the role of anal sensation receptors, as opposed to the rectal complex, may not be to

as well as the possibility of some in the sigmoid colon.

over half the anal tone and is therefore still important in maintaining continence.

for this.

increasing age.

the EAS component.

autonomous. [47]

The movement of faeces into the distal rectum from the sigmoid colon is impeded by its two lateral angulations and its spiral folds. [37] Resistance to movement through the anorectum is provided by the sharp anteroposterior angulation and the anal sphincters. The anorectal angle is maintained by the striated pelvic muscles, mainly the puborectalis. The anal sphincters form a high pressure zone consisting of two overlapping muscles: the internal anal sphincter (IAS) composed of smooth muscle, and the external anal sphincter (EAS) composed of striated muscle. Tonic change in the IAS is entirely reflex whilst that in the EAS is under voluntary control. Contraction of the puborectalis sling in conjunc‐ tion with contraction of the EAS is thought to assist the role of this sphincter. It does not appear to play as important a role in the maintenance of continence as the EAS.

The two sphincters can function independently of each other, depending on the need to accommodate faecal matter, ascertain the nature of the rectal contents, preserve conti‐ nence or to defaecate. At rest the sphincters maintain a high pressure zone which has an asymmetric profile with the highest pressures in the outermost sphincter area. [37] The asymmetry is largely maintained by contraction of the EAS which predominantly sur‐ rounds the distal anal canal and is submaximally tonically active under resting condi‐ tions. However, approximately 80 percent of the total sphincter tone is due to the activity of the IAS. Cyclical variations in resting pressure within the anal canal including spontane‐ ous relaxations of the sphincter have been observed in adults [32, 38] and in children. [39] There is a reduction in IAS tone, resting EAS activity and colonic motor activity during sleep in adults. [37] There is some suggestion that the EAS undergoes periodic change in tonic activity. [40]

With the arrival of sufficient faeces in the rectal canal to cause it to distend to a thresh‐ old volume there is a reflex relaxation of the IAS accompanied by contraction of the EAS. This rectoanal inhibitory reflex (RAIR) is associated with an increase in rectal pressure due to rectal contraction and within one second a transient sensation. [41] The triggering of the RAIR appears to be dependent on the rate of rectal distension: slow continuous filling allows a greater volume to collect before the IAS relaxes. Further increases in rectal contents beyond this threshold produce a gradation of sensation from that of wind, to an urge to defaecate, to the experience of pain. [42] Following each increase in rectal contents and volume, the EAS recovers resting tone after the brief increase in activity. There is howev‐ er a rebound increase in resting pressure of the IAS and the baseline rectal pressure increases for a period accompanied by an increase in rectal contractions. [30]

The rectal contractions reduce earlier with slower rates of filling but accommodation of the rectal contents can occur longitudinally without the necessity of relaxation of the rectal wall. [43] The increases in rectal contractions and axial pressures possibly tamp the stool into the proximal anal canal thereby increasing the defaecatory urge. [44] As the volume increases the relaxation of the IAS increases in strength and duration until recovery no longer occurs and there is a sustained relaxation. Parallel to this the contraction of the EAS increases in strength and duration, maintaining continence. Prior to sustained relaxation of the IAS during the resting phases, Frenckner [45] determined that the IAS is responsible for just over half the anal tone and is therefore still important in maintaining continence.

subside with the rectum accommodating to continuing distension. Resistance to the movement

The movement of faeces into the distal rectum from the sigmoid colon is impeded by its two lateral angulations and its spiral folds. [37] Resistance to movement through the anorectum is provided by the sharp anteroposterior angulation and the anal sphincters. The anorectal angle is maintained by the striated pelvic muscles, mainly the puborectalis. The anal sphincters form a high pressure zone consisting of two overlapping muscles: the internal anal sphincter (IAS) composed of smooth muscle, and the external anal sphincter (EAS) composed of striated muscle. Tonic change in the IAS is entirely reflex whilst that in the EAS is under voluntary control. Contraction of the puborectalis sling in conjunc‐ tion with contraction of the EAS is thought to assist the role of this sphincter. It does not

appear to play as important a role in the maintenance of continence as the EAS.

The two sphincters can function independently of each other, depending on the need to accommodate faecal matter, ascertain the nature of the rectal contents, preserve conti‐ nence or to defaecate. At rest the sphincters maintain a high pressure zone which has an asymmetric profile with the highest pressures in the outermost sphincter area. [37] The asymmetry is largely maintained by contraction of the EAS which predominantly sur‐ rounds the distal anal canal and is submaximally tonically active under resting condi‐ tions. However, approximately 80 percent of the total sphincter tone is due to the activity of the IAS. Cyclical variations in resting pressure within the anal canal including spontane‐ ous relaxations of the sphincter have been observed in adults [32, 38] and in children. [39] There is a reduction in IAS tone, resting EAS activity and colonic motor activity during sleep in adults. [37] There is some suggestion that the EAS undergoes periodic change in

With the arrival of sufficient faeces in the rectal canal to cause it to distend to a thresh‐ old volume there is a reflex relaxation of the IAS accompanied by contraction of the EAS. This rectoanal inhibitory reflex (RAIR) is associated with an increase in rectal pressure due to rectal contraction and within one second a transient sensation. [41] The triggering of the RAIR appears to be dependent on the rate of rectal distension: slow continuous filling allows a greater volume to collect before the IAS relaxes. Further increases in rectal contents beyond this threshold produce a gradation of sensation from that of wind, to an urge to defaecate, to the experience of pain. [42] Following each increase in rectal contents and volume, the EAS recovers resting tone after the brief increase in activity. There is howev‐ er a rebound increase in resting pressure of the IAS and the baseline rectal pressure increases

The rectal contractions reduce earlier with slower rates of filling but accommodation of the rectal contents can occur longitudinally without the necessity of relaxation of the rectal wall. [43] The increases in rectal contractions and axial pressures possibly tamp the stool into the proximal anal canal thereby increasing the defaecatory urge. [44] As the volume increases the relaxation of the IAS increases in strength and duration until recovery no longer occurs

for a period accompanied by an increase in rectal contractions. [30]

of stool into the rectum allows its accumulation in the distal colon.

6 Fecal Incontinence - Causes, Management and Outcome

tonic activity. [40]

The progression from mild to acute urgency generally occurs with the attainment of sustained increase in rectal tone and dilatation of the IAS. The sense of urgency is likely due to activation of stretch receptors in the proximal rectum or sigmoid colon. [43] There is disagreement about whether acute urgency and sustained relaxation of the IAS always occur together in normal children [4, 16, 46] while in adults Sun et al. [43] found no evidence for this.

There are significant differences between age groups in normal children in both the maximal tolerable rectal volume, and the threshold volume required to elicit rectal contractions (rectorectal reflex). [33] The thresholds for these increased and decreased respectively with increasing age.

Although some component of the EAS response to the inhibitory reflex is spinal (as it is observed to an extent in paraplegic patients) [47] depending on the level of the lesion it is susceptible to conscious control and therefore must be modulated by CNS involvement. [48] During sleep there is no diminution of the IAS response but there is a significant reduction in the EAS component.

Very high levels of rectal distension can be associated with reflex abolition of both EAS and IAS activity causing a profound reduction in anal pressure [41] resulting in automatic defae‐ cation. [49] This has been noted in normal children [4, 50] and adults. [51] This reflex is present in paraplegic patients with intact peripheral nerves and distal spinal reflexes so it is probably autonomous. [47]

The sensory receptors are complex in that not only the presence but also the nature of rectal contents are perceived, and the sensation due to IAS relaxation is felt differently from that due to rectal distension. [52] Receptors exist in the anal canal and may exist in the rectum and the muscles of the pelvic floor. There is disagreement about the origins of rectal sensation, whether mediated by receptors in the pelvic floor and not in the rectum, or whether as Sun [43] and Loening-Baucke [53] have postulated there are at least two types of rectal receptors: rapidly adapting mucosal receptors and slowly adapting mechanoreceptors in or on the rectal wall, as well as the possibility of some in the sigmoid colon.

Sun [41] found that the duration of IAS relaxation and sensation in adults were not correlated although the former was always shorter than the latter. However, a strong association was found between the durations of EAS contraction and sensation. Transient sensation was not generally perceived if rectal contractions were not elicited and the EAS did not contract unless perception occurred. [30] Buser et al. [52] found that some adults with faecal incontinence did experience sensation at a time when EAS contraction was absent, so postulated that the EAS contracts as the result of rather than the cause of sensation. Read and Read [54] have suggested that the role of anal sensation receptors, as opposed to the rectal complex, may not be to preserve continence but to identify the rectal contents or signal the end of defaecation. [49] If this is the case then the RAIR allows testing of the rectal contents by these receptors, providing conscious information on which suitable actions may be taken. It has been suggested the spontaneous cyclical IAS relaxations fulfil the same purpose. [38]

concomitant reduction in sensation leading to soiling or, at least, to its continuation. [56] Attempts to identify pathophysiology which may be present in children with faecal inconti‐ nence have largely concentrated on studies of resting anorectal pressure and motility charac‐

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9

The aim of treatment is to for the patient to achieve the ability to be in charge of his/her own continence and defaecation. [57, 58] To this end the any significant faecal impaction needs to be relieved and a regular output established. Treatment for encopresis falls into three stages with the first being initial disimpaction with commencement of maintenance laxatives or prokinetic agents. The second stage is the establishment of a good bowel habit by the use of behaviour modification; and thirdly, the correction, if necessary, of abnormal defaecation dynamics. The first two modes of treatment are frequently adequate to resolve the problem but if the encopresis is refractory. Many children respond well but there is undoubtedly a

Laxative treatment regimens vary in detail but generally aim to produce one to two bowel actions per day. The extent of the faecal retention determines the type of medication. Poly‐ ethylene glycol ("macrogol") based regimens are increasingly accepted as a first line, but there is still an occasional place for stimulant laxatives such as senna derivatives or bisacodyl. [57] Enemas and suppositories are now only infrequently used for disimpaction. Increased fibre is

Concurrently with laxative medication, a star chart with a reward system both for successful defaecation in the toilet and for soil-free days can be used as positive reinforcement aimed towards achieving an improvement in toileting habit. Regular sits three times a day for 5-10 minutes with a minimum of distraction is an effective regimen [11] In addition, clarification of the physiology of encopresis to parents and children to alleviate guilt is very important, as is attentive follow-up to maintain compliance and monitor progress. In a referred population of children presenting with encopresis this regimen can be expected to result in complete remission from soiling in approximately half [11, 12, 60] and in addition to be independent of

The rationale for the development of biofeedback had been to provide a correction of disturbed anorectal dynamics, and especially for paradoxical sphincteric contraction or anismus. [61] The method recommended for biofeedback generally is the same as, or an adaption of,

teristics, sensation, the RAIR and the investigation of anismus.

group who continue to have long term problems past puberty. [59]

of use only if the current intake is inadequate. [58]

**4.2. Behaviour modification**

laxatives in the same or less.[4, 9]

**4.3. Biofeedback for treatment of anismus**

**4. Treatment**

**4.1. Laxatives**

An alternative or supplementary mechanism for the identification of the physical nature of faeces may be associated with the different rates of distension of the rectal wall accompanying the propulsion of material from the distal colon. As well as differences in RAIR thresholds, rapid rectal distension has been found to produce a different sensation from gradual distension to the same volume so that distinction between these may provide the discriminatory infor‐ mation. [43] However, whatever the order and origins of stimuli, it is obvious that once the rectal contents have reached the threshold for reflex relaxation of the IAS then at least subconscious awareness of stool in the rectum and immediate contraction of the EAS are essential for the preservation of continence. The ability to experience a sense of urgency before profound reflex anal dilatation occurs is likewise essential.

With an increase in intra-abdominal pressure there is a reflex compensatory increase in EAS activity to a level which provides an anal pressure in excess of the rectal pressure. [30] This allows continence to be maintained when coughing, sneezing, blowing up balloons, laughing or any other activity which poses a threat by its effect on abdominal pressure. Voluntary squeezing or tightening up of the EAS to maintain continence involves no increase in intraabdominal pressure. [6]

Voluntary defaecation takes place in three phases. Initially there is an increase in abdominal pressure and rectal pressure brought about by closure of the glottis, fixation of the diaphragm and contraction of abdominal, perianal and hamstring muscles combined with contraction of the puborectalis sling and both sphincters. [37] Then the pelvic muscles relax allowing straightening of the rectoanal angle and of both sphincters. The normal anorectal angle at rest is approximately 90° and increases to 125° during straining. At the same time strong colorectal contractions assist expulsion of the stool and the anal sphincters relax. Electrical activity in the EAS is greatly reduced at this stage. Schuster [49] suggested that this relaxation takes place when the threshold for automatic defaecation is reached. As defaecation proceeds the rectal pressure gradually falls. The third stage involves the return to the original state after a rebound contraction of the anal sphincters.

It can be seen from the complex nature of continence and defaecation that there are many opportunities for problems to occur both through physiological deficits and disordered processes. [36] Insufficient IAS or EAS resting tone, inadequate or delayed EAS response to the rectoanal inhibitory reflex, elevated or absent threshold of sensation from rectal distension and a blunted feeling of urgency have all been proposed as possible causes or at least contrib‐ utors to faecal incontinence. Inadequate colonic propulsion, failure of the IAS to relax, inappropriate contraction of the EAS and puborectalis, failure of the levators to lift the pelvic floor, luminal obstruction or an impairment in the central control of defaecation may singly or in combination result in obstructed defaecation. Failure to relax the striated musculature of the pelvic floor during straining has been termed anismus [55] and probably results in incomplete evacuation, faecal retention, chronic distension of the rectum, and possibly concomitant reduction in sensation leading to soiling or, at least, to its continuation. [56] Attempts to identify pathophysiology which may be present in children with faecal inconti‐ nence have largely concentrated on studies of resting anorectal pressure and motility charac‐ teristics, sensation, the RAIR and the investigation of anismus.

#### **4. Treatment**

preserve continence but to identify the rectal contents or signal the end of defaecation. [49] If this is the case then the RAIR allows testing of the rectal contents by these receptors, providing conscious information on which suitable actions may be taken. It has been suggested the

An alternative or supplementary mechanism for the identification of the physical nature of faeces may be associated with the different rates of distension of the rectal wall accompanying the propulsion of material from the distal colon. As well as differences in RAIR thresholds, rapid rectal distension has been found to produce a different sensation from gradual distension to the same volume so that distinction between these may provide the discriminatory infor‐ mation. [43] However, whatever the order and origins of stimuli, it is obvious that once the rectal contents have reached the threshold for reflex relaxation of the IAS then at least subconscious awareness of stool in the rectum and immediate contraction of the EAS are essential for the preservation of continence. The ability to experience a sense of urgency before

With an increase in intra-abdominal pressure there is a reflex compensatory increase in EAS activity to a level which provides an anal pressure in excess of the rectal pressure. [30] This allows continence to be maintained when coughing, sneezing, blowing up balloons, laughing or any other activity which poses a threat by its effect on abdominal pressure. Voluntary squeezing or tightening up of the EAS to maintain continence involves no increase in intra-

Voluntary defaecation takes place in three phases. Initially there is an increase in abdominal pressure and rectal pressure brought about by closure of the glottis, fixation of the diaphragm and contraction of abdominal, perianal and hamstring muscles combined with contraction of the puborectalis sling and both sphincters. [37] Then the pelvic muscles relax allowing straightening of the rectoanal angle and of both sphincters. The normal anorectal angle at rest is approximately 90° and increases to 125° during straining. At the same time strong colorectal contractions assist expulsion of the stool and the anal sphincters relax. Electrical activity in the EAS is greatly reduced at this stage. Schuster [49] suggested that this relaxation takes place when the threshold for automatic defaecation is reached. As defaecation proceeds the rectal pressure gradually falls. The third stage involves the return to the original state after a rebound

It can be seen from the complex nature of continence and defaecation that there are many opportunities for problems to occur both through physiological deficits and disordered processes. [36] Insufficient IAS or EAS resting tone, inadequate or delayed EAS response to the rectoanal inhibitory reflex, elevated or absent threshold of sensation from rectal distension and a blunted feeling of urgency have all been proposed as possible causes or at least contrib‐ utors to faecal incontinence. Inadequate colonic propulsion, failure of the IAS to relax, inappropriate contraction of the EAS and puborectalis, failure of the levators to lift the pelvic floor, luminal obstruction or an impairment in the central control of defaecation may singly or in combination result in obstructed defaecation. Failure to relax the striated musculature of the pelvic floor during straining has been termed anismus [55] and probably results in incomplete evacuation, faecal retention, chronic distension of the rectum, and possibly

spontaneous cyclical IAS relaxations fulfil the same purpose. [38]

8 Fecal Incontinence - Causes, Management and Outcome

profound reflex anal dilatation occurs is likewise essential.

abdominal pressure. [6]

contraction of the anal sphincters.

The aim of treatment is to for the patient to achieve the ability to be in charge of his/her own continence and defaecation. [57, 58] To this end the any significant faecal impaction needs to be relieved and a regular output established. Treatment for encopresis falls into three stages with the first being initial disimpaction with commencement of maintenance laxatives or prokinetic agents. The second stage is the establishment of a good bowel habit by the use of behaviour modification; and thirdly, the correction, if necessary, of abnormal defaecation dynamics. The first two modes of treatment are frequently adequate to resolve the problem but if the encopresis is refractory. Many children respond well but there is undoubtedly a group who continue to have long term problems past puberty. [59]

#### **4.1. Laxatives**

Laxative treatment regimens vary in detail but generally aim to produce one to two bowel actions per day. The extent of the faecal retention determines the type of medication. Poly‐ ethylene glycol ("macrogol") based regimens are increasingly accepted as a first line, but there is still an occasional place for stimulant laxatives such as senna derivatives or bisacodyl. [57] Enemas and suppositories are now only infrequently used for disimpaction. Increased fibre is of use only if the current intake is inadequate. [58]

#### **4.2. Behaviour modification**

Concurrently with laxative medication, a star chart with a reward system both for successful defaecation in the toilet and for soil-free days can be used as positive reinforcement aimed towards achieving an improvement in toileting habit. Regular sits three times a day for 5-10 minutes with a minimum of distraction is an effective regimen [11] In addition, clarification of the physiology of encopresis to parents and children to alleviate guilt is very important, as is attentive follow-up to maintain compliance and monitor progress. In a referred population of children presenting with encopresis this regimen can be expected to result in complete remission from soiling in approximately half [11, 12, 60] and in addition to be independent of laxatives in the same or less.[4, 9]

#### **4.3. Biofeedback for treatment of anismus**

The rationale for the development of biofeedback had been to provide a correction of disturbed anorectal dynamics, and especially for paradoxical sphincteric contraction or anismus. [61] The method recommended for biofeedback generally is the same as, or an adaption of, anorectal manometry with some sort of visual or auditory feedback of sphincteric contraction. Unfortunately critical evaluation in controlled studies has failed to provide evidence of superior efficacy to standard treatments. [62, 63]

[5] Barr RG, Levine MD, Wilkinson RH, Mulvihill D. Chronic and occult stool retention: a clinical tool for its evaluation in school-aged children. Clin Pediatr (Phila)

Childhood Encopresis — Pathophysiology, Evaluation and Treatment

http://dx.doi.org/10.5772/57071

11

[6] Loening-Baucke V. Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis. J Pediatr

[8] Sandler RS, Jordan MC, Shelton BJ. Demographic and dietary determinants of consti‐

[9] Loening-Baucke VA. Factors responsible for persistence of childhood constipation. J

[10] Levine MD. Children with encopresis: A descriptive analysis. Pediatrics

[11] Nolan T, Debelle G, Oberklaid F, Coffey C. Randomised trial of laxatives in treatment

[12] Levine MD, Bakow H. Children with encopresis: a study of treatment outcome. Pe‐

[13] Halpern WI. The treatment of encopretic children. J Am Acad Child Psychiatry

[14] Levine MD, Mazonson P, Bakow H. Behavioral symptom substitution in children

[15] Gabel S, Hegedus AM, Wald A, Chandra R, Chiponis D. Prevalence of behavior problems and mental health utilization among encopretic children: implications for

[16] Clayden GS, Lawson JO. Investigation and management of long-standing chronic

[18] Rutter M, Tizard J, Whitmore K. Education, health, and behaviour; psychological and

[19] van der Wal MF, Benninga MA, Hirasing RA. The prevalence of encopresis in a mul‐ ticultural population. Journal of Pediatric Gastroenterology & Nutrition

[20] Loening-Baucke V. Factors determining outcome in children with chronic constipa‐

[7] Loening-Baucke V. Encopresis. Curr Opin Pediatr 2002;14:570-575.

pation in the US population. Am J Public Health 1990;80:185-9.

1979;18:674, 676, 677-9, passim.

Pediatr Gastroenterol Nutr 1987;6:915-22.

of childhood encopresis. Lancet 1991;338:523-527.

cured of encopresis. Am J Dis Child 1980;134:663-7.

behavioral pediatrics. J Dev Behav Pediatr 1986;7:293-7.

constipation in childhood. Arch Dis Child 1976;51:918-23.

medical study of childhood development. Wiley, 1970.

tion and faecal soiling. Gut 1989;30:999-1006.

[17] Bellman M. Studies on encopresis. Acta Paediatr Scand 1966;170:1-151.

1990;116:214-22.

1975;56:412-416.

1977;16:478-99.

2005;40:345-8.

diatrics 1976;58:845-52.

#### **5. Discussion**

Encopresis in childhood is an important cause of soiling, with socially disabling consequences. It is usually associated with constipation and is thought to be secondary to periodic relaxation of the anal sphincters in the presence of a loaded rectum with secondary seepage. The pathophysiology of disturbed anorectal function is relatively poorly studied in children and results often interpreted with data obtained from adult studies. Most children do have some type of manometric abnormality and many have a degree of rectal enlargement. Dynamic abnormalities also exist and the best studied is paradoxical sphincteric contraction or "anis‐ mus'.

Treatment regimens which include a combination laxatives for disimpaction and maintenance, together with behavioural interventions centred around encouraging toileting are generally effective but there is a group of children who go on to have significant long term problems.

#### **Author details**


#### **References**


anorectal manometry with some sort of visual or auditory feedback of sphincteric contraction. Unfortunately critical evaluation in controlled studies has failed to provide evidence of

Encopresis in childhood is an important cause of soiling, with socially disabling consequences. It is usually associated with constipation and is thought to be secondary to periodic relaxation of the anal sphincters in the presence of a loaded rectum with secondary seepage. The pathophysiology of disturbed anorectal function is relatively poorly studied in children and results often interpreted with data obtained from adult studies. Most children do have some type of manometric abnormality and many have a degree of rectal enlargement. Dynamic abnormalities also exist and the best studied is paradoxical sphincteric contraction or "anis‐

Treatment regimens which include a combination laxatives for disimpaction and maintenance, together with behavioural interventions centred around encouraging toileting are generally effective but there is a group of children who go on to have significant long term problems.

[1] Loening-Baucke V. Biofeedback therapy for fecal incontinence. Dig Dis 1990;8:112-24.

[3] Abrahamian FP, Lloyd-Still JD. Chronic constipation in childhood: a longitudinal

[4] Loening-Baucke VA. Sensitivity of the sigmoid colon and rectum in children treated

[2] Clayden GS. Constipation and soiling in childhood. Br Med J 1976;1:515-7.

study of 186 patients. J Pediatr Gastroenterol Nutr 1984;3:460-7.

for chronic constipation. J Pediatr Gastroenterol Nutr 1984;3:454-9.

superior efficacy to standard treatments. [62, 63]

10 Fecal Incontinence - Causes, Management and Outcome

**5. Discussion**

mus'.

**Author details**

and A.G. Catto-Smith1,2\*

\*Address all correspondence to: tony.cattosmith@rch.org.au

2 Dept of Pediatrics, University of Melbourne, Australia

1 Dept of Gastroenterology, Royal Children's Hospital Melbourne, Australia

C. Coffey1

**References**


[21] Wald A, Chandra R, Chiponis D, Gabel S. Anorectal function and continence mecha‐ nisms in childhood encopresis. J Pediatr Gastroenterol Nutr 1986;5:346-51.

[36] Bharucha AE. Fecal Incontinence. In: Parkman HP, McCallum RW, Rao SSC, eds. GI Motility Testing. Thorofare, New Jersey: Slack Incorporated, 2011:383-397.

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[37] Bharucha AE. Pelvic floor: anatomy and function. Neurogastroenterol Motil

[38] Enck P, Eggers E, Koletzko S, Erckenbrecht JF. Spontaneous variation of anal "rest‐

[39] Loening-Baucke VA, Younoszai MK. Abnormal and sphincter response in chronical‐

[40] Kumar D, Williams NS, Waldron D, Wingate DL. Prolonged manometric recording of anorectal motor activity in ambulant human subjects: evidence of periodic activity.

[41] Sun WM, Read NW, Miner PB. Relation between rectal sensation and anal function in normal subjects and patients with faecal incontinence. Gut 1990;31:1056-61.

[42] Tantiphlachiva K, Rao SSC. Anorectal Manometry. In: Parkman HP, McCallum RW, Rao SSC, eds. GI Motility. Thorofare, New Jersey: Slack Incorporated, 2011:163-178.

[43] Sun WM, Read NW, Prior A, Daly JA, Cheah SK, Grundy D. Sensory and motor re‐ sponses to rectal distention vary according to rate and pattern of balloon inflation.

[44] Bharucha AE, Croak AJ, Gebhart JB, Berglund LJ, Seide BM, Zinsmeister AR, An KN, Bharucha AE, Croak AJ, Gebhart JB, Berglund LJ, Seide BM, Zinsmeister AR, An K-N. Comparison of rectoanal axial forces in health and functional defecatory disor‐ ders. American Journal of Physiology - Gastrointestinal & Liver Physiology

[45] Frenckner B, Euler CV. Influence of pudendal block on the function of the anal

[46] Molnar D, Taitz LS, Urwin OM, Wales JK. Anorectal manometry results in defecation

[48] Whitehead WE, Orr WC, Engel BT, Schuster MM. External anal sphincter response to rectal distention: learned response or reflex. Psychophysiology 1982;19:57-62.

[50] Aaronson I, Nixon HH. A clinical evaluation of anorectal pressure studies in the di‐

[51] Williamson JL, Nelson RL, Orsay C, Pearl RK, Abcarian H. A comparison of simulta‐ neous longitudinal and radial recordings of anal canal pressures. Dis Colon Rectum

[47] Frenckner B. Function of the anal sphincters in spinal man. Gut 1975;16:638-44.

[49] Schuster MM. The riddle of the sphincters. Gastroenterology 1975;69:249-62.

agnosis of Hirschsprung's disease. Gut 1972;13:138-46.

ing" pressure in healthy humans. Am J Physiol 1991;261:G823-6.

ly constipated children. J Pediatr 1982;100:213-8.

2006;18:507-19.

Gut 1989;30:1007-11.

2006;290:G1164-9.

1990;33:201-6.

Gastroenterology 1990;99:1008-15.

sphincters. Gut 1975;16:482-9.

disorders. Arch Dis Child 1983;58:257-61.


[36] Bharucha AE. Fecal Incontinence. In: Parkman HP, McCallum RW, Rao SSC, eds. GI Motility Testing. Thorofare, New Jersey: Slack Incorporated, 2011:383-397.

[21] Wald A, Chandra R, Chiponis D, Gabel S. Anorectal function and continence mecha‐ nisms in childhood encopresis. J Pediatr Gastroenterol Nutr 1986;5:346-51.

[22] Partin JC, Hamill SK, Fischel JE, Partin JS. Painful defecation and fecal soiling in chil‐

[23] Meunier P, Marechal JM, de Beaujeu MJ. Rectoanal pressures and rectal sensitivity studies in chronic childhood constipation. Gastroenterology 1979;77:330-6.

[24] Corazziari E, Cucchiara S, Staiano A, Romaniello G, Tamburrini O, Torsoli A, Auric‐ chio S. Gastrointestinal transit time, frequency of defecation, and anorectal manome‐

[25] Loening-Baucke VA, Cruikshank BM. Abnormal defecation dynamics in chronically

[26] Emery Y, Descos L, Meunier P, Louis D, Valancogne G, Weil G. [Terminal constipa‐ tion caused by abdominopelvic asynchrony: analysis of etiological, clinical, mano‐ metric data and therapeutic results after rehabilitation by biofeedback]. Gastroenterol

[27] Speakman CT, Henry MM. The work of an anorectal physiology laboratory. Bail‐

[28] Enck P, Bielefeldt K, Rathmann W, Purrmann J, Tschope D, Erckenbrecht JF. Epi‐ demiology of faecal incontinence in selected patient groups. Int J Colorectal Dis

[29] Arhan P, Devroede G, Jehannin B, Faverdin C, Revillon Y, Lefevre D, Pellerin D. Idi‐ opathic disorders of fecal continence in children. Pediatrics 1983;71:774-9.

[30] Sun WM, Read NW. Anorectal function in normal human subjects: effect of gender.

[31] Rasmussen OO, Colstrup H, Lose G, Christiansen J. A technique for the dynamic as‐

[32] Pedersen IK, Christiansen J. A study of the physiological variation in anal manome‐

[33] Meunier P, Louis D, Jaubert de Beaujeu M. Physiologic investigation of primary chronic constipation in children: comparison with the barium enema study. Gastro‐

[34] Myo K, Thein Win N, Kyaw-Hla S, Thein Thein M, Bolin TD. A prospective study on defecation frequency, stool weight, and consistency. Arch Dis Child 1994;71:311-3;

[35] Sandler RS, Drossman DA. Bowel habits in young adults not seeking health care. Dig

sessment of anal sphincter function. Int J Colorectal Dis 1990;5:135-41.

try in healthy and constipated children. J Pediatr 1985;106:379-82.

constipated children with encopresis. J Pediatr 1986;108:562-6.

dren. Pediatrics 1992;89:1007-9.

12 Fecal Incontinence - Causes, Management and Outcome

Clin Biol 1988;12:6-11.

1991;6:143-146.

lieres Clin Gastroenterol 1992;6:59-73.

Int J Colorectal Dis 1989;4:188-96.

try. Br J Surg 1989;76:69-70.

enterology 1984;87:1351-7.

discussion 313-4.

Dis Sci 1987;32:841-5.


[52] Buser WD, Miner PB, Jr. Delayed rectal sensation with fecal incontinence. Successful treatment using anorectal manometry. Gastroenterology 1986;91:1186-91.

**Chapter 2**

**Fecal Incontinence**

http://dx.doi.org/10.5772/57502

**1. Introduction**

**2. Epidemiology**

disability [6].

Additional information is available at the end of the chapter

by a medical problem and treatment is available [1].

Fecal incontinence (FI) is defined as the recurrent, involuntary passing of solid or liquid stool [1-5]. FI is a common condition that results in significant physical and psychological

FI includes the inability to hold a bowel movement until reaching a toilet as well as passing stool into one's underwear without being aware of it happening. Feces is solid waste that is passed as a bowel movement and includes undigested food, bacteria, mucus, and dead cells. Mucus is a clear liquid that coats and protects tissues in the digestive system [3]. FI is a challenging condition of diverse etiology and devastating psychosocial impact [1,3,4]. It severely impacts on the quality of life of many sufferers and their families, often being given as the reason for admission to a care home [7]. Therefore FI can be upsetting and embarrassing. Many people with FI feel ashamed and try to hide the problem. However, people with FI should not be afraid or embarrassed to talk with their health care provider. FI is often caused

Although FI can be both emotionally and socially debilitating, the embarrassment associated with it is so great that it often prevents patients from seeking much needed help from their health care providers. Nursing care begins with case finding and continues through conser‐

FI affects approximately 5% of the general population but its prevalence increases with age. Nearly 18 million United States (US) adults, about one in 12, have FI. FI is common in women; 1:1,010 women in the United States have FI. Nearly 70% of patients with FI have never

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

vative management, which has greatly improved over the past 15 years [8].

Arzu Ilce


**Chapter 2**

## **Fecal Incontinence**

Arzu Ilce

[52] Buser WD, Miner PB, Jr. Delayed rectal sensation with fecal incontinence. Successful treatment using anorectal manometry. Gastroenterology 1986;91:1186-91.

[53] Loening-Baucke V, Read NW, Yamada T. Further evaluation of the afferent nervous

[54] Read MG, Read NW. Role of anorectal sensation in preserving continence. Gut

[55] Preston DM, Lennard-Jones JE. Anismus in chronic constipation. Dig Dis Sci

[56] Catto-Smith AG, Nolan TM, Coffey CM. Clinical significance of anismus in encopre‐

[57] Catto-Smith A, Chase J, Edgar D, Fields J, Gibb S, Grattan B, Johnston M, Josephs K. Impact Paediatric Bowel Care Pathway: Australia: The Continence Foundation of

[58] Catto-Smith AG. 5. Constipation and toileting issues in children. Med J Aust

[59] van Ginkel R, Reitsma JB, Buller HA, van Wijk MP, Taminiau JA, Benninga MA. Childhood constipation: longitudinal follow-up beyond puberty. Gastroenterology

[60] Lowery SP, Srour JW, Whitehead WE, Schuster MM. Habit training as treatment of encopresis secondary to chronic constipation. J Pediatr Gastroenterol Nutr

[61] Rao SS, Enck P, Loening-Baucke V. Biofeedback therapy for defecation disorders. Dig

[62] Loening-Baucke V. Biofeedback training in children with functional constipation. A

[63] Nolan T, Catto-Smith T, Coffey C, Wells J. Randomised controlled trial of biofeed‐ back training in persistent encopresis with anismus. Arch Dis Child 1998;79:131-135.

pathways from the rectum. Am J Physiol 1992;262:G927-33.

sis. J Gastroenterol Hepatol 1998;13:955-960.

1982;23:345-7.

14 Fecal Incontinence - Causes, Management and Outcome

1985;30:413-8.

Australia, 2007.

2005;182:242-6.

2003;125:357-63.

1985;4:397-401.

Dis 1997;15 Suppl 1:78-92.

critical review. Dig Dis Sci 1996;41:65-71.

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/57502

### **1. Introduction**

Fecal incontinence (FI) is defined as the recurrent, involuntary passing of solid or liquid stool [1-5]. FI is a common condition that results in significant physical and psychological disability [6].

FI includes the inability to hold a bowel movement until reaching a toilet as well as passing stool into one's underwear without being aware of it happening. Feces is solid waste that is passed as a bowel movement and includes undigested food, bacteria, mucus, and dead cells. Mucus is a clear liquid that coats and protects tissues in the digestive system [3]. FI is a challenging condition of diverse etiology and devastating psychosocial impact [1,3,4]. It severely impacts on the quality of life of many sufferers and their families, often being given as the reason for admission to a care home [7]. Therefore FI can be upsetting and embarrassing. Many people with FI feel ashamed and try to hide the problem. However, people with FI should not be afraid or embarrassed to talk with their health care provider. FI is often caused by a medical problem and treatment is available [1].

Although FI can be both emotionally and socially debilitating, the embarrassment associated with it is so great that it often prevents patients from seeking much needed help from their health care providers. Nursing care begins with case finding and continues through conser‐ vative management, which has greatly improved over the past 15 years [8].

## **2. Epidemiology**

FI affects approximately 5% of the general population but its prevalence increases with age. Nearly 18 million United States (US) adults, about one in 12, have FI. FI is common in women; 1:1,010 women in the United States have FI. Nearly 70% of patients with FI have never

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

discussed it with a physician. People of any age can have a bowel control problem, though FI is more common in older adults. Approximately 70% of institutionalized older adults have FI. Obstetric injury is the primary reason for FI in women. Forty-three percent of women who undergo anal sphincter repair following birth still experience FI 12 weeks after surgery, and 11% report FI for as long as 18 months after surgery. FI is common among women with pelvic floor disorders; 20% of women affected by urinary incontinence have FI [4,9-11].

**Etiologic factors**

Fecal Incontinence

17

http://dx.doi.org/10.5772/57502

Perianorectal trauma

Anal sphincter injury

Rectal prolapse Chronic straining

Myelomeningocele Multiple sclerosis

Neurologic disorders Spinal cord

Diarrhea

Obstruction and overflow

Pelvic fracture Abnormal anal sphincter or pelvic floor function

Obstetric procedures or childbirth Anorectal surgery complications

Brain injuries, stroke and cerebrovascular disease

Neuropathy (as may occur in diabetes, for example) Loose stool consistency or bowel irritation or inflammation

> Inflammatory bowel disease or irritable bowel syndrome Short bowel syndrome resulting from bowel resection

Inability to access the toilet independently for any reason

Decreased mobility (resulting from stroke, arthritis, lower back problems, or weakness)

Medications with antimotility adverse effects

Gastrointestinal infections

Radiation enteritis

Dementia or delirium

Impaction Neoplasms

Restraints

Congenital anorectal malformations

**Table 1.** Etiologic factors of FI [8]

İdiopathic incontinence

Imperforate anus Hirschsprung's disease

Cognitive or functional disability

#### **3. Risk factors**

FI has many causes, including; diarrhea or constipation, muscle damage or weakness, nerve damage or trauma, loss of stretch in the rectum, aging, congenital disorders, hemorrhoids and rectal prolapse, rectocele, inactivity [1,7,12].

Having any of the following can increase the risk: disease or injury that damages the nervous system; poor overall health from multiple chronic, or long lasting, illnesses, a difficult childbirth with injuries to the pelvic floor, the muscles, ligaments and tissues that support the uterus, vagina, bladder, and rectum [9-11]. Apart from these there are many etiologic factors are given in table 1 [8].

Additional risk factors include obesity [4]. More than 50% of US women are overweight (body mass index 25-30 kg/m2 ) or obese (body mass index, 30 kg/ m2 ), and the prevalence of obesity is increasing by almost 6% per year [6].


**Figure 1.** Bristol Stool Chart [13]

#### **Etiologic factors**

Perianorectal trauma

discussed it with a physician. People of any age can have a bowel control problem, though FI is more common in older adults. Approximately 70% of institutionalized older adults have FI. Obstetric injury is the primary reason for FI in women. Forty-three percent of women who undergo anal sphincter repair following birth still experience FI 12 weeks after surgery, and 11% report FI for as long as 18 months after surgery. FI is common among women with pelvic

FI has many causes, including; diarrhea or constipation, muscle damage or weakness, nerve damage or trauma, loss of stretch in the rectum, aging, congenital disorders, hemorrhoids and

Having any of the following can increase the risk: disease or injury that damages the nervous system; poor overall health from multiple chronic, or long lasting, illnesses, a difficult childbirth with injuries to the pelvic floor, the muscles, ligaments and tissues that support the uterus, vagina, bladder, and rectum [9-11]. Apart from these there are many etiologic factors

Additional risk factors include obesity [4]. More than 50% of US women are overweight (body

), and the prevalence of obesity

) or obese (body mass index, 30 kg/ m2

floor disorders; 20% of women affected by urinary incontinence have FI [4,9-11].

**3. Risk factors**

are given in table 1 [8].

mass index 25-30 kg/m2

**Figure 1.** Bristol Stool Chart [13]

rectal prolapse, rectocele, inactivity [1,7,12].

16 Fecal Incontinence - Causes, Management and Outcome

is increasing by almost 6% per year [6].

Anal sphincter injury

Obstetric procedures or childbirth

Anorectal surgery complications

Pelvic fracture

Abnormal anal sphincter or pelvic floor function

Rectal prolapse

Chronic straining

Neurologic disorders

Spinal cord

Brain injuries, stroke and cerebrovascular disease

Myelomeningocele

Multiple sclerosis

Neuropathy (as may occur in diabetes, for example)

Loose stool consistency or bowel irritation or inflammation

Diarrhea

Gastrointestinal infections

Inflammatory bowel disease or irritable bowel syndrome

Short bowel syndrome resulting from bowel resection

Radiation enteritis

Obstruction and overflow

Impaction

Neoplasms

Medications with antimotility adverse effects

Cognitive or functional disability

Dementia or delirium

Decreased mobility (resulting from stroke, arthritis, lower back problems, or weakness)

Restraints

Inability to access the toilet independently for any reason

Congenital anorectal malformations

Imperforate anus

Hirschsprung's disease

İdiopathic incontinence

**Table 1.** Etiologic factors of FI [8]

The ideal stool consistency is type three or four on the Bristol stool chart (figure 1). Type one and two stools are hard and can be difficult to pass. Type five, six and seven stools are soft to liquid hard to retain and make it difficult for the person with FI to remain continent [12].

development of FI. Some of these factors can be easily treated. while others may require

Fecal Incontinence

19

http://dx.doi.org/10.5772/57502

The healthcare professional should check the condition of the anorectal skin. Enzymes present in faeces can cause incontinence dermatitis, especially if the person has also incontinence of urine. Older people who are living in nursing homes have an increased risk of developing incontinence dermatitis, because large number of residents have continance problems. The healthcare professional should check the anal region for abnormalities such as external haemorroids, skin tags, rectal prolapse, and an anus that gapes open. A cognitive assessment is essential when assessing the older person who has FI. When staff are fully aware of any problems wiıh memory and reasonlng, they can devise a plan to treat or manage incontinance

The person may be referred to a doctor who specializes in problems of the digestive system, such as a gastroenterologist, proctologist, or colorectal surgeon, or a doctor who specializes in problems of the urinary and reproductive systems, such as a urologist or urogynecologist. The specialist will perform a physical exam and may suggest one or more of the following medical tests: Anal manometry, anal ultrasound, magnetic resonance imaging (MRI), defecography,

Fecal incontinence is not a disease but a symptom and can be treate. Treatment for FI may include one or more of the following: eating, diet, and nutrition, medications, bowel training,

**Eating, Diet, and Nutrition:** A food diary should list foods eaten, portion size, and when FI occurs. After a few days, the diary may show a link between certain foods and FI. A food diary

Dietary modifications are often included as an early treatment strategy for FI, but minimal data exist to guide the recommendations on types of dietary changes. Increasing soluble fiber intake has been shown to improve FI. Overweight and obese women report a high prevalence of monthly FI associated with low dietary fiber intake. Increasing dietary fiber may be a treatment for FI [6]. If constipation is causing fecal incontinence, dietary may recommend drinking plenty of fluids and eating fiber-rich foods. If diarrhea is contributing to the problem,

The bowel is sensitive to the amount of fibre eaten, and also to contain foods. If a diet contains too much fibre the person may develop loose stools, if the diet is lacking in fibre, the person may become constipated. People who eat too much or too litttle fibre may develop FI. Certain foods, such as figs, prunes and plums, contain a natural laxative that can affect bowel habit. Some spices, such as chilli, can also affect the bowel. Excessive consumption of foods and

flexible sigmoidoscopy or colonoscopy, anal electromyography (EMG) [2,12,14].

pelvic floor exercises and biofeedback, surgery, rectal irrigation, colostomy [11,14].

can also be helpful to a health care provider treating a person with FI [1,9,15].

high-fiber foods can also add bulk to stools and make them less watery [16]

drinks sweetened with sorbitol (an artificial sweetener) can cause loose stools [12].

management.

[2,12,14].

**5. Treatment**

Some medication can cause constipation or diarrhea such as pain medications, iron and depression (table 2) [12].


**Table 2.** Medications that cause constipation and diarrhea [12].

Additionally, antibiotics can affect the bacreria in the gut which can increase the risk of developing *Clostridium difficile* and other forms of diarrhea [12].

#### **4. Assesment/ Diagnosis**

Health care providers diagnose FI based on a person's lifestyl, medical history, physical exam, and medical test results [2,12,14].

A stool diary is a chart for recording daily bowel movement details. Medical history enables the assessor to work out the possible causes or contributing factors that have led to the development of FI. Some of these factors can be easily treated. while others may require management.

The healthcare professional should check the condition of the anorectal skin. Enzymes present in faeces can cause incontinence dermatitis, especially if the person has also incontinence of urine. Older people who are living in nursing homes have an increased risk of developing incontinence dermatitis, because large number of residents have continance problems. The healthcare professional should check the anal region for abnormalities such as external haemorroids, skin tags, rectal prolapse, and an anus that gapes open. A cognitive assessment is essential when assessing the older person who has FI. When staff are fully aware of any problems wiıh memory and reasonlng, they can devise a plan to treat or manage incontinance [2,12,14].

The person may be referred to a doctor who specializes in problems of the digestive system, such as a gastroenterologist, proctologist, or colorectal surgeon, or a doctor who specializes in problems of the urinary and reproductive systems, such as a urologist or urogynecologist. The specialist will perform a physical exam and may suggest one or more of the following medical tests: Anal manometry, anal ultrasound, magnetic resonance imaging (MRI), defecography, flexible sigmoidoscopy or colonoscopy, anal electromyography (EMG) [2,12,14].

#### **5. Treatment**

The ideal stool consistency is type three or four on the Bristol stool chart (figure 1). Type one and two stools are hard and can be difficult to pass. Type five, six and seven stools are soft to liquid hard to retain and make it difficult for the person with FI to remain continent [12].

Some medication can cause constipation or diarrhea such as pain medications, iron and

**Medications that cause constipation**

**Medications that cause diarrhea**

Additionally, antibiotics can affect the bacreria in the gut which can increase the risk of

Health care providers diagnose FI based on a person's lifestyl, medical history, physical exam,

A stool diary is a chart for recording daily bowel movement details. Medical history enables the assessor to work out the possible causes or contributing factors that have led to the

Medication group Example

Opiates Morphine sulphate

lron preparations Ferrous sulphate Anticholinergics Oxybutinin Diureties Frusemide

Antispasmodics Propantheline Antihypertensives Captopril Antipsychotics Risperidone

Medication group Example Digitals Digoxin

Antidiabetics Metformin Antiobesity Orlistat

**Table 2.** Medications that cause constipation and diarrhea [12].

**4. Assesment/ Diagnosis**

and medical test results [2,12,14].

Antidepressants Fluoxetine (Prozac)

developing *Clostridium difficile* and other forms of diarrhea [12].

Codeine based analgesia Co-dydramol, co-codamol

Antidepressants Amitriptyline, citalopram

depression (table 2) [12].

18 Fecal Incontinence - Causes, Management and Outcome

Fecal incontinence is not a disease but a symptom and can be treate. Treatment for FI may include one or more of the following: eating, diet, and nutrition, medications, bowel training, pelvic floor exercises and biofeedback, surgery, rectal irrigation, colostomy [11,14].

**Eating, Diet, and Nutrition:** A food diary should list foods eaten, portion size, and when FI occurs. After a few days, the diary may show a link between certain foods and FI. A food diary can also be helpful to a health care provider treating a person with FI [1,9,15].

Dietary modifications are often included as an early treatment strategy for FI, but minimal data exist to guide the recommendations on types of dietary changes. Increasing soluble fiber intake has been shown to improve FI. Overweight and obese women report a high prevalence of monthly FI associated with low dietary fiber intake. Increasing dietary fiber may be a treatment for FI [6]. If constipation is causing fecal incontinence, dietary may recommend drinking plenty of fluids and eating fiber-rich foods. If diarrhea is contributing to the problem, high-fiber foods can also add bulk to stools and make them less watery [16]

The bowel is sensitive to the amount of fibre eaten, and also to contain foods. If a diet contains too much fibre the person may develop loose stools, if the diet is lacking in fibre, the person may become constipated. People who eat too much or too litttle fibre may develop FI. Certain foods, such as figs, prunes and plums, contain a natural laxative that can affect bowel habit. Some spices, such as chilli, can also affect the bowel. Excessive consumption of foods and drinks sweetened with sorbitol (an artificial sweetener) can cause loose stools [12].

A conscious effort to have a bowel movement at a specific time of day, for example, after eating. Establishing when you need to use the toilet can help you gain greater control [16].

is not needed. The person can return to normal physical activities 1 week after the procedure

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**Bowel diversion:** It is an operation that reroutes the normal movement of stool out of the body when part of the bowel is removed. The operation diverts the lower part of the small intestine or colon to an opening in the wall of the abdomen, the area between the chest and hips. An external pouch is attached to the opening to collect stool. The procedure is performed by a

**Colostomy:** It is generally considered only after other treatments have been tried [16].

Containment products, such as incontinence pads and pants, are widely used to collect feaces and provide a degree of protection, but should only be considered once all other treatment

Incontinance pads are not ideal when a person is FI with profuse diarrhoea or loose stools. In these cases, Fecal containment device may be appropriate, such as Dignicare (Bard) or Flexi-

Fecal containment device (FCD) prevents contact of perineal skin with fecal matter, reducing the risk for incontinence-associated dermatitis, pressure ulcer formation, fecal contamination

FCD is an external drainage pouch that fits over the anus to collect stool. FCD and a bowel waste management system (BMS), which consists of an indwelling rectal catheter through which liquid or semi-liquid stool passes and is drained into an external drainage pouch. This

of wounds and reduction in frequency of diaper, clothing, and linen changes [19].

surgeon in a hospital and anesthesia is used [2-18].

**6. Fecal containment devices**

options have been explored [7].

**Figure 2.** Fecal containment device [20].

patients should monitoring fluid and electrolyte status [20].

Seal (Convatec) [12].

**Rectal irrigation:** can be very benefical for some patients [12].

[18].

**Medications:** If diarrhea is causing FI, medication may help. Health care providers sometimes recommend using bulk laxatives, such as Citrucel and Metamucil, to develop more solid stools that are easier to control. Antidiarrheal medications such as loperamide or diphenoxylate may be recommended to slow down the bowels and help control the problem [14]. If chronic constipation is causing FI, Laxatives may use [16].

Skin should be protected from Fecal enzymes by using either a barrier cream, such as Proshield Plus Skin Protective or Sudocrem", or a barier film such as Cavilon no sting barrier film [12].

**Kegel exercises and biofeedback:** Kegels or pelvic floor exercises can be problematic in frail older people who often have impaired cognition [12], but specially trained physiotherapists teach simple exercises that can increase anal muscle strength. People learn how to strengthen pelvic floor muscles, sense when stool is ready to be released and contract the muscles if having a bowel movement at a certain time is inconvenient. To perform Kegel exercises, contract the muscles that you would normally use to stop the flow of urine and stool. Hold the contraction for three seconds, then relax for three seconds. Repeat this pattern 10 times. As your muscles strengthen, hold the contraction longer, gradually working your way up to three sets of 10 contractions every day [16].

If the biofeedback session is aimed at strengthening your pelvic muscles, the practitioner will insert a slim sensor into your rectum. (In women, it is sometimes placed in the vagina, or an additional sensor may be used there.) Other electrodes will be placed on your abdomen to help record muscle contractions there. A computer screen provides feedback about the strength of your contractions and about whether you are using the correct muscles. If the biofeedback training is aimed at improving your ability to sense stool in the rectum, the practitioner will use anorectal manometry equipment to vary the pressure in your rectum. This is intended to increase the sensitivity of the rectum, which, in turn, helps some patients to recognize the presence of stool before the situation becomes despereat [17].

**Surgery:** Surgery may be an option for FI that fails to improve with other treatments or for FI caused by pelvic floor or anal sphincter muscle injuries [15].

**Sphincteroplasty** the most common FI surgery, reconnects the separated ends of a sphincter muscle torn by childbirth or another injury. Sphincteroplasty is performed at a hospital by a colorectal, gynecological or general surgeon [15].

**Artificial anal sphincter** involves placing an inflatable cuff around the anus and implanting a small pump beneath the skin that the person activates to inflate or deflate the cuff. This surgery is much less common and is performed at a hospital by a specially trained colorectal surgeon [18].

**Nonabsorbable bulking agents** can be injected into the wall of the anus to bulk up the tissue around the anus. The bulkier tissues make the opening of the anus narrower so the sphincters are able to close better. The procedure is performed in a health care provider's office; anesthesia is not needed. The person can return to normal physical activities 1 week after the procedure [18].

**Bowel diversion:** It is an operation that reroutes the normal movement of stool out of the body when part of the bowel is removed. The operation diverts the lower part of the small intestine or colon to an opening in the wall of the abdomen, the area between the chest and hips. An external pouch is attached to the opening to collect stool. The procedure is performed by a surgeon in a hospital and anesthesia is used [2-18].

**Rectal irrigation:** can be very benefical for some patients [12].

**Colostomy:** It is generally considered only after other treatments have been tried [16].

#### **6. Fecal containment devices**

A conscious effort to have a bowel movement at a specific time of day, for example, after eating.

**Medications:** If diarrhea is causing FI, medication may help. Health care providers sometimes recommend using bulk laxatives, such as Citrucel and Metamucil, to develop more solid stools that are easier to control. Antidiarrheal medications such as loperamide or diphenoxylate may be recommended to slow down the bowels and help control the problem [14]. If chronic

Skin should be protected from Fecal enzymes by using either a barrier cream, such as Proshield Plus Skin Protective or Sudocrem", or a barier film such as Cavilon no sting barrier film [12].

**Kegel exercises and biofeedback:** Kegels or pelvic floor exercises can be problematic in frail older people who often have impaired cognition [12], but specially trained physiotherapists teach simple exercises that can increase anal muscle strength. People learn how to strengthen pelvic floor muscles, sense when stool is ready to be released and contract the muscles if having a bowel movement at a certain time is inconvenient. To perform Kegel exercises, contract the muscles that you would normally use to stop the flow of urine and stool. Hold the contraction for three seconds, then relax for three seconds. Repeat this pattern 10 times. As your muscles strengthen, hold the contraction longer, gradually working your way up to three sets of 10

If the biofeedback session is aimed at strengthening your pelvic muscles, the practitioner will insert a slim sensor into your rectum. (In women, it is sometimes placed in the vagina, or an additional sensor may be used there.) Other electrodes will be placed on your abdomen to help record muscle contractions there. A computer screen provides feedback about the strength of your contractions and about whether you are using the correct muscles. If the biofeedback training is aimed at improving your ability to sense stool in the rectum, the practitioner will use anorectal manometry equipment to vary the pressure in your rectum. This is intended to increase the sensitivity of the rectum, which, in turn, helps some patients to recognize the

**Surgery:** Surgery may be an option for FI that fails to improve with other treatments or for FI

**Sphincteroplasty** the most common FI surgery, reconnects the separated ends of a sphincter muscle torn by childbirth or another injury. Sphincteroplasty is performed at a hospital by a

**Artificial anal sphincter** involves placing an inflatable cuff around the anus and implanting a small pump beneath the skin that the person activates to inflate or deflate the cuff. This surgery is much less common and is performed at a hospital by a specially trained colorectal

**Nonabsorbable bulking agents** can be injected into the wall of the anus to bulk up the tissue around the anus. The bulkier tissues make the opening of the anus narrower so the sphincters are able to close better. The procedure is performed in a health care provider's office; anesthesia

Establishing when you need to use the toilet can help you gain greater control [16].

constipation is causing FI, Laxatives may use [16].

20 Fecal Incontinence - Causes, Management and Outcome

presence of stool before the situation becomes despereat [17].

caused by pelvic floor or anal sphincter muscle injuries [15].

colorectal, gynecological or general surgeon [15].

contractions every day [16].

surgeon [18].

Containment products, such as incontinence pads and pants, are widely used to collect feaces and provide a degree of protection, but should only be considered once all other treatment options have been explored [7].

Incontinance pads are not ideal when a person is FI with profuse diarrhoea or loose stools. In these cases, Fecal containment device may be appropriate, such as Dignicare (Bard) or Flexi-Seal (Convatec) [12].

Fecal containment device (FCD) prevents contact of perineal skin with fecal matter, reducing the risk for incontinence-associated dermatitis, pressure ulcer formation, fecal contamination of wounds and reduction in frequency of diaper, clothing, and linen changes [19].

**Figure 2.** Fecal containment device [20].

FCD is an external drainage pouch that fits over the anus to collect stool. FCD and a bowel waste management system (BMS), which consists of an indwelling rectal catheter through which liquid or semi-liquid stool passes and is drained into an external drainage pouch. This patients should monitoring fluid and electrolyte status [20].

FCD, nurses responsibilities involved in the placement and maintenance of an FCD, including application (and removal) of the FCD based on the treating clinician's orders and manufac‐ turer's instructions, the treating clinician's orders for the FCD, including pre-procedure analgesia. Any allergies; uses alternate materials during the procedure if allergies (e.g., latex) are noted [20].

**•** Institute a prompted toileting program for persons with impaired cognitive status (e.g.,

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**•** Acute or transient FI frequently occurs in the acute care or long term care facility because of inadequate access to toileting facilities, insufficient assistance with toileting,

**•** Normalizing stool consistency by adequate intake of fluids (30ml/kg of body weight/

**•** Establishing a regular routine of fecal elimination based on established patterns of

**•** Bowel reeducation is designed to reestablish normal defecation patterns and to normalize stool consistency to reduce or eliminate the risk of recurring FI associated

**6.** Begin a prompted defecation program for the adult with dementia, mental retardation, or related learning disabilities. Prompted urine and fecal elimination programs have been shown to reduce or eliminate incontinence in the long term care facility and community

**7.** Begin a scheduled stimulation defecation program, including the following steps, for

**•** Implement strategies to normalize stool consistency, including adequate intake of fluid

**•** Whenever feasible, determine a regular schedule for bowel elimination (typically every

**•** Provide a stimulus before assisting the patient to a position on the toilet. Digital stimulation, stimulating suppository, "mini-enema," or pulsed evacuation enema may

**•** The scheduled, stimulated defecation program relies on consistency of stool and a mechanical or chemical stimulus to produce a bolus contraction of the rectum with

**8.** Begin a pelvic floor reeducation or muscle exercise program for persons with sphincter incompetence or pseudodyssynergia of the pelvic muscles, or refer persons with fecal

**•** Before beginning the program, cleanse the bowel of impacted fecal material.

day or every other day) based on previous patterns of bowel elimination.

and fiber and avoidance of foods associated with diarrhea.

bowel elimination (patterns established before onset of incontinence).

**5.** For the patient with intermittent episodes of FI related to acute changes in stool consis‐

retardation, dementia).

**•** Provide adequate privacy for toileting.

**•** Respond promptly to requests for assistance with toileting.

tency, begin a bowel reeducation program consisting of:

**•** Cleansing the bowel of impacted stool if indicated.

day) and dietary or supplemental fiber.

with changes in stool consistency [10].

persons with neurological conditions causing FI:

evacuation of fecal material [10,24,27].

settings [10,27].

be used.

or inadequate privacy when attempting to toilet [10,23,26,27].

#### **7. Nursing care**


A focused physical examination helps determine the severity of fecal leakage and its likely etiology. A functional assessment provides information concerning the impact of func‐ tional status on stool elimination patterns and incontinence [23,24].

	- **•** Identify usual toileting patterns among persons in the acute care or long term care facility and plan opportunities for toileting accordingly.
	- **•** Provide assistance with toileting for patients with limited access or impaired functional status (e.g., mobility, dexterity, access).

FCD, nurses responsibilities involved in the placement and maintenance of an FCD, including application (and removal) of the FCD based on the treating clinician's orders and manufac‐ turer's instructions, the treating clinician's orders for the FCD, including pre-procedure analgesia. Any allergies; uses alternate materials during the procedure if allergies (e.g., latex)

**1.** In a reasonably private setting, directly question any patient at risk about the presence of FI. If the client reports altered bowel elimination patterns, problems with bowel control or "uncontrollable diarrhea," complete a focused nursing history including previous and present bowel elimination routines, dietary history, frequency and volume of uncontrol‐ led stool loss, and aggravating and alleviating factors. Unless questioned directly, patients are unlikely to report the presence of FI [21]. The nursing history determines the patterns of stool elimination to characterize involuntary stool loss and the likely etiology of thein

**2.** Complete a focused physical assessment including inspection of perineal skin, pelvic muscle strength assessment, digital examination of the rectum for presence of impaction and anal sphincter strength, and evaluation of functional status (mobility, dexterity, visual

A focused physical examination helps determine the severity of fecal leakage and its likely etiology. A functional assessment provides information concerning the impact of func‐

**1.** Complete an assessment of cognitive function. Dementia, acute confusion, and mental

**2.** Document patterns of stool elimination and incontinent episodes via a bowel record, including frequency of bowel movements, stool consistency, frequency and severity of incontinent episodes, precipitating factors, and dietary and fluid intake. This document is used to confirm the verbal history and to assist in determining the likely etiology of

stool incontinence. It also serves as a baseline to evaluate treatment efficacy [22].

**3.** Identify the probable causes of FI. FI is frequently multifactorial; therefore identification of the probable etiology of FI is necessary to select a treatment plan likely to control or

**•** Identify usual toileting patterns among persons in the acute care or long term care

**•** Provide assistance with toileting for patients with limited access or impaired functional

tional status on stool elimination patterns and incontinence [23,24].

facility and plan opportunities for toileting accordingly.

retardation are risk factors for FI [22,25].

eliminate the condition [22,25,26].

status (e.g., mobility, dexterity, access).

**4.** Improve access to toileting:

are noted [20].

**7. Nursing care**

22 Fecal Incontinence - Causes, Management and Outcome

continence [22].

acuity).

	- **•** Cleansing the bowel of impacted stool if indicated.
	- **•** Normalizing stool consistency by adequate intake of fluids (30ml/kg of body weight/ day) and dietary or supplemental fiber.
	- **•** Establishing a regular routine of fecal elimination based on established patterns of bowel elimination (patterns established before onset of incontinence).
	- **•** Bowel reeducation is designed to reestablish normal defecation patterns and to normalize stool consistency to reduce or eliminate the risk of recurring FI associated with changes in stool consistency [10].
	- **•** Before beginning the program, cleanse the bowel of impacted fecal material.
	- **•** Implement strategies to normalize stool consistency, including adequate intake of fluid and fiber and avoidance of foods associated with diarrhea.
	- **•** Whenever feasible, determine a regular schedule for bowel elimination (typically every day or every other day) based on previous patterns of bowel elimination.
	- **•** Provide a stimulus before assisting the patient to a position on the toilet. Digital stimulation, stimulating suppository, "mini-enema," or pulsed evacuation enema may be used.
	- **•** The scheduled, stimulated defecation program relies on consistency of stool and a mechanical or chemical stimulus to produce a bolus contraction of the rectum with evacuation of fecal material [10,24,27].

incontinence related to sphincter dysfunction to a nurse specialist or other therapist with clinical expertise in these techniques of care. Pelvic muscle reeducation, including biofeedback, pelvic muscle exercise, and/or pelvic muscle relaxation techniques, is a safe and effective treatment for selected persons with FI related to sphincter or pelvic floor muscle days function [23,26,27].

**8. Evidence — Based practices in fecal incontinence**

response to treatment [30].

outcomes indicated supporting each treatment method.

postoperative comparison, cohort, time, or matched case-control series.

B. Evidence of Type II, III, or IV and generally consistent findings

C. Evidence of Type II, III, or IV but inconsistent findings

D. Little or no systematic empirical evidence

**Table 3.** Grades of Recommendations [31]

negative errors (high power).

errors or both (Iow power).

**V.** Case reports and clinical examples.

**Table 4.** Levels of Evidence [31]

A. Evidence of Type I or consistent findings from multiple studies of Type II, III, or IV

and accounts for individual patient characteristics and clinician expertise.

Evidence Based Practice (EBP) is the use of systematic decision-making processes or provision of services which have been shown, through available scientific evidence, to consistently improve measurable patient outcomes. Instead of tradition, gut reaction or single observations as the basis for making decisions, EBP relies on data collected through experimental research

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Evidence Based Treatments (EBTs) are interventions which have scientific findings to dem‐ onstrate their effectiveness or efficacy in improving patient outcomes. Treatments are often placed along a continuum of support based on the rigorousness and amount of supporting research ranging from treatments which have strong support to those which are untested to those which have produced negative outcomes. Data sources used to make these evidence determinations include randomized experiments, which compare treatment with a control or placebo group or compare the treatment with another already established treatment; and single case design experiments which compare an individual subject's baseline with their

There are four or five generally accepted evidence levels along the continuum of research support on which experts attempt to categorize practices, based on the body of evidence and

**I.** Meta-analysis of multiple well-designed, controlled studies, randomized trials with low false- positive and low false-

**II.** At least one well-designed experimental study; randomized trials with high false-positive or high false-negative

**III.** Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperative-

**IV.** Well-designed, nonexperimental studies, such as cornparative and correlational descriptive and case studies.


#### **8. Evidence — Based practices in fecal incontinence**

incontinence related to sphincter dysfunction to a nurse specialist or other therapist with clinical expertise in these techniques of care. Pelvic muscle reeducation, including biofeedback, pelvic muscle exercise, and/or pelvic muscle relaxation techniques, is a safe and effective treatment for selected persons with FI related to sphincter or pelvic floor

**9.** Begin a pelvic muscle biofeedback program among patients with urgency to defecate and FI related to recurrent diarrhea. Pelvic muscle reeducation, including biofeedback, can reduce uncontrolled loss of stool among persons who experience urgency and diarrhea as provacative factors for FI [28]. Reducing the incidence of diarrhea can help to reduce

**10.** Cleanse the perineal and perianal skin following each episode of FI. When incontinence is frequent, use an incontinence cleansing product specifically designed for this purpose. Frequent cleaning with soap and water, dry as possible may compromise perianal skin

**11.** Apply mineral oil or a petroleum based ointment to the perianal skin when frequent episodes of FI occur. These products form a moisture and chemical barrier to the perianal skin that may prevent or reduce the severity of compromised skin integrity with severe

**12.** Assist the patient to select and apply a containment device for occasional episodes of FI. A fecal containment device will prevent soiling of clothing and reduce odors in the patient

**13.** Teach the caregivers of the patient with frequent episodes of FI and limited mobility to regularly monitor the sacrum and perineal area for pressure ulcerations.Limited mobility, particularly when combined with FI, increases the risk of pressure ulceration. Routine cleansing, pressure reduction techniques, and management of fecal and urinary inconti‐

**14.** Consult the physician concerning the use of an anal continence plug for the patient with frequent stool loss. The anal continence plug is a device that can reduce or eliminate

**15.** Apply a fecal pouch to the patient with frequent stool loss, particularly when FI produces altered perianal skin integrity. Fecal pouches contain stool loss, reduce odor, and protect the perianal skin from chemical irritation resulting from contact with stool [14,23].

**16.** Consult the physician concerning the use of a rectal tube for the patient with severe FI. A large-sized French indwelling catheter has been used for fecal containment when incon‐

tinence is severe and perianal skin integrity significantly compromised [26].

persistent liquid or solid stool incontinence in selected patients [18,28].

integrity and enhance the irritation produced by fecal leakage [1,29].

muscle days function [23,26,27].

24 Fecal Incontinence - Causes, Management and Outcome

bowel incontinence [10,23].

with uncontrolled stool loss [28].

nence reduces this risk [23,24,21].

FI [28].

Evidence Based Practice (EBP) is the use of systematic decision-making processes or provision of services which have been shown, through available scientific evidence, to consistently improve measurable patient outcomes. Instead of tradition, gut reaction or single observations as the basis for making decisions, EBP relies on data collected through experimental research and accounts for individual patient characteristics and clinician expertise.

Evidence Based Treatments (EBTs) are interventions which have scientific findings to dem‐ onstrate their effectiveness or efficacy in improving patient outcomes. Treatments are often placed along a continuum of support based on the rigorousness and amount of supporting research ranging from treatments which have strong support to those which are untested to those which have produced negative outcomes. Data sources used to make these evidence determinations include randomized experiments, which compare treatment with a control or placebo group or compare the treatment with another already established treatment; and single case design experiments which compare an individual subject's baseline with their response to treatment [30].

There are four or five generally accepted evidence levels along the continuum of research support on which experts attempt to categorize practices, based on the body of evidence and outcomes indicated supporting each treatment method.


**Table 3.** Grades of Recommendations [31]

**I.** Meta-analysis of multiple well-designed, controlled studies, randomized trials with low false- positive and low falsenegative errors (high power).

**II.** At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (Iow power).

**III.** Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperativepostoperative comparison, cohort, time, or matched case-control series.

**IV.** Well-designed, nonexperimental studies, such as cornparative and correlational descriptive and case studies.

**V.** Case reports and clinical examples.

**Table 4.** Levels of Evidence [31]


**8.1. Assessment**

**8.2. Diagnosis**

disease, or neoplasms [31].

**8.3. Nonoperative treatment**

elderly [31].

are problematic in patients with lactose intolerance.

responded to simple dietary modification or medication.

factors with reliability and validity [31].

Severity instruments assess type, frequency, and amount of incontinence. Impact question‐ naires address quality of life and attempt to evaluate the effect of incontinence on emotional, occupational, physical, and social function. Both should evaluate these relatively subjective

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A detailed medical history mav help to elicit contributing or exacerbating factors, such as gastrointestinal or neurologic disorders. An obstetric account or history of previous anorectal

Inspection of the perianal skin may reveal excoriation, surgical scars, or fistulas, and the anus mav be noted to gape upon spreading the buttocks. Mucosal or full-thickness prolapse may be elicited with a Valsalva maneuver. Digital examination mav provide a rough estimate of resting and squeeze pressures and is helpful to evaluate for a rectal mass or the presence of impacted stool, which would suggest overflow as a possible mechanism for incontinence. Anoscopy and flexible sigmoidoscopy mav help to identify hemorrhoids, inflammatory bowel

Nonoperative therapy is usually the first maneuver to improve the symptoms of FI. Most patients with mild FI should usually receive an initial trial of nonoperative management.

Gradual increase of fiber intake during a period of several days can reduce symptoms, such as abdominal bloating and discomfort that mav be associated with increased fiber intake. Fiber supplements in the form of powder, granule, or pill of ten facilitate this goal. Dairy products

Antidiarrheal agents, adsorbents, such as kaopectate (Pharmacia & Upjohn, Peapack, NJ), act by absorbing excess fluid in the stool. Commonly used opium derivatives are loperamide (Imodium, McNeil Consumer Healthcare, Fort Washington, PA), diphenoxylate hydrochlor‐ ide plus atropine sulphate (Lomotil, Searle, Chicago, IL), codeine, and tincture of opium.

Biofeedback mav be considered a first-line option for many patients with FI who have not

Supportive counseling and practical advice regarding diet and skin care can improve the success of biofeedback. Biofeedback mav be considered before attempting sphincter repair or for those who have persistent or recurrent symptoms after sphincter repair. it mav have a role in the early postpartum period in females with symptomatic sphincter weakness. Biofeedback and a pelvic floor exercise program can produce improvement that lasts more than two years. Biofeedback home training is an alternative to ambulatory training programs, especially in the

Evaluation and management of abnormal colonic transit also can be helpful.

surgery or perineal trauma can direct/prompt a more focused examination.

**Table 5.** Evidence- Based Practices İn Fecal İncontinence [31]

#### **8.1. Assessment**

**Level of Evidence**

**1.** Evaluation of FI should include consideration of severity and impact. **Class II B**

**1.** A problem-specific history and physical examination should be performed. **Class V D**

**2.** Antidiarrheal agents, such as adsorbents or opium derivatives, mav reduce FI symptoms. **Class III C**

emptying in appropriate patients and minimize further postdefecation leakage **Class V <sup>D</sup>**

incontinence with some voluntary sphincter contraction. **Class III <sup>B</sup>**

defect of the external anal sphincter. **Class II <sup>A</sup>**

mobilization of both ends of the sphincters are performed. **Class II <sup>A</sup>**

symptoms and residual anterior sphincter defect after a previous sphincter repair. **Class III <sup>B</sup>**

generally recommended. **Class III <sup>B</sup>**

**6.**Sacral nerve stimulation (SNS) is a promising modality for FI. **Class III B**

neuropathic FI. **Class III <sup>B</sup>**

irreparable sphincter disruption. **Class III <sup>B</sup>**

patients with significant sphincter disruption. **Class III <sup>B</sup>**

delivery to the anal canal) procedure mav be useful for selected patients with moderate FI. **Class IV <sup>C</sup>**

**2.** Endoanal ultrasound is usually the procedure of choice to diagnose sphincter defects in patients with suspected sphincter injury. Anorectal physiology studies mav be helpful in

**1.** A trial of increased fiber intake is recommended in milder forms of FI to improve

26 Fecal Incontinence - Causes, Management and Outcome

**3.** Enemas, laxatives, and suppositories mav help to promote more complete bowel

**4.** Biofeedback is recommended as an initial treatment for motivated patients with

**5.** An anal plug is effective in controlling FI in a smail minority of patients who can tolerate

**1.**Sphincter repair is appropriately offered to highly symptomatic patients with a defined

**2.** Overlapping or direct sphincter repair yield similar results, as long as adequate

**3.** Repeat anal sphincter repair could be considered in patients who have recurrent

**7.** Postanal repair or total pelvic floor repair has a limited role in the treatment of

**8.** Dynamic graciloplasty mav have a role in the treatment of severe FI when there is

**9.** The artificial bowel sphincter has a role in the treatment of severe FI, especially in

10. The SECCA (safety and effectiveness of temperature-controlled radiofrequency energy

**11.** A stoma (colostomy or ileostomy) is appropriate for patients with limiting FI in which available treatments have failed, are inappropriate because of comorbidities, or when

**Table 5.** Evidence- Based Practices İn Fecal İncontinence [31]

**4.** Repair of the internal anal sphincter alone has a poor functional outcome and is not

**5.** When passiye FI caused by internal sphincter dysfunction is the predominant symptom, injectable therapy seems to be effective and safe, although its long-term efficacy has yet

**Assessment**

**Diagnosis**

symptoms.

its use.

**Surgical Options**

to be defined.

preferred by the patient.

guiding management.

**Nonoperative Treatment**

**Grade of Recommendation**

**Class II B**

**Class III B**

**Class V D**

**Class II B**

**Class III B**

Severity instruments assess type, frequency, and amount of incontinence. Impact question‐ naires address quality of life and attempt to evaluate the effect of incontinence on emotional, occupational, physical, and social function. Both should evaluate these relatively subjective factors with reliability and validity [31].

#### **8.2. Diagnosis**

A detailed medical history mav help to elicit contributing or exacerbating factors, such as gastrointestinal or neurologic disorders. An obstetric account or history of previous anorectal surgery or perineal trauma can direct/prompt a more focused examination.

Inspection of the perianal skin may reveal excoriation, surgical scars, or fistulas, and the anus mav be noted to gape upon spreading the buttocks. Mucosal or full-thickness prolapse may be elicited with a Valsalva maneuver. Digital examination mav provide a rough estimate of resting and squeeze pressures and is helpful to evaluate for a rectal mass or the presence of impacted stool, which would suggest overflow as a possible mechanism for incontinence. Anoscopy and flexible sigmoidoscopy mav help to identify hemorrhoids, inflammatory bowel disease, or neoplasms [31].

#### **8.3. Nonoperative treatment**

Nonoperative therapy is usually the first maneuver to improve the symptoms of FI. Most patients with mild FI should usually receive an initial trial of nonoperative management.

Gradual increase of fiber intake during a period of several days can reduce symptoms, such as abdominal bloating and discomfort that mav be associated with increased fiber intake. Fiber supplements in the form of powder, granule, or pill of ten facilitate this goal. Dairy products are problematic in patients with lactose intolerance.

Antidiarrheal agents, adsorbents, such as kaopectate (Pharmacia & Upjohn, Peapack, NJ), act by absorbing excess fluid in the stool. Commonly used opium derivatives are loperamide (Imodium, McNeil Consumer Healthcare, Fort Washington, PA), diphenoxylate hydrochlor‐ ide plus atropine sulphate (Lomotil, Searle, Chicago, IL), codeine, and tincture of opium. Evaluation and management of abnormal colonic transit also can be helpful.

Biofeedback mav be considered a first-line option for many patients with FI who have not responded to simple dietary modification or medication.

Supportive counseling and practical advice regarding diet and skin care can improve the success of biofeedback. Biofeedback mav be considered before attempting sphincter repair or for those who have persistent or recurrent symptoms after sphincter repair. it mav have a role in the early postpartum period in females with symptomatic sphincter weakness. Biofeedback and a pelvic floor exercise program can produce improvement that lasts more than two years. Biofeedback home training is an alternative to ambulatory training programs, especially in the elderly [31].

#### **8.4. Surgical options**

The SECCA (safety and effectiveness of temperature-controlled radiofrequency energy delivery to the anal canal) procedure consists of the delivery of temperature-controlled radiofrequency energy to the anal sphincters. It is believed that the heat generated causes collagen contraction, healing, and remodeling, leading to shorter and tighter muscle fibers [31]. [9] Madoff RD, Williams JG, Caushaj PF. Fecal incontinence. N Engl J Med

Fecal Incontinence

29

http://dx.doi.org/10.5772/57502

[10] Wong WD, Congliosi SM, Spencer MP, et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis

[11] Whitehead WE, Borrud L, Goode PS, et al. Fecal incontinence in U.S. adults: epidemi‐

[12] Nazarko L, Fecal incontinence: diagnosis, treatmentandmanagement. Nursing & Res‐

[13] Cabot Health, Bristol Stool Chart http://www.cabothealth.com.au/articles/bristol-

[14] Keating JP, Stewart PJ, Eyers AA, et al. Are special investigations of value in the management of patients with fecal incontinence? Dis Colon Rectum 2012 ; 40:896.

[15] Slavin JL. Position of the American Dietetic Association: health implications of diet‐ ary fiber. Journal of the American Dietetic Association.2008;108(31):1716–1731.

[16] Mayo Clinic, Fecal İncontinence, http://www.mayoclinic.com/health/fecal-inconti‐

[17] Harvard Health PublicationS, Better Bladder and Bowel Control, 38- 41,

[18] Ko CY, Tong J, Lehman RE, et al. Biofeedback is effective therapy for fecal inconti‐

[19] Schub E, Fecal Containment Devices: Providing Patient Care. Cinahl Information

[20] Fecal containment device http://www.convatec.com/continence-critical-care/flexi-

[21] Duel BP, Gonzalez R. The button cecostomy for management of fecal incontinence.

[22] Norton C, Chelvanayagam S, Wilson-Barnett J, et al. Randomized controlled trial of

[23] Gray M, Burns SM. Continence management. Crit Care Nurs Clinics N Am 1996;8(1):

[24] Fynes M, O'Herlihy C. The influence of mode of delivery on anal sphincter injury

[25] Jensen LL, Lowry AC. Biofeedback improves functional outcome after sphinctero‐

seal-family-of-products/flexi-seal-fms.aspx (accessed 30 november 2013)

biofeedback for fecal incontinence. Gastroenterology 2003;125:1320-29.

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plasty. Dis Colon Rectum 1997;40(2):197-200

#### **Author details**

Arzu Ilce\*

Address all correspondence to: arzuilce@hotmail.com

Abant Izzet Baysal University, Bolu Health School, Department of Nursing Turkish, Bolu, Turkey

#### **References**


[9] Madoff RD, Williams JG, Caushaj PF. Fecal incontinence. N Engl J Med 1999;326:1002-07.

**8.4. Surgical options**

28 Fecal Incontinence - Causes, Management and Outcome

**Author details**

Address all correspondence to: arzuilce@hotmail.com

Association. Gastroenterology 2009; 116:732.

col 2009;200:5661-5666.

Care 2012; 14: 5.

110: 9.

vikoff, Cinahl Information Systems, May 6, 2011

Arzu Ilce\*

Turkey

**References**

The SECCA (safety and effectiveness of temperature-controlled radiofrequency energy delivery to the anal canal) procedure consists of the delivery of temperature-controlled radiofrequency energy to the anal sphincters. It is believed that the heat generated causes collagen contraction, healing, and remodeling, leading to shorter and tighter muscle fibers [31].

Abant Izzet Baysal University, Bolu Health School, Department of Nursing Turkish, Bolu,

[1] Jarrett ME, Mowatt G, Glazener CM, et al. Systematic review of sacral nerve stimula‐

[2] Rao SS, American College of Gastroenterology Practice Parameters Committee. Diag‐ nosis and management of fecal incontinence. American College of Gastroenterology

[3] Barnett JL, Hasler WL, Camilleri M. American Gastroenterological Association medi‐ cal position statement on anorectal testing techniques. American Gastroenterological

[4] Caple C, Cabrera G, Strayer DA, Incontinence, Fecal, in Women, Editor Diane Pra‐

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[6] Markland AD, Richter HE, Burgio KL, et al. Fecal incontinence in obese women with urinary incontinence: prevalence and role of dietary fiber intake. Am J Obstet Gyne‐

[7] Woodward S, Management options for Fecal incontinence. Nursing & Residential

[8] Bliss DZ and Norton C, Conservative Management of Fecal Incontinence. AJN 2010;

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**Chapter 3**

**Anal Incontinence as a**

Małgorzata Kołodziejczak and

(soiling), to incontinence of solid stools.

stool consistency, high-pressure zone and abdominal pressure.

Iwona Sudoł-Szopińska

http://dx.doi.org/10.5772/57358

**1. Introduction**

**Complication of Vaginal**

**Delivery and Anorectal Surgery**

Additional information is available at the end of the chapter

Incontinence is a complex term and encompasses a broad spectrum of disorders with various intensities. They range from gas incontinence, through incontinence of liquid stools

The factors determining the function of faecal continence comprise: structural elements such as the anal sphincter muscles and pelvic floor muscles, including the Parks angle (be‐ tween the long axis of the rectum and that of the anal canal), as well as functional elements such as central nervous system, anorectal sensation, volume and compliance of the rectum,

Faecal incontinence affects 2-7% of the adult population. The range of the problem is not exactly known due to its embarrassing nature and reluctance to report stool and/or gas incontinence to physicians [1, 2, 3]. The majority of patients are women. It has been reported that 1 on 10 women suffers from various types of incontinence [4], the most common cause being obstetric trauma (60%). The second most common cause is iatrogenic injury to the anal sphincter muscles sustained during anorectal surgeries (approximately 16%) [5, 6]. More and more often, incontinence is caused by injuries that occur after inserting foreign bodies to the rectum and after traffic injuries. The number of patients with inflammatory bowel diseases is rising as well. Neurogenic incontinence is also a contributor [7]. This chapter discusses two groups of causes: obstetric and those occurring after anorectal surgery.

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


**Chapter 3**
