Makindo Medical Notes

Faecal incontinence is the involuntary loss of stool or flatus, which can be socially disabling and distressing. It is often multifactorial, arising from sphincter weakness, altered stool consistency, neurological disease, or structural abnormalities. Assessment requires careful history, examination, and targeted investigations to guide management.

🛠️ Causes of Faecal Incontinence

• 💪 Anal Sphincter Weakness: Common after obstetric trauma, anal surgery, or neurological conditions affecting sphincter control.
• 💩 Diarrhoea: Loose stools overwhelm sphincter control, e.g., in IBS, IBD, or infections.
• 🚫 Chronic Constipation with Overflow: Impaction leads to leakage of liquid stool around hard faeces.
• 🧠 Neurological Disorders: Stroke, multiple sclerosis, and spinal cord injuries impair control or sensation.
• ⬇️ Rectal Prolapse: Prolapsed rectum weakens anal closure and sensation.
• 👵 Age-related Changes: Natural decline in sphincter tone and rectal sensation with ageing.

🧑‍⚕️ Clinical Features

• Involuntary leakage of stool (solid, liquid) or flatus.
• Urgency and inability to defer defecation.
• Soiling of underwear and perianal irritation.
• History of childbirth trauma, anorectal surgery, neurological illness, or chronic bowel dysfunction.
• Associated symptoms: diarrhoea, constipation, abdominal pain, or rectal mass symptoms.

🔍 Investigations

• Clinical Examination: Inspection and digital rectal exam to assess tone, perianal sensation, prolapse, and impaction.
• Anorectal Manometry: Gold standard to measure sphincter pressures and rectal sensation.
• Endoanal Ultrasound: Defines sphincter defects (esp. post-obstetric injury).
• Defecography: Imaging for rectal prolapse or pelvic floor dysfunction.
• Stool Tests & Colonoscopy: Rule out diarrhoeal causes (IBD, infection, malignancy).
• Neurological Imaging/Tests: MRI brain/spine or pudendal nerve studies if neuropathy suspected.

💊 Management

Treatment is guided by underlying cause. Often a multidisciplinary approach involving gastroenterology, colorectal surgery, physiotherapy, and continence nurses is required.

• Lifestyle & Conservative:
  • Dietary changes → optimise stool consistency (fibre supplements for constipation, low FODMAP for diarrhoea).
  • Regular bowel routines and toileting schedules.
  • Skin care and continence pads for hygiene and dignity.
• Pelvic Floor & Behavioural:
  • Pelvic floor (Kegel) exercises to strengthen sphincters.
  • Biofeedback therapy → retrains sphincter coordination and sensation.
• Medical:
  • Anti-diarrhoeals (loperamide) for loose stools.
  • Laxatives / stool softeners for constipation and impaction prevention.
  • Treat underlying conditions (IBD, infections, endocrine disorders).
• Surgical / Advanced:
  • Sphincteroplasty for obstetric or surgical defects.
  • Rectopexy for rectal prolapse.
  • Sacral nerve stimulation (neuromodulation) for refractory cases.
  • Stoma formation (colostomy) in severe, intractable incontinence.

🚑 Special Considerations

• Children: Often secondary to constipation/encopresis rather than sphincter weakness.
• Elderly: Multifactorial – reduced mobility, dementia, medications, alongside age-related sphincter weakness.
• Post-Obstetric Injury: Early recognition and repair of 3rd/4th degree tears reduce long-term faecal incontinence risk.

📌 Key Points

• Always exclude faecal impaction as a cause of overflow incontinence.
• Faecal incontinence is not always due to sphincter weakness – diarrhoea and constipation are common reversible causes.
• Management is stepwise → start with conservative measures, escalate to surgery if needed.
• Strong emphasis on quality of life, dignity, and psychological support.