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Epidemiology, Pathophysiology, and Classification of Fecal Incontinence: State of the Science Summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Workshop

Bharucha, Adil E MBBS, MD1; Dunivan, Gena MD2; Goode, Patricia S MSN, MD3; Lukacz, Emily S MD, MAS4; Markland, Alayne D DO, MSc3; Matthews, Catherine A MD5; Mott, Louise RN6; Rogers, Rebecca G MD2; Zinsmeister, Alan R PhD7; Whitehead, William E PhD5,8; Rao, Satish S C MD, PhD9; Hamilton, Frank A MD10

American Journal of Gastroenterology: January 2015 - Volume 110 - Issue 1 - p 127–136
doi: 10.1038/ajg.2014.396
REVIEW: CLINICAL AND SYSTEMATIC REVIEWS
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In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

1Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA

2Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA

3Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA

4Department of Reproductive Medicine, UC San Diego Health Systems, La Jolla, California, USA

5Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA

6Simon Foundation, Langley, British Columbia, Canada

7Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA

8Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA

9Department of Gastroenterology, Georgia Regents University, Augusta, Georgia, USA

10National Institutes of Diabetes, Digestive and Kidney Diseases, National Institute of Health, Bethesda, Maryland, USA

Correspondence: Adil E. Bharucha, MBBS, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA. E-mail: bharucha.adil@mayo.edu

Received 02 June 2014; accepted 01 November 2014

Guarantor of the article: Adil E. Bharucha, MBBS, MD.

Specific author contributions: All authors presented at the symposium, participated in writing, and reviewed the final submitted version of this manuscript.

Financial support: Bharucha was partly supported by NIH grants R01 DKDK78924 from the National Institutes of Health (NIH). Whitehead was partly supported by Agency for Healthcare Research and Quality grant R01 HS018695 and NIH grant R21 DK096545.

Potential competing interest: Whitehead received research support from Salix Pharmaceuticals.

© The American College of Gastroenterology 2015. All Rights Reserved.
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