Introductory Chapter: Challenges in the Diagnosis and Treatment of Faecal Incontinence

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1
Chapter
Introductory Chapter: Challenges
in the Diagnosis and Treatment of
Faecal Incontinence
JohnCamilleri-Brennan
1. Introduction
Faecal incontinence is defined as the involuntary loss of faeces and flatus
through the anal canal and the inability to postpone defaecation until socially
convenient. In the majority, it is a physically debilitating and socially stigmatising
condition that may have an adverse effect on one’s quality of life. There are many
aspects of one’s life that are affected by this condition. Faecal incontinence has been
shown to be associated with poor self-esteem, embarrassment, and depression.
Those afflicted with this condition frequently need to plan and organise their lives
around the availability of and easy access to bathrooms and frequently avoid social
and leisure activities, especially venturing outdoors.
The prevalence of faecal incontinence in the UK is estimated to be about 2% of
the general population. Certainly the prevalence increases with age. Other inde-
pendent risk factors include female sex, physical limitations, poor general health,
and loose and frequent stools. From the financial point of view, the investigation
and treatment of faecal incontinence may add to a significant cost to the health
budget of most countries. In fact, the annual cost to treat and care for patients in the
UK with urinary and faecal incontinence and the consequences thereof is of about
£500 million. In addition, there are significant financial costs to the patients, their
families, and their employers due to the time taken off work and unemployment.
1.1 Diagnostic challenges
The pathophysiology of faecal incontinence is multifactorial. This presents the
first challenge: that of reaching a correct diagnosis. A thorough clinical assessment
of the patient is therefore mandatory. A detailed history, including a cognitive
assessment in most cases, is necessary. The characteristics of the faeces and the type
and frequency of incontinence should be noted. Urge incontinence is suggestive of
poor external anal sphincter function, whilst passive and post-defaecatory incon-
tinence indicates that internal anal sphincter function is weak. Any red flag symp-
toms, the symptoms suggestive of colorectal cancer such as rectal bleeding, should
be identified. Importance should be placed on secondary symptoms such as pruritus
ani and perianal skin, since these may reflect upon the severity of the inconti-
nence and may in some cases be the presenting complaint. Various questionnaires
that enable the clinician to quantify the degree of incontinence, the severity of
symptoms, and the impact on quality of life are available. These include symptom-
specific questionnaires, such as the ones developed by Vaizey etal. [1] and Jorge
and Wexner [2], the Fecal Incontinence Quality of Life Scale (FIQOL) developed

Current Topics in Faecal Incontinence
2
by Rockwood etal. [3], and also generic questionnaires such as the Short Form 36
(SF 36) [4]. Further information is obtained from a full examination of the patient,
including the abdomen and perineum, and a neurological examination in some
cases. Beneficial investigations include a flexible sigmoidoscopy, anal manometry
(resting and squeeze pressure), rectal compliance, pudendal nerve terminal motor
latency (PNTML), endoanal ultrasound, and defaecating proctography. Clinicians,
however, need to be able to determine which test to perform and when. Crucially
important is the correct interpretation of the results to ensure as accurate a diagno-
sis as possible. This presents a difficulty in itself due to our incomplete knowledge in
some areas of physiology and pathophysiology and also due to the weak correlation
between subjective and objective parameters.
1.2 Treatment challenges
The treatment of faecal incontinence is most often demanding. Determining
the appropriate treatment depends upon the accuracy of the diagnosis but also has
to be tailored to the individual patient, taking into consideration the individual
circumstances.
There are many publications listing the various modalities of conservative and
operative treatment options. The main aim is to treat the patients’ incontinence
conservatively in the first instance. Stool consistency may be improved with the
use of loperamide and codeine, biofeedback and pelvic floor exercises may help
improve rectal evacuation, anal plugs minimise passive incontinence, and so on.
Failure of medical therapy may lead to consideration of surgical options, of which
a variety are available. For example, traumatic disruption to the anal sphincter and
pelvic floor may be repaired, either by simple muscle apposition or, in exceptional
circumstances, by more advanced and complex techniques such as the gracilis
neosphincter. However, direct surgery on the colon, rectum, and anal sphincter
is both invasive and irreversible, as well as being associated with poorly sustained
long-term outcomes and well-established complications. A less invasive surgical
mode of treatment is sacral nerve stimulation (SNS), which has been shown to be
effective in the improvement of continence in a selected group of patients. Other
more minimally invasive procedures, such as the SECCA procedure and the use of
anal bulking agents, have an important role to play. Scientific advances in the field
of anal implants, with their associated clinical benefits and safety profile, are mak-
ing these minimally invasive operations a more viable and effective option. A colos-
tomy always remains an option and may be considered in certain circumstances,
such as in those who are bed-bound, those with upper motor neurone lesions, and
those where other surgical options have failed or are considered inappropriate.
The choice of treatment is not always straightforward. It is therefore advisable
that patients are managed in a multidisciplinary setting, especially those who failed
conservative management and may require operative intervention. Continence
multidisciplinary team meetings to discuss patients with challenging continence
issues are therefore highly commended [5].
Moving forwards, we are faced with exciting challenges as technology is rapidly
advancing. A main example is the intrinsically innervated BioSphincter, which has
the potential to improve the quality of life of so many of our patients. Watch this
space!

3
Introductory Chapter: Challenges in the Diagnosis and Treatment of Faecal Incontinence
DOI: hp://dx.doi.org/10.5772/intechopen.90514
Author details
JohnCamilleri-Brennan
University of Glasgow, UK
*Address all correspondence to: johncbrennan@doctors.org.uk
© 2020 The Author(s). Licensee IntechOpen. 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.

4
Current Topics in Faecal Incontinence
[1] Vaizey CJ, Carapeti E, Cahill JA,
Kamm MA.Prospective comparison of
faecal incontinence grading systems.
Gut. 1999;44:77-80
[2] Jorge JMN, Wexner SD.Etiology and
management of faecal incontinence.
Diseases of the Colon and Rectum.
1993;36:77-97
[3] Rockwood TH, Church JM,
Fleshman JW, etal. Fecal incontinence
quality of life scale: Quality of life
instrument for patients with fecal
incontinence. Diseases of the Colon and
Rectum. 2000;43(1):9-17
[4] Ware JE Jr, Sherbourne CD.The
MOS 36-item short-form health survey
(SF-36). I.Conceptual framework
and item selection. Medical Care.
1992;30:473-483
[5] National Institute for Clinical
Excellence (NICE). The Management of
Faecal Incontinence in Adults. Clinical
Guideline 49 NICE 2007
References