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Ask Dr. Michael Salkin Your Own Question
Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 24453
Experience:  University of California at Davis graduate veterinarian with 44 years of experience
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Round stool (perfectfly round) on awakening in her bed never

Customer Question

round stool (perfectfly round) on awakening in her bed never had accidents before
Submitted: 9 months ago.
Category: Dog Veterinary
Expert:  Dr. Michael Salkin replied 9 months ago.

Koko appears to have become fecal incontinent if she's unaware of stool passing while asleep. There are quite a few differential etiologies for fecal incontinence so I'm going to post a synopsis of this disorder for you. Please take your time reading it. It's designed for vets but you'll get a good idea of what Koko's vet needs to consider. Pay particular attention to neurogenic etiologies such as degenerative disk disease (a "slipped disk") in a 5 year old.

Definition

Inability to retain feces

Epidemiology

Species, Age, Sex

  • Young animals: inappropriate house training, congenital disorders
  • Old animals: senility/cognitive dysfunction, degenerative disorders, neoplasia

Genetics and Breed Predisposition

  • German shepherd: degenerative lumbosacral stenosis, perianal fistulas
  • English bulldog, Manx cat: congenital spinal malformations

Risk Factors

  • Perineal surgery, radiation therapy
  • Pelvic or lumbosacral trauma
  • Perianal diseases
  • Tail avulsion fractures

Associated Disorders

Urinary incontinence

Clinical Presentation

History, Chief Complaint

Sphincter incontinence:

  • Unaware of fecal elimination; unassociated with defecation behavior
  • Small amounts of normal or abnormal feces dribble out, especially when intra-abdominal pressure increases suddenly (e.g. coughing).
  • Paraparesis
  • Urinary incontinence may be present.
  • Perineal soiling
  • Dogs with spinal lesions and episodic incontinence may be aware of the need to defecate but are unable to control the urge.

Reservoir incontinence:

  • Animal aware of incontinence; defecation behavior present, but is unable to control the time and place of elimination
  • Abnormal feces, suggestive of rectocolonic disease (diarrhea, mucoid feces, hematochezia)
  • Defecation associated with signs of rectocolonic disease (tenesmus, dyschezia)

Behavior:

  • House soiling with normal feces and defecation
  • Destructive behavior

Physical Exam Findings

Sphincter incontinence:

  • Non-neurogenic:
  • Neurogenic:
    • Spinal, lumbosacral pain
    • Hyperesthesia of hindlimbs or perineum
    • Lower motor neuron (LMN) signs: paresis/paralysis with decreased muscle tone, spinal reflexes, and anal tone; abnormal bulbocavernosus, rectal inflation, or anal reflexes; ± loss of tail tone and voluntary movement
    • Upper motor neuron (UMN) signs: increased spinal reflexes, ataxia
    • Intracranial disease: abnormal behavior, mentation, or cranial nerve examination

Reservoir incontinence:

  • Abnormal feces: diarrhea, constipation
  • Rectal masses, mucosal changes, pain on digital rectal examination
  • Signs of gastrointestinal disease (weight loss, anorexia, vomiting)

Behavior: normal physical exam

Etiology and Pathophysiology

Sphincter incontinence: diseases of the anal sphincter or adjacent structures

  • Non-neurogenic: anatomic disruption of the anal sphincter preventing functional seal. Anal tone and reflexes normal.
  • Neurogenic: normal sphincter anatomy
    • LMN dysfunction: sphincter dysfunction due to inadequate sensory or motor nerve supply
    • UMN dysfunction: incompletely understood; combination of reduced rectal sensation (disruption of afferent sensory pathways), lack of conscious control of the external anal sphincter, and exaggerated sacral defecation reflex (loss of inhibitory influences on reflex activity)

Reservoir incontinence; diseases of the colon/rectum:

  • Diseases impairing colonic-rectal compliance, capacity, or causing irritation
  • Normal sphincter anatomy and neural supply
  • Altered fecal consistency or excessive volume: feces enter into rectum too rapidly for normal control to take place.
  • Urge incontinence
  • “Overflow incontinence”: liquid feces seeping around constipated fecal material

 Diagnosis

Diagnostic Overview

fecal incontinence is a sign, not a diagnosis. The underlying cause must be identified for optimal treatment and accurate prognostication. Neurologic exam, behavioral history, and rectal palpation are indicated in all cases.

Differential Diagnosis

See p. 1301 for detailed differential diagnosis.

  • Sphincter incontinence
    • Non-neurogenic
    • Neurogenic sphincter incompetence
  • Reservoir incontinence
  • Behavioral

Initial Database

  • Physical examination including perineal and digital rectal examination
  • Fecal analysis
  • Neurologic examination (see p. 1201), especially:
    • Perineal and tail sensation
    • Anal sphincter and tail tone
  • Minimum database (complete blood count, serum biochemistry panel, urinalysis ± culture and sensitivity): nonspecific findings

Advanced or Confirmatory Testing

  • Sphincter incontinence: as dictated by working diagnosis
  • Reservoir incontinence:
    • Colonoscopy, proctoscopy
    • Rectal-colonic mucosal biopsy: cytologic, histopathologic analysis

 Treatment

Treatment Overview

  • Treat the primary cause.
  • Supportive care

Chronic Treatment

As needed, according to underlying cause:

  • Intestinal motility altering agents: loperamide, diphenoxylate
  • Amitriptyline has been successful in an open-label trial in humans with idiopathic fecal incontinence.
  • Maintain low intrarectal pressures:
    • Frequent opportunities to defecate if some control is present
    • Induction of reflex defecation: warm moist washcloth on anus/perineum
    • Reduce/avoid evening feedings (stimulus for nocturnal incontinence).
  • Prevent fecal scalding (clip and clean perineum, intermittent tail wrap if long-haired, barrier cream).
  • Change in environment to make incontinence more acceptable, “doggy diapers
  • Surgical: consider referral to a board certified surgeon.
    • Anorectal reconstruction
    • Silicon elastomer sling
    • Neosphincter
    • Fecal diversion procedures: colonostomy
    • Semitendinous muscle transfer flap

Nutrition/Diet

May respond to a therapeutic diet trial: either low-residue or high-fiber (soluble or insoluble) diets can be tried. Success is variable and depends on the underlying etiology.

Possible Complications

  • Fecal soiling predisposes to perineal dermatitis and, in females, urinary tract infections.
  • Constipation possible with motility-modifying medication

Recommended Monitoring

Medical management must be regarded as a therapeutic trial; response guides subsequent treatment and diagnostic testing if necessary.

 Prognosis & Outcome

Guarded to poor with:

  • Many neurogenic sphincter causes (degenerative neuropathies, dysautonomia, lumbosacral stenosis)
  • Severe anal sphincter lesions
  • Underlying cause not found

Fair to good with:

  • Controlled rectocolonic disease
  • Behavioral causes treated with effective behavioral modification
  • There have been some encouraging results with surgical correction of even long-standing focal UMN spinal lesions.

 Pearls & Considerations

Comments

  • fecal incontinence caused by UMN spinal cord lesions may develop before limb deficits.
  • fecal incontinence is a common reason for client-requested euthanasia.
  • Response and client satisfaction are highly variable and based on client expectation and ability.

Prevention

Precise and atraumatic technique when performing perineal surgery

Please respond with further questions or concerns if you wish.