Fecal incontinence (FI) is an uncontrolled passage of feces either due to passive incontinence, urge incontinence, or a combination of both. FI is more common in women than men with the highest incidence occurring in nursing home residents. Risk factors include childbirth, especially with tears or nerve damage to the anal sphincter, age-related changes, neurologic conditions, structural damage to the anal muscles or nerves, diarrhea, chronic constipation, and certain medications. FI is a sensitive topic for many people and can significantly affect quality of life.
Management of FI depends on the severity, cause, and other coexisting conditions. It can range from more conservative measures like dietary changes and bowel training to surgical options to repair the anal sphincter, implant an artificial sphincter, or in severe cases the need for a colostomy.
In this Guidelines Side-by-Side, we have compared the latest clinical practice guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) and the American College of Obstetricians and Gynecologists (ACOG) on fecal incontinence. The recommendations made are meant to guide clinical practice, taking into consideration the unique desires and needs of individual patients.
Guidelines for Comparison
| Item | The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence | Fecal Incontinence |
|---|---|---|
| Authoring Organization | American Society of Colon and Rectal Surgeons | American College of Obstetricians and Gynecologists |
| Publication Date | May 2023 | March 2019 |
| Graded Recommendations | Yes | Yes |
| Links | Summary | Summary |
| Full Text | Full Text |
Key Takeaways
- Differences between these two guidelines include:
- Patient population:
- As one might assume, the population addressed in the ACOG guideline is limited to women, whereas the ASCRS guidelines includes a wider range of patients.
- Screening:
- ACOG included a recommendation for screening women for fecal incontinence which was not addressed in the recommendations from the ASCRS.
- Testing:
- ACOG does not routinely recommend any diagnostic testing for women with fecal incontinence unless there are “red flag” symptoms present that would warrant consideration for a colonoscopy.
- ASCRS recommends considering anorectal physiology testing and endoanal ultrasound.
- Management:
- ACOG recommends sacral nerve stimulation be considered as a treatment option for women who failed more conservative treatments, but ASCRS recommends this as a first-line treatment option.
- Anal sphincter bulking agents are recommended as an option for short-term treatment of FI according to ACOG, but are not routinely recommended for treatment by ASCRS.
- ASCRS offers antegrade colonic enemas and colostomy consideration for some patients, but neither of these therapies are addressed in the ACOG guideline.
- Patient population:
- Both the ASCRS and ACOG agree on the following:
- Evaluation:
- Should include history and physical examination.
- Testing:
- Pudendal nerve terminal motor latency testing is not routinely recommended.
- Endoscopy is recommended for patients with “red flag” symptoms.
- Management:
- First-line treatment includes dietary changes, medical management, and bowel training.
- Sphincteroplasty may be considered in patients with sphincter defects.
- Evaluation:
Comparison of Recommendations
| Topic | ASCRS | ACOG |
|---|---|---|
| Screening | Not Addressed. | Women with risk factors should be screened for fecal incontinence. |
| Evaluation | A history should be obtained to help determine the cause of incontinence and should include specific risk factors for incontinence and characterize the duration and severity of symptoms. | Women who report fecal incontinence symptoms should undergo a complete medical history, symptoms assessment, and physical examination of the rectal, vaginal, and perineal areas. No specific laboratory tests are needed for the initial evaluation of fecal incontinence unless diarrheal infectious processes are suspected. |
| Measures that assess the nature and severity of incontinence and the impact of incontinence on quality of life should be used as a part of the assessment of FI. | ||
| A physical examination is an essential component of the evaluation of patients with FI. | ||
| Testing | Anorectal physiology testing (manometry, anorectal sensation, volume tolerance, and compliance) can be considered to help define the elements of dysfunction and guide management. | Ancillary diagnostic testing (such as anal sphincter imaging, defecography, anorectal mammography, and pudendal nerve terminal motor latency testing), is not recommended for the routine evaluation of fecal incontinence. |
| Endoanal ultrasound may be useful to evaluate sphincter anatomy when planning a sphincter repair. | ||
| Pudendal nerve terminal motor latency testing is not routinely recommended. | ||
| Endoscopy should be performed according to established screening guidelines and in patients presenting with symptoms that warrant further evaluation (ie, changes in bowel habits, bleeding). | Any women presenting with fecal incontinence and a change in her bowel habits should be considered for a colonoscopy, especially when accompanied by any "red flag" symptoms, including unexplained weight loss, abdominal pain, rectal bleeding, melena, or anemia. | |
| Management | Dietary and medical management are recommended as first-line therapy for patients with FI. | Nonsurgical treatments for fecal incontinence are associated with modest short-term efficacy and a low risk of adverse events and are recommended for initial management, except in cases of fistulae or rectal prolapse. |
| Bowel training programs can improve rectal evacuation in selected patients. | It is reasonable for obstetrician-gynecologists to initiate conservative interventions, such as dietary manipulation, bowel scheduling, fiber supplementation, and stool-modifying agents. Patients who are candidates for surgical therapy (such as women with rectovaginal fistulas or rectal prolapse) or who do not respond to conservative treatments should receive further evaluation and treatment by a healthcare provider with expertise in pelvic surgery. | |
| Dietary manipulation (ie, food diaries and dietary changes) and bowel schedule (ie, regular toileting) should be offered to women with fecal incontinence in conjunction with other treatments because these treatments may help improve symptoms and are associated with few adverse events. | ||
| Biofeedback may be considered for patients with FI | Pelvic floor muscle exercises with or without biofeedback can be recommended for the treatment of fecal incontinence to strengthen the anal sphincter and levator ani muscles, but there are insufficient data on the most effective treatment protocol. | |
| Fiber, antimotility agents, and laxatives can be recommended as useful treatments for fecal incontinence. | ||
| Surgical treatments should not be considered for the initial management of fecal incontinence (except in cases of fistulas or rectal prolapse) because surgical treatments provide only short-term improvement and are associated with more frequent and more severe complications compared with nonsurgical interventions. | ||
| Vaginal mechanical inserts are not routinely recommended for FI. | Not Addressed. | |
| Anal mechanical insert devices are not routinely recommended for FI. | Not Addressed. | |
| Anal sphincteroplasty may be considered in patients with a defect in the external anal sphincter, but clinical results often deteriorate over time. | Sphincteroplasty can be considered in women with anal sphincter disruption and fecal incontinence symptoms who have failed conservative treatments. | |
| Repeat anal sphincter reconstruction after a failed overlapping sphincteroplasty should generally be avoided. | Not Addressed. | |
| Sacral neuromodulation may be considered as a first-line surgical option for incontinent patients with or without sphincter defects. | Sacral nerve stimulation can be considered as a surgical treatment option for women with fecal incontinence with or without anal sphincter disruption who have failed conservative treatments. | |
| Injection of biocompatible bulking agents into the anal canal is not routinely recommended for the treatment of FI. | Anal sphincter bulking agents may be effective in decreasing fecal incontinence episodes up to 6 months and can be considered as a short-term treatment option for fecal incontinence in women who have failed more conservative treatments. | |
| Application of temperature-controlled radiofrequency energy to the sphincter complex is not recommended to treat FI. | Not Addressed. | |
| Antegrade colonic enemas can be considered in highly motivated patients who are seeking an alternative to a stoma. | Not Addressed. | |
| Colostomy is an option for patients who have failed or do not wish to pursue other therapies for FI. | Not Addressed. |
This concludes our Guidelines Side-by-Side on fecal incontinence. Don’t forget to sign up for alerts to stay informed on the latest published guidelines and articles.
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