Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Abstract

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field.

The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Introduction

Faecal incontinence (FI) can severely affect the quality of life of patients by limiting their social life and relationships, causing depression and confinement.

Although the commonly accepted definition of FI appears simple (“failure to control the elimination of stool and/or flatus recurring for >3 months”) [1], [2], FI covers several conditions. These can be classified, according to the underlying pathophysiological mechanisms, into stress incontinence [3], urge (active) incontinence [4], [5], [6], passive incontinence [4], faecal soiling [2], which includes “post-defecatory incontinence” [2], [4], and overflow incontinence due to faecal impaction, very frequent in children with encopresis and elderly patients [7], [8].

Before embarking on the diagnostic and therapeutic work-up, a complete clinical history should always be collected. This includes detailed questions on bowel habits, diets, comorbidities, and ongoing pharmacological therapies altering bowel motility or neuromuscular function.

The identification of risk factors for FI is another fundamental issue. Age is a recognized risk factor both in men and in women [9], [10]. Obstetric injuries, gynaecological and ano-rectal surgery should always be investigated. Multiparty, urinary incontinence, obesity, reduced physical activity, functional limitations, current cigarette smoking, diabetes, hypertension, presence of neurologic disease, depression and use of psychoactive drugs can all increase the likelihood of FI in women over 62 years of age [11], [12].

Diabetes, multiple sclerosis, cognitive deterioration and systemic sclerosis can affect the integrity of ano-rectal function. Chronic diarrhoea, irritable bowel syndrome, or cholecystectomy are independent risk factors for FI [13]. Constipation due to obstructed defecation is another recognized risk factor for post-defecatory incontinence.

However, a preliminary rectal examination is essential to the workup of FI in order to detect any signs of organic and functional disease of the anus and distal rectum [14], [15], [16]. This should also include a careful inspection of the anus and perineum not only in resting but also during straining and squeezing [15], [16], looking at anal symmetry and morphology, descending perineum rectal prolapse and scars [17]. Inspection must include the scratch reflex [18]. Vaginal examination in women with FI must be considered, since vaginal delivery can cause FI through anal sphincter and pelvic floor injury [19], [20]. Given the possible association between pelvic organ prolapse and FI [21], [22], [23], examination of external genitalia, perineum, and vagina with a speculum, as well as bimanual pelvic examination, is mandatory [24].

Major advances in understanding the pathophysiologic mechanisms and in developing new diagnostic and therapeutic strategies have been achieved in recent decades, but there is still uncertainty about the optimal diagnostic and/or therapeutic procedure to be adopted for each type of FI.