Faecal incontinence is a common problem that requires appropriate medical intervention, once diagnosed. Discussed in this article is the recent ACG guideline that highlights the symptoms, management and treatment recommendations for the issue.

A meticulous anorectal examination is mandatory in every patient with faecal incontinence (FI). Patients with FI who do not respond to education and conservative measures should undergo biofeedback.

Pictorial representations of stool form using the Bristol Stool Form Scale and bowel diaries are useful tools that can assist the diagnosis of FI. These are efficient and reliable methods that can help evaluate bowel habits and predict colonic transit.

Physical examination in faecal incontinence

Physical examination should be conducted to exclude diseases in which FI is secondary.

1. A meticulous anorectal examination is mandatory in every patient with FI. This can help identify rectal masses and gauge anal sphincter tone and pelvic floor motion at rest, during voluntary contraction of the anal sphincter and pelvic floor muscles, and during simulated evacuation.
2. A digital examination should be performed before referral for anorectal manometry (ARM).
3. Perianal pinprick sensation and the anal wink reflex can be used to evaluate the integrity of the sacral lower motor neuron reflex arc.
4. Other abnormalities in patients with FI include:

• Abnormal (i.e., increased or reduced) pelvic floor motion during the evacuation
• Impacted stool in the rectal vault
• Perianal soiling with faeces
• Reduced anal resting tone or weak squeeze responses are common

In patients with mild symptoms, conservative measures may be sufficient.

1. If symptoms improve and there are no features to suggest an organic disorder, further testing may not be necessary.
2. If symptoms do not improve, diagnostic testing should be conducted to decide management.

Diagnostic tests for faecal incontinence

The diagnostic tests for faecal incontinence should be tailored as per the patient's age, probable aetiological factors, symptom severity, impact on quality of life, response to conservative medical management, and availability of tests.

1. ARM, rectal BET, and rectal sensation should be performed in patients who fail to respond to conservative measures.
2. Pelvic floor, anal canal imaging and anal EMG should be considered in patients with anal weakness.

The anal cough reflex can be used for evaluating the integrity of the lower motor neuron innervation of the external anal sphincter. Rectal sensation in FI may be normal, increased, or decreased. Rectal sensory and rectal evacuation dynamics may change with biofeedback therapy.

Initial tests and therapy- The next course of testing is based on the results of initial tests and therapy.

1. Anal imaging with endoanal ultrasound or MRI should be considered in patients with weak pressures especially if surgery is being considered.
2. Internal sphincter defects usually show more severe anorectal injury than do external sphincter injuries alone.
3. Endoanal ultrasound helps visualise the internal sphincter. MRI is the best option for identifying external sphincter atrophy and to differentiate an external anal sphincter tear from a scar.

In patients who have refractory symptoms, further testing may be considered (especially if surgery is being considered):

1. Assessment of rectal compliance and sensation with a barostat.
2. Needle EMG of the anal sphincter should be considered in patients with clinically suspected neurogenic sphincter weakness, especially in cases with features suggestive of proximal (i.e., sacral root) involvement. However, this test has low clinical significance because of its low reliability.
3. Assessment of pelvic floor motion by dynamic MRI or barium proctography.

Treatment recommendations in faecal incontinence

1. Antidiarrheal drugs (e.g., loperamide, diphenoxylate with atropine, bile salt binding agents, anticholinergic agents, and clonidine) are recommended when FI is accompanied by diarrhoea.
2. Patients with FI who do not respond to education and conservative measures should undergo biofeedback (i.e., pelvic floor rehabilitative techniques with visual or auditory feedback).
3. Anal plugs, vaginal balloons, and other devices to impede defecation can be considered in selected patients who do not respond to conservative measures and biofeedback
4. Injecting bulking agents such as dextranomer sodium can be considered in selected patients with FI who do not respond to conservative therapy or biofeedback.
5. Sacral nerve stimulation (SNS) is recommended in patients with moderate to severe FI who have failed conservative measures, biofeedback, and other low-cost, low-risk techniques.
6. Anal sphincteroplasty is recommended for acute injuries to the anal sphincters.
7. End stoma can be offered to patients with severe FI who have not responded to other treatments.

This is part 1 of our series on benign anorectal disorders. Stay tuned for the next article in this series.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.