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Am Fam Physician. 1999;60(8):2372-2374

Fecal incontinence is a serious and embarrassing problem that affects up to 5 percent of the general population and up to 39 percent of nursing home residents. Providing effective treatment is challenging because of the difficulties in identifying the underlying etiology. Risk factors include female gender, older age, physical limitations and poor health. Previous studies in women have shown that obstetric or iatrogenic surgical injuries damage the internal or external sphincters, and straining or childbirth can injure the pudendal nerves. Anal ultrasound detects defects in the sphincter complex in up to 87 percent of incontinent women. Anorectal physiologic studies can identify pudendal nerve injuries in many of the remaining patients. Although men make up the smaller percentage of patients with fecal incontinence, only about one third seek treatment. Chen and associates reviewed their experience in managing fecal incontinence in male patients referred for evaluation.

A total of 37 male patients were seen over a period of three years. Of these, 10 had major incontinence or episodes of incontinence to solid feces, while the other 27 had minor incontinence or episodes of incontinence to liquid stool or flatus. The frequency of these episodes was usually once daily. Thirty-eight percent reported the need to wear a pad. Pruritus ani was the most common secondary symptom, followed by rectal bleeding and pain, and abdominal pain. Anal ultrasound and anorectal physiologic studies were performed on all patients.

Patient medical histories varied. Sixteen patients had hemorrhoids, and 12 had a history of anal surgery. Nine patients had a sphincter complex defect detected by anal ultrasound. Pruritis was more common in patients with a normal sphincter complex. None of the patients gave a history of anore-ceptive intercourse.

Management typically consisted of dietary modifications (usually a low-residue diet), constipating agents (usually loperamide) and, if necessary, agents to assist complete evacuation (usually a rectal bisacodyl suppository, 5 to 10 mg, or microlax enemas). Hemorrhoids were treated with rubber-band ligation.

During the follow-up period, most patients showed significant improvement or total resolution in symptoms (35 percent) or slight improvement in symptoms (21 percent). Nine patients reporting improvement had taken constipating medication. Resolution of symptoms was significantly higher in those with normal anal ultrasound studies revealing absence of sphincter complex defects. Fifteen patients showed no improvement in symptoms.

The authors conclude that anal ultrasound is the most useful study for predicting the success of nonoperative treatment of fecal incontinence in men. Patients without sphincter defect demonstrated on anal ultrasound also tended to have less severe incontinence, while those with a demonstrated defect were more likely to require surgical intervention. In a discussion following the article, one of the authors states that specific dietary recommendations for this condition are still unclear. Additional work-up of male patients with fecal incontinence of uncertain etiology should include ambulatory colonic motility studies and magnetic resonance imaging of the pelvic lumbosacral area to identify back problems. Because the results of sphincter repair are not that good, surgery should be reserved for use in patients with unresolved, severe symptoms.

editor's note: Treatment of fecal incontinence requires an understanding of the etiology of the problem. Mavrantonis and Wexner suggest the following five categories: (1) incontinence secondary to altered stool consistency; (2) incontinence resulting from inadequate reservoir capacity or compliance; (3) incontinence secondary to inadequate rectal sensation; (4) incontinence caused by direct sphincter injury; and (5) incontinence resulting from pelvic floor denervation. Surgical repair can provide satisfactory results but is less successful in patients with anorectum or colon cancer, chronic intractable diarrhea and inflammatory bowel disease.—r.s.

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