The major factors necessary for fecal continence are;
1) an intestine content (fecal material / stool) that is substantially firm and bulky,
2) a passively distensible, capacious and evacuable rectum and
3) an effective barrier to outflow.
Therefore, changes in the quantity and/or quality of stool, the inability of the rectum to accommodate, damage to the anal sphincter mechanism and/or an impaired sensation can result in fecal incontinence.
As a result, common causes of fecal incontinence are;
b) fecal impaction with overflow,
c) impaired rectal storage,
d) loss of rectal sensation to distension, and
e) isolated or combined weakness/impairment of the sphincter and puborectalis muscle.
Frequently, it is a combination of more than one of these mechanisms (new onset diarrhea with pre-existing anal sphincter dysfunction that was subclinical in its expression).
Normal continence involves the coordinated interaction between multiple different nerve pathways and the pelvic and perineal musculature. Many other factors, like systemic disease, emotional effect, bowel motility, stool consistency, evacuation efficiency, pelvic floor stability, and sphincter integrity, play a role in normal regulation of the anal sphincter. Failure at any level may result in an impaired ability to control gas or stool (especially if the motion is liquid). Following investigations are needed for the identifying the cause, if this has been going on for more than 2-3 weeks;
1) Endoanal ultrasound,
4) Anorectal manometry
5) Anorectal electrophysiology testing
The treatment entails;
1) Biofeedback; Pelvic floor exercises with biofeedback are beneficial when combined with the addition of dietary modifications. Biofeedback educates regarding pelvic floor coordination, recognition of sensory thresholds, and conditioning of the pelvic musculature, and it helps develop improved pelvic floor habits.
2) Dietary modification: a food diary may be useful to detect offensive items, such as citrus or spicy foods, caffeine, and alcohol, that may be associated with incontinence. Avoiding these may decrease the irritant load to the rectum.
3) Medications; The two most commonly used drugs are loperamide and diphenoxylate with atropine. Loperamide is currently the treatment of choice because it not only thickens the stool but also has been shown to increase anal sphincter tone and improve continence mechanisms.
4) Anal sphincteroplasty; it is a surgical procedure and is done when the above medical treatment fails and if the injury of the sphincter of anus is demonstrated.
5) Artificial sphincters
6) Sacral nerve stimulation.
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