Chronic Faecal Incontinence – Review of the Disease State, Therapeutic Alternatives and Algorithmic Approach to Treatment

Faecal incontinence (FI) may be defined as the recurrent uncontrolled passage of faecal material, normally of one month’s duration or greater, in an individual with a developmental age of at least four years.¹ While many patients also have the involuntary passage of flatus, this symptom alone does not constitute classical FI. Despite the fact that the physical consequences of incontinence are minor, it is the psychosocial stigmata that are overwhelming, with diminished self-esteem, social isolation and stigmatisation and the anxiety of anticipated accidents. There may also be significant economic ramifications, such as loss of employment and the need for institutionalisation. Unbeknownst to many, incontinence is the second leading cause of institutionalisation in the US.^2–4 With regard to the associated costs of FI, Borrie and Davidson noted that in a long-term care facility the annual cost of nursing time and supplies was over US$9,500 per patient for dealing solely with incontinence.⁵ It has been estimated by some that the cost of adult nappies and protective clothing in the US exceeds US$400,000,000 per year.⁶ Attempts to accurately determine the true prevalence of FI are difficult, because patients are reluctant to mention FI to their physicians and physicians normally do not inquire about the control of bowel function. In a random telephone survey of 2,570 households in Wisconsin, during which time 7,000 people were interviewed, the prevalence of significant incontinence was noted to be 2.2 %, and 63 % of incontinent individuals were female. In the subsequent multivariate analysis, independent risk factors for FI were gender (female), advancing age, poor overall health and significant physical limitations.⁷ Similar results were noted in 2002, in a survey of over 15,000 individuals, during which a prevalence of 1.4 % of respondents had major FI. Advancing age was an independent risk factor; however, there were no sex-related differences, suggesting that men may represent an under-recognised and underserved demographic with a significant problem.⁸ Other studies have found that prevalence increases with age, with a 0.5–1 % occurrence in people younger than 65 years and 3–8 % in people older than 65 years.⁹ While the general population-based prevalence numbers appear relatively modest, there is a striking difference in postpartum demographics. In a survey of 21,824 eligible postpartum women, 8,774 (40 %) responded to the survey and 2,569 (29 %) reported FI since delivery. Forty-six per cent of this subset reported incontinence of stool, the onset beginning after delivery of their first child.¹⁰ In another cohort of 457 women, more than one in four women reported developing persistent FI within six months of childbirth.