Review

Faecal incontinence in adults

Robert D Madoff, Susan C Parker, Madhulika G Varma, Ann C Lowry Lancet 2004; 364: 621–32
Division of Colon and Rectal
Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, but Surgery, Department of
Surgery, University of
incontinent patients should not accept their debility as either inevitable or untreatable. Education of the general
Minnesota, Minneapolis, MN,
public and of health-care providers alike is important, because most cases are readily treatable. Many cases of mild USA (R D Madoff MD,
incontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best cared S C Parker MD, A C Lowry MD)
for after complete physiological assessment. Recent advances in therapy have led to promising results, even for and Department of Surgery,
University of California, San
patients with refractory incontinence. Health-care providers must make every effort to communicate fully with
Francisco, CA (M G Varma MD)
incontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them to
Correspondence to:
resume an active and productive lifestyle. Dr Robert D Madoff, 393 Dunlap
Street North, Suite 500, St Paul,
Faecal incontinence is a surprisingly common disorder outpatients2 found an overall prevalence of 18·4%. The MN 55104, USA
madof001@ umn.edu
that receives little attention in general and medical prevalence was twice as high for patients visiting a
publications. It can contribute to medical morbidity gastroenterologist (26·0%) as for those seeing a
(such as urinary-tract infections and decubitus ulcers) primary-care physician (13·4%). The US data, stratified
and can burden patients with substantial, continuous by frequency of episodes, showed that incontinence
financial expenses,1 but its main effect is on quality of occurred daily in 2·7% of patients, weekly in 4·5%, and
life. Patients with faecal incontinence suffer monthly or less in 7·1%. Symptomatic faecal
embarrassment, shame, and sometimes depression; incontinence occurs in 21% of women presenting with
some must plan their life around maintaining easy and urinary incontinence, pelvic-organ prolapse, or both.7
rapid access to a toilet. Not uncommonly, patients Faecal incontinence disproportionately affects
curtail or even entirely avoid activities that other individuals with severe physical and mental disabilities.
members of society take for granted: shopping, going to Patients living in institutions have an extremely high
the cinema, dining out, or having sexual intercourse. rate of faecal incontinence. Poor functional status,
Sadly, many of these lifestyle limitations are impaired cognitive ability, and limited mobility all
unnecessary, because most cases of faecal incontinence contribute to incontinence in nursing-home residents,8
are treatable. Barriers to treatment include the and the rates of incontinence rise with the length of
unwillingness of patients to broach the subject with time spent in nursing homes.9 A Canadian study of
health-care providers because of embarrassment or lack long-term hospital patients found a prevalence of 46%.10
of knowledge about the availability of treatment. Even Similarly, in a US survey of patients in nursing homes,
worse, many health-care providers are similarly reticent 47% had faecal incontinence.3 One explanation for these
or ignorant. strikingly high proportions is the advanced age, severe
debility, and numerous associated medical problems of
Epidemiology this population. However, another explanation could be
Faecal incontinence is the involuntary loss of rectal that faecal incontinence affecting a child or parent
contents through the anal canal. The true prevalence is simply cannot be managed by most families and that its
unknown, owing to the lack of standard definitions development generally mandates nursing-home
based on severity and frequency, differences in data placement. Two studies of older patients (one focused
collection, under-reporting of symptoms by patients, on patients in nursing homes, the other on those living
and variations in the populations sampled. International at home) found an association between severe faecal
population-based studies have provided widely varying incontinence and increasing mortality.9,11
estimates of prevalence, ranging from 0·004% to 18%.2–6 Under-reporting of symptoms by patients is a major
A US telephone survey found a prevalence of 2·2%; of reason for undertreatment. Only a third of symptomatic
the people who reported symptoms, 30% were over 65 patients in the USA discuss their faecal incontinence
years old and 63% were female.5 Most reported clinical with their physicians.2 In the United Arab Emirates,
series have a substantial predominance of female 60% of multiparous women with faecal incontinence do
patients, but epidemiological studies tend to show an not seek medical advice because of embarrassment, the
equal sex distribution. The reason for this discrepancy is
not known, but it might relate partly to the age and sex
Search strategy and selection criteria
of individuals who actively seek treatment.
The prevalence of faecal incontinence strongly MEDLINE was used to search for articles related to faecal
depends on the population studied. In Switzerland,7 the incontinence, emphasising those published from January,
prevalence was 4·4% in the community, 5·6% for 1998. The Cochrane Database of Systemic Reviews was also
general outpatients, 6·7% for antenatal patients, and queried for reviews related to faecal incontinence.
15·9% for urogynaecology patients. A US study of

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 Review
Puborectalis
Rectum
X-section
Anus
Pelvis
Sacrum
Rectum
Internal
sphincter
External
sphincter
Puborectalis
Internal sphincter
External sphincter
Figure 1: The anal sphincter complex
hope that the problem will resolve spontaneously, the
assumption that faecal incontinence is normal, or low
expectations of medical care.12
Aetiology
The anal sphincter complex consists of the internal and
external anal sphincter and the puborectalis muscle
(figure 1).13 The smooth muscle of the internal anal
sphincter has autonomic innervation and contributes
about 55% of the resting tone of the anal canal.14 The
external anal sphincter is a striated muscle that has a
predominance of slow-twitch, fatigue-resistant muscle
fibres.15 It is continuously active and provides 20–30% of
the anal resting tone;14 the remainder is provided by
expansion of the anal vascular cushions.14,16 The external
anal sphincter and puborectalis muscle function as one
unit, bring about voluntary sphincter contraction, and
normally double the sphincter pressure of the anal canal
during voluntary contraction.17 The external anal
sphincter is innervated by the inferior branch of the
pudendal nerve, which emerges from Alcock’s canal on
the medial aspect of the ischium and traverses the
ischiorectal fossa. The puborectalis muscle is also
directly innervated by the S3 and S4 sacral nerves.18,19
Sensation is provided by receptors in the pelvic floor that
detect rectal distension20 and by various receptors in the
anal transition zone.20,21
Congenital malformations such as imperforate anus,
rectal agenesis, and cloacal defect all can cause faecal
incontinence. The severity depends on the bulk and
development of pelvic-floor muscles and the degree of
impairment of sensory mechanisms.
A greater proportion of cases of faecal incontinence
are acquired. Sphincter disruption resulting from
vaginal delivery is the most common sphincter injury.
Other causes of anatomical defects, including anorectal
surgery and trauma from impalement or pelvic fracture,
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account for much of the faecal incontinence seen in
men. Lateral internal sphincterotomy,22,23 fistulotomy,22
haemorrhoidectomy, and anal dilation can all result in
incontinence.24,25 Sphincter-sparing colorectal resections
can also produce incontinence, because of loss of the
rectal reservoir and stretching of the sphincter during
surgery.26,27 Isolated degeneration of the internal anal
sphincter has been reported as a cause of soiling in both
men and women.28
Physical examination significantly underestimates the
frequency of postpartum sphincter disruption.29 Occult
sphincter defects have been detected by ultrasonography
in up to 35% of primiparous women after normal
vaginal delivery; the associated incontinence rate has
ranged from 13% to 23%.30,31 More recent reports
indicate a lower rate of sphincter defects, 8–16%, with
little or no evidence of incontinence in the immediate
postpartum period.32,33
A meta-analysis of 717 vaginal deliveries found a
frequency of sphincter defects of 26·9% in primiparous
women and a frequency of new sphincter defects of
8·5% in multiparous women.34 Although only 29·7% of
sphincter defects were symptomatic in the postparum
period, the probability of faecal incontinence resulting
from these defects was calculated to be 76·8–82·8%.
Disruption of the sphincter complex is associated with
diminished sphincter pressures,33 and defects occur
more frequently in women who have undergone forceps
delivery.30,32,35 Other risk factors for incontinence in
women include undergoing the first delivery, giving
birth to a baby weighing over 4 kg, and delivering a baby
who is in the occiput posterior position.36 Postal surveys
of postpartum women have reported incontinence rates
of 9·6% to 17·0%,37,38 with up to 50% of women having
faecal urgency or incontinence after third-degree
obstetric lacerations.36,39
Traction injury to the pudendal nerve commonly
accompanies obstetric sphincter laceration and
contributes to faecal incontinence.40 The injury is caused
by descent of the perineal floor, which stretches the
nerve as it emerges from its fixed site of exit from
Alcock’s canal. The result is muscle denervation and
subsequent reinnervation by nerve sprouting.41 An
identical neuropathy causes incontinence in patients
with rectal prolapse,42 chronic straining at stool,43,44 and
pelvic-floor descent.44
Faecal impaction is an important cause of
incontinence, particularly in older people and those
living in institutions. Impaction-associated overflow
incontinence has generally been attributed to chronic
reflex inhibition of the internal anal sphincter, but
physiological studies have shown that the cause is a
combination of decreased anorectal sensation and
reduced sphincter pressures. Factors contributing to
impaction include inadequate fibre and water intake,
metabolic disorders (hypercalcaemia, hypokalaemia,
hypothyroidism), immobility, dementia, depression, and
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 Review

drugs (eg, narcotics, antipsychotics, antidepressants, Panel: Causes of incontinence

diuretics, and calcium-channel blockers).45
Despite the importance of adequate pelvic-floor Congenital
function, maintenance of continence depends on an Imperforate anus
intact chain of anatomical structures and physiological Rectal agenesis
mechanisms, a sequence extending from the anus to the Cloacal defects
brain. Patients must have the awareness and desire to Myelomeningocele
maintain continence. Many patients with dementia are Meningocele
incontinent because of a lack of interest in, or awareness Anatomical
of, bowel function. Neurological disease or injury that Obstetric injury, vaginal delivery
affects the brain, spinal cord, or peripheral nerves can Anorectal surgery
cause incontinence. Congenital neurological causes Sphincter-sparing bowel resection
include spina bifida, myelomeningocele, and Pelvic fracture
meningocele. Acquired neurological causes include Anal impalement
stroke, tumours, spinal-cord injury, multiple sclerosis,
and diabetic autonomic neuropathy. Neurological
Abnormal gastrointestinal function can also cause Diabetes mellitus
faecal incontinence. Excessive stool volume and rapid Multiple sclerosis
gut transit can overwhelm an entirely normal pelvic Stroke
floor. Contributory abnormalities include intestinal Dementia
malabsorption, inflammatory bowel disease, and Central nervous system tumour, infection, trauma
infectious diarrhoea. Spina bifida
Finally, we should emphasise that in many cases Pudendal neuropathy
faecal incontinence arises from a combination of Functional
factors. Pudendal neuropathy commonly accompanies Psychiatric disorder
obstetric sphincter injury, as already noted. Similarly, Malabsorption
women with pre-existing irritable bowel syndrome have Inflammatory bowel disease
more postpartum defecatory urgency and incontinence Radiation proctitis
to flatus than those without, despite a similar frequency Hypersecretory tumours
of sphincter injury.46 The fact that many women with Rectal intussusception, prolapse
sphincter injuries do not develop incontinence until Faecal impaction
later in life also suggests a cumulative, multifactorial Physical disabilities
process. The possible causes of incontinence are
summarised in the panel.
infrequent loss of solid stool.47 The degree of
Assessment incontinence can also be inferred from the patient’s use
Many patients find the subject of faecal incontinence of pads or other protection and from restrictive changes
difficult to discuss, so they may provide limited or in lifestyle, but these behavioural factors may be more
misleading information. Common complaints include strongly influenced by the patient’s anxiety than the
urgency, pruritus (which is caused by soiling), and actual severity of the disorder. Incontinence can be
“diarrhoea,” a term commonly used by patients to classified into two categories on basis of the history:
denote incontinence. Clinicians eliciting such passive (unconscious loss of stool) and urge (inability to
complaints should investigate further, particularly if the control a perceived impending bowel movement).48
patient’s history (eg, recent vaginal delivery) or physical Many patients with physical and psychological
findings suggest faecal incontinence. True incontinence impairments have faecal incontinence, so assessment of
must be differentiated from perineal soiling due to the patient’s functional status is important. Physical
inadequate hygiene or prolapsing haemorrhoids. disabilities can impede access to a toilet, preclude
transfer to or sitting on a commode, or prevent cleaning
History up after bowel movements. Cognitive impairment can
When taking the history, clinicians should attend to affect the ability to sense the need to defecate or the
these essential elements: the onset and type of desire to defecate in a controlled way. Environmental
incontinence (flatus, liquid, or solid stool); the frequency assessment in some cases uncovers contributory factors
of episodes; and any related changes in bowel function to incontinence, such as a lack of accessible toilets.
or stool consistency. Solid stool is easier to control than
liquid, so the loss of solid stool generally indicates a Scoring systems
greater degree of physiological impairment. However, Planning of treatment and assessment of the results
loss of liquid stool is more troublesome to patients than requires a judgment of the severity of incontinence. In

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 Review
Normal appearance
External sphincter defect
Internal sphincter defect
Figure 2: Endoanal ultrasonography
contrast to many other disorders, no physiological index
of faecal incontinence accurately reflects clinical
severity.49 That fact led to the development of scoring
systems based on patients’ reports of symptoms.50 The
most widely used system includes as variables the
frequency and type of incontinence, the extent of
lifestyle changes, and the need to wear a pad.51 Although
none of the currently used scoring systems has been
psychometrically validated, the scores with all four
624
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systems compared in one study correlated with the
physician’s clinical impression.50,52
Several issues must be resolved before an ideal scoring
system is developed: the definition of incontinence must
be standardised; the optimum method of data collection
must be decided on (ie, diary versus patients’ recall); the
need for data beyond type and frequency must be
assessed; and the assignment of numerical values to the
combinations of type and frequency must be validated.
The developers of the faecal incontinence severity index
used patients’ input to assign numerical values, but
further work is necessary.47,50 Interpretation of
publications on incontinence is difficult because of the
lack of standardisation, and even more important,
because various methods are used for data collection.
For example, maintenance of a daily diary of bowel
movements is a far more stringent method than
patients’ recall, so results of treatment may appear to be
worse. Even the diary approach is limited by the
confounding factor of the patient’s activity: the most
severely affected patient can appear continent by
refusing to venture from a nearby toilet.
Quality of life should be assessed independently of
severity, because the two measures do not necessarily
correlate. Overall health-status instruments and
gastrointestinal quality-of-life instruments have been
used to measure quality of life related to faecal
incontinence, with mixed results.53,54 A recently validated
incontinence-specific quality-of-life scale measures four
variables (lifestyle, coping/behaviour, depression/self-
perception, and embarrassment); it is more sensitive
than global scales.55
Physical examination
Physical examination reveals the cause of the
incontinence in many cases. Pertinent findings include
a thinned or deformed perineal body and scars from
previous surgery or trauma. Breakdown of the perianal
skin is a consequence, not a cause of incontinence, but
skin condition should be noted and addressed. Gaping
of the anus suggests rectal prolapse, which can usually
be demonstrated with Valsalva’s manoeuvre. Digital
rectal examination can be used to diagnose faecal
impaction associated with overflow incontinence; such
an examination is essential to exclude tumours in the
anal canal or low rectum. Furthermore, the examiner
can assess both resting anal-sphincter tone and the
patient’s ability to augment it with voluntary squeeze
effort. Diminished perianal sensation and the absence
of an anal wink suggest a neurogenic cause of
incontinence.
Endoscopy to exclude a mass or inflammatory
condition is a key adjunct to the physical examination.
Flexible sigmoidoscopy is adequate in most cases, but
complete colonoscopy should be done if the patient has
unexplained diarrhoea, bleeding, or changed bowel
habits. The patient’s ability to retain a 100 mL water
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 Review

enema is a useful bedside measure of sphincter

function.

Anorectal physiology testing

Testing of anorectal physiology is useful both as a
diagnostic tool and as a way to quantify the magnitude
of the physiological defect. Such testing is particularly
important when the results of the physical examination
are normal, when rectal prolapse is suspected but not
demonstrable, or when surgery is contemplated. Useful
laboratory studies include endoanal ultrasonography,
anal manometry, electromyography, and defecography.

Imaging
Endoanal ultrasonography is a simple and rapid
technique that permits accurate delineation of anal-
sphincter anatomy (figure 2). When done by an
experienced ultrasonographer, the method has
sensitivity and specificity of almost 100% in identifying
defects of the internal and external sphincter.56 It can
also reveal unsuspected sphincter injuries in a patient
thought to have neurogenic incontinence or rule out
significant anatomical pathology in a patient with
suspected sphincter disruption; either result might lead
to a change in the planned therapy.57 Sphincter
abnormalities are shown on endoanal ultrasonography
in up to 90% of women whose sole risk factor for faecal
incontinence is obstetric trauma; thus, this imaging
technique is essential for complete assessment of
incontinent parous women.
MRI is another approach to pelvic-floor imaging
(figure 3).58 The need for an endoanal coil to optimise
imaging remains controversial. Advantages of MRI
include lower dependency on the operator, a wider field
of view, and the ability to undertake dynamic studies of
pelvic-floor function. Endoanal ultrasonography and
MRI have similar accuracy in diagnosing defects of the
external anal sphincter, but endoanal ultrasonography is
more accurate in diagnosing injuries of the internal anal
sphincter.59

Manometry
Anal manometry assesses function of the internal and
external anal sphincter, the rectoanal inhibitory reflex,
and rectal sensation. It uses a microballoon, a water-
perfused catheter, or a solid-state transducer. In a
relaxed patient, resting pressures mainly reflect function
of the internal anal sphincter; squeeze pressures
represent voluntary contraction of the external anal
sphincter. Normal values of both resting and squeeze
pressures vary among patients: they are lower in women
than men and in older patients of both sexes.17 Despite a
general relation between sphincter pressure and
continence, sphincter pressure varies substantially in
both continent and incontinent populations.17,49 That fact
helps emphasise the multifactorial nature of
incontinence. Furthermore, successful treatment of
Figure 3: MRI of the normal pelvis
Sagittal phased-array images of the anal canal and perianal structures.
AC=anococcygeal body; BS=bulbospongiosus; EAS=external anal sphincter;
PB=perineal body; PU=pubic bone. Reprinted with permission.58
incontinent patients will not necessarily correct
manometric abnormalities, and in fact it commonly
does not.
The rectoanal inhibitory reflex causes relaxation of the
internal anal sphincter in response to rectal distension.
It is demonstrated by a drop in resting anal pressure in
response to inflation of a rectal balloon. This reflex could

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 Review

Faecal incontinence
• Assess/treat aetiology of diarrhoea: colitis, hypersecretory
tumour, radiation, overflow
• Medical treatment: fibre, dietary, barrier cream, antidiarrhoeal
agents, bowel regimen
Improves
Major defect?
Yes No
Overlapping
sphincteroplasty
Improves
Endoanal ultrasonography:
persistent sphincter defect?
Yes
Repeat sphincteroplasty with
or without biofeedback
Neurophysiological tests
History and physical Diarrhoea? Neurophysiological assessment of incontinent patients
examination is done by single-fibre electromyography or pudendal-
nerve terminal motor latency (PNTML) testing. Single-
Yes No
fibre electromyography shows multiphasic action
potentials in the external anal sphincter, a finding
diagnostic of muscle denervation and subsequent
Anorectal physiology testing reinnervation.41 Although it provides more direct
• Anorectal manometry
• Pudendal nerve testing
evidence of denervation, single-fibre electromyography
Does not • Endoanal ultrasonography has largely been supplanted in many centres by PNTML
resolve • Defecography (optional) testing, which uses a glove-mounted intra-anal electrode
rather than a needle electrode.66 PNTML testing
Sphincter defect? measures conduction time from stimulation of the
nerve at the ischial spine to contraction of the external
Yes No anal sphincter. Because PNTML testing measures
conduction time in the fastest remaining nerve fibres,
significant nerve damage is sometimes overlooked.
Results are also influenced by the patient’s body type
Biofeedback and the technician’s expertise.67 Long latencies are
associated with traction injury to the nerve as well as
with primary neuropathies. Pudendal neuropathy is
seen in up to 70% of patients with faecal incontinence,
Improves Fails
and in more than 50% of patients with sphincter
Fails
injury.68 Some investigators have related the presence of
pudendal neuropathy to poor results after
sphincteroplasty,69 but others have not been able to
Consider indications, demonstrate an association.70 Enthusiasm for PNTML
age, comorbidities,
No technical issues testing has been tempered by the lack of consensus
about its accuracy and predictive value for outcome after
surgery.

Dynamic graciloplasty Defecography

Improves
Figure 4: Algorithm for incontinence
Artifical sphincter
Fails Sacral stimulation
permit “sampling” of the rectal contents by the
transitional-zone receptors, a process that assists in the
decision to initiate or defer defecation. The exact
mechanism of the decision process remains uncertain.
This reflex is absent in patients with Hirschsprung’s
and Chagas’ diseases; its loss after low rectal
anastomosis is associated with poor functional
outcome.60
Rectal sensory testing includes volumetric
measurements of the first detectable sensation, the
sensation of fullness, and the maximum tolerated
volume by balloon distension. Hypersensitivity can be
seen with inflammatory disorders, after irradiation, and
with irritable bowel syndrome;61 it can lead to urge
incontinence. Blunted sensation can also contribute to
incontinence;62,63 it is associated with megarectum and
with neurogenic disorders such as diabetes and multiple
sclerosis.64,65
Defecography examines rectal emptying of a soft barium
Stoma
paste under fluoroscopy. Although useful for
assessment of patients with obstructed defecation, it has
limited value in most incontinent patients. Its main role
in patients with faecal incontinence is to help diagnose
occult rectal prolapse or other suspected pelvic-floor
abnormalities (such as a poorly emptying rectocele).
Treatment
Medical therapy
An algorithm for the treatment of incontinence is given
in figure 4. Initial treatment should be conservative.
Dietary changes (eg, avoidance of foods that cause
diarrhoea or urgency), the addition of supplementary
fibre, and bowel habit training are useful for most
patients. They may even be the only treatment necessary
for those with mild incontinence. Barrier creams, cotton
wicks at the anus, and rectal washouts can prevent or
ameliorate anal excoriation secondary to leakage. In
patients with diarrhoea, assessment of the cause and
specific treatment directed at the underlying cause are
needed. Patients with idiopathic diarrhoea are treated
with antidiarrhoeal medications, such as loperamide,
diphenoxylate, and bile-acid binders. Loperamide
decreases intestinal motility and secretion and increases

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sphincter pressure.71 Bulking agents, such as psyllium
compounds, are also used, because control of solid stool
is easier than control of liquid stool. Conversely, patients
with constipation and faecal impaction may need
routine enemas or laxatives to empty the rectum, so that
overflow incontinence does not occur. Incontinent
patients with associated irritable bowel syndrome
present a therapeutic challenge, given their alternating
symptoms of diarrhoea and constipation.
Novel approaches to the medical treatment of
incontinence include oestrogen replacement therapy in
postmenopausal women,72 amitriptyline,73 and valproate
sodium.74 Topical 10% phenylephrine increased resting
anal pressure in healthy volunteers75 and improved
seepage in patients with ileoanal reservoirs,76 but it was
ineffective in a randomised controlled trial of
incontinent patients.77
Biofeedback
Biofeedback is commonly the first treatment
recommended if medical therapy fails. It is appealing
because it is simple, cheap, and without adverse physical
effects. The goal is improved contraction of the external
anal sphincter in response to rectal distention. Various
protocols and feedback equipment have been
reported.78–86 In general, three different protocols are
used: coordination training, which teaches patients to
contract the sphincter muscle in response to rectal
distension; sensory training, which teaches patients to
recognise progressively smaller volumes of rectal
distension; and strength training, which teaches
patients to isolate and exercise the sphincter muscle
without using rectal distension. The length and the
number of sessions recommended vary widely. In most
centres, manometry equipment or an electromyographic
rectal probe is used to provide information to patients.
The technique chosen does not seem to affect the
likelihood of success.87
Success rates after biofeedback range from 38% to
100%.64,78,88–90 The presence of a sphincter defect limits
but does not preclude the possibility of a good
response.90 Pudendal neuropathy does not adversely
affect clinical outcome,91,92 though poor results have been
reported in patients with severe neurogenic faecal
incontinence who lack rectal sensation.93 The reported
success rates for coordination training and for strength
training do not differ significantly.
Interpretation of reports on biofeedback is difficult.
Most studies have been retrospective. Parallel design
and randomisation have rarely been used. The definition
of success varies widely, and follow-up is short. In most
studies, the sample size is small and criteria for
selection of patients are not reported. Few studies
include controls.78,94 Studies comparing biofeedback with
attentive medical care alone are rare and have given
conflicting results.88,95 However, a randomised controlled
trial showed no advantage of biofeedback over standard
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Review
medical and nursing care (advice) or advice plus
sphincter exercises.96
Many issues about biofeedback remain unresolved. It
is not uniformly available and not covered by all health
insurance schemes. No clear criteria for selection of
patients have been identified. The optimum protocol,
equipment, and duration of treatment are unknown.
The mechanism of improvement is poorly understood.
No consistent change in sphincter pressures, rectal
sensation, or duration of contraction has been reported.
Long-term follow-up data are limited, albeit promising,
in a few small studies.97–99
Surgery
To restore the anal aperture by repairing sphincter
defects is the cornerstone of surgery for incontinence.
At the time of a recognised obstetric injury, immediate
direct repair is advocated, yet persistent defects are
common.29,35,100 If immediate repair is not attempted,
patients should wait at least 3 months before surgery, so
that the magnitude of the functional deficit can be
defined, physiological assessment can be done, and local
tissue inflammation and oedema can resolve.
Sphincteroplasty
Established injuries in symptomatic patients are treated
by overlapping sphincteroplasty. In this technique, a
curvilinear incision is made over the perineal body, and
the scarred sphincter remnant is dissected back to
healthy muscle on either side. The scar is transected, but
not excised, and is used as part of the overlapping repair
to restore an intact ring of muscle. Many surgeons
plicate the levator muscles anteriorly, in an effort to add
length to the restored anal canal, but no objective data
support this approach. Other surgeons avoid levator-
muscle plication out of fear of causing dyspareunia.
Individual repair of the internal and external anal
sphincter has been advocated by some researchers, but it
is not widely practised; moreover, proof of its superiority
to single-layer repair is lacking.101 Routine sphinctero-
plasty is generally done without creation of a diverting
stoma; randomised trials have shown no benefit from
diversion and morbidity was increased.102,103
As with all therapies for incontinence, the reported
success of sphincteroplasty depends on the definitions
of incontinence and on the data-collection method. Still,
most series report that 60–88% of patients achieve an
excellent or good outcome, defined as perfect continence
or as incontinence to flatus with minor staining.69,70,104–106
About 15–20% experience no change or a worse
outcome. However, several studies have shown that the
results of sphincteroplasty deteriorate substantially with
time.105,107–109
Some69,106,109,110 but not all series69,103,108 suggest that the
presence of pudendal neuropathy adversely affects the
outcome of overlapping sphincter repair. Patients for
whom sphincteroplasty fails should undergo follow-up
627
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ultrasonography to ensure that the muscle wrap is
intact; patients with persisting defects can undergo
repeat repair after 6–12 months.111,112 Biofeedback can be
effective salvage therapy for patients with suboptimum
results after sphincteroplasty.91
Diversion
If all other therapies have failed or if comorbidities
preclude more aggressive therapy, faecal diversion
remains an excellent alternative. Many patients express
reluctance to live with a stoma, but counselling by the
physician and an enterostomal therapist can be
persuasive. Colostomy admittedly does not confer
continence, but it does restore control of bowel
evacuation and permits resumption of a normal
personal and social life. Emphasis should be placed on
creating a well-constructed stoma at an appropriate site,
to limit difficulty with its management.
Innovations
Restoration of continence to patients when traditional
treatment fails, or when traumatic or neurogenic
injuries are extensive, remains a challenge. Even after
an initial successful result with biofeedback or anterior
sphincteroplasty, only about 50% of patients retain the
post-treatment degree of continence for 3 years or
longer.97,106,108 Options available to such patients include
dynamic graciloplasty, an artificial anal sphincter, and
sacral-nerve stimulation.
Dynamic graciloplasty and artificial anal sphincters
are advanced variations of anal encirclement. The
earliest and simplest version of anal encirclement was
the use of silver wire, described by Thiersch in 1891.
Later, Pickrell and colleagues described anal
encirclement by use of the gracilis muscle, and other
researchers have favoured use of gluteal-muscle flaps.113
Functional results with passive muscle wraps are
limited by the inability of patients to maintain, at all
times, continuous voluntary contraction of the muscle.
Dynamic graciloplasty combines transposition of the
gracilis muscle with electrical stimulation via an
implantable pulse generator. Application of graded
electrical stimulation allows conversion of the fast-
twitch, fatiguable gracilis muscle to a slow-twitch,
fatigue-resistant muscle that more closely resembles the
anal sphincter.114
Baeten and co-workers first reported the use of
electrical stimulation with a gracilis-muscle wrap for
faecal incontinence in 1988115 and subsequently
reported a 72% continence rate. However, multicentre
studies have been unable to replicate this degree of
success without substantial morbidity and high
reoperation rates.116,117 This discrepancy appears to arise
at least partly from a relative lack of experience with the
technique. Surgeons new to the operation have higher
morbidity rates and lower success rates than those with
substantial experience.116 Dynamic graciloplasty
628
For personal use. Only reproduce with permission from Elsevier Ltd
remains an option for refractory incontinence in a
limited number of centres, but it is not approved for use
in the USA.
The artificial anal sphincter (Acticon Neosphincter,
American Medical Systems, Minneapolis, MN, USA)
maintains continence via a fluid-filled cuff that
surrounds and compresses the anal canal. The patient
controls the device via a pump placed in the scrotum or
labia majora. Squeezing the pump nine to 12 times
forces the fluid from the cuff into a reservoir balloon,
which is implanted behind the pubic bone in
preperitoneal tissues. Once the cuff is deflated, the anal
canal is open, allowing the passage of stool. The cuff
then gradually reinflates to occlude the anal canal until
defecation is again desired.
Christiansen and Lorentzen first reported
implantation of an artificial anal sphincter for faecal
incontinence in 1987.118 Since then, variable results with
the technique have been reported.119–124 Lehur and
colleagues reported successful results in 75% of
patients, with 29% requiring at least temporary removal
of the device.123 By contrast, Malouf and co-workers
reported successful results in only 38% of patients;
infection, particularly with meticillin-resistant
Staphylococcus aureus, was the major cause of failure.124
In a multicentre clinical trial, 67% of patients had a
functional device in place at 1 year postoperatively.125
The mean incontinence score (range 0–120) dropped
from 105 (incontinent to liquids and solids daily) to 48
(seepage). The infection rate necessitating surgical
revision was 25%. In all, 46% of patients (51 of 112)
required surgical revision; 37% (41 of 112) required
device removal, seven of whom (17%) underwent
successful reimplantation.
The artificial anal sphincter is suitable for many of the
same patients who are candidates for dynamic
graciloplasty. However, the perineal soft tissue must be
sufficient to allow placement of a Silastic cuff around
the anal canal. The device is now available in Europe,
Canada, and the USA.
Sacral-nerve stimulation, like the artificial anal
sphincter, was initially devised for urinary incontinence.
Matzel and colleagues introduced the use of such
stimulation in 1995 to treat patients with functional, but
not anatomical, deficits of the anal sphincter muscle.126
The procedure entails placing an electrode in a sacral
foramen (generally S3) to stimulate the sacral nerves.
The desired effect is maximum contraction of pelvic
muscles, with the minimum possible stimulation of the
fibres to the leg. Once the optimum site has been
selected, the lead is connected to a temporary external
pulse generator for 2 weeks of test stimulation. If
function improves adequately, a permanent pulse
generator is implanted. Both the initial operation for
lead placement and the subsequent one for placement of
the pulse generator are done under local anaesthesia
with conscious sedation.
www.thelancet.com Vol 364 August 14, 2004

Recent series of patients treated by sacral-nerve
stimulation have shown promising results with little
morbidity.127,128 Success rates after short-term stimulation
approach 90%.129 The great majority of patients for whom
test stimulation is successful remain continent after
permanent implantation.127,130–132 However, infection and
lead displacement remain challenging in up to 25% of
patients.133 Because of continuing pain, device reposi-
tioning or explantation has been needed for several
patients.127,130
Most studies of sacral-nerve stimulation have shown
improvement in both resting and squeeze anal
pressures as well as increased rectal sensation.133
Ambulatory manometry has shown reduced rectal
contractility and suppression of spontaneous anal
relaxation.129 The mechanism by which these effects are
mediated remains uncertain, though many researchers
believe that sacral-nerve stimulation works by
modulating local reflex arcs. The mechanism could well
be multifactorial. Sacral-nerve stimulation is available in
Europe; in the USA, qualifying patients with faecal
incontinence can enrol in a trial approved by the Food
and Drug Administration.
Recent work has investigated novel minimally invasive
approaches to faecal incontinence. One option, the
addition of a bulking agent to the anal canal to augment
resting tone, stems from the routine use of bulking
agents for treatment of urinary incontinence caused by
intrinsic urinary-sphincter deficiency. The successful
use of implantable microballoons,134 carbon-coated
beads,135 autologous fat,136 silicone,137 and collagen138 have
each been reported in small series with low morbidities.
However, both the magnitude and the durability of
improvement have varied with such techniques.139 A
second investigational approach has used radio-
frequency energy to apply a series of small submucosal
burns to the anal canal. A pilot series showed promising
results,140 but a larger trial showed a lesser degree of
improvement.141
Conclusion
Faecal incontinence is an embarrassing and sometimes
debilitating disorder. Although incontinence is generally
treatable, many patients remain untreated because they
do not report their symptoms or because their health-
care provider is not familiar with available treatment
options. Conservative therapy is successful for many
cases of mild incontinence, but more severe cases
should be formally assessed before treatment is
undertaken. Recent advances have provided new
therapeutic options for patients with refractory
incontinence.
Conflict of interest statement
Robert D Madoff consults for Medtronic, manufacturer of the hardware
used for dynamic graciloplasty and sacral-nerve stimulation, and for
Solvay Pharmaceuticals, manufacturer of topical phenylephrine
hydrochloride. Susan C Parker consults for Medtronic and for American
www.thelancet.com Vol 364 August 14, 2004
For personal use. Only reproduce with permission from Elsevier Ltd
Review
Medical Systems, manufacturer of the Acticon Neosphincter artificial
bowel sphincter. None of the authors received payment (except from
The Lancet) for writing this review.
Acknowledgments
We thank Alexandra A Broek for assistance in preparation of the review,
and Mary E Knatterud for editorial help.
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