Assessment and Investigation of Fecal Incontinence and Constipation



Fecal incontinence and constipation are common conditions that have a significant impact upon a patient’s quality of life. The maintenance of continence and act of defecation result from the complex interaction of many factors that is reflected in the many different etiologies of fecal incontinence and constipation, and the many different investigations available. As with all medical practice, a thorough history and examination forms the solid foundation required to assessing such patients, with supplementary information from specialist tests being useful in some. The symptoms of both constipation and fecal incontinence may in a few be the presenting symptoms of a colorectal or anal neoplasm. Such a diagnosis should be excluded in the assessment and with appropriate investigations. The assessment of a patient with incontinence and constipation is described, followed by a detailed discussion of the most useful specialist tests of anorectal and colonic function.


Fecal Incontinence Anal Canal External Anal Sphincter Internal Anal Sphincter Pudendal Nerve 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Macmillan AK, Merrie AE, Marshall RJ, Parry BR. The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature. Dis Colon Rectum. 2004;47:1341–9.PubMedCrossRefGoogle Scholar
  2. 2.
    NICE Clinical Guidance number 49. Fecal incontinence. Accessed November 2010.
  3. 3.
    Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut. 1999;44:77–80.PubMedCrossRefGoogle Scholar
  4. 4.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum. 1999;42:1525–32.PubMedCrossRefGoogle Scholar
  5. 5.
    Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36:77–97.PubMedCrossRefGoogle Scholar
  6. 6.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum. 2000;43:9–16.PubMedCrossRefGoogle Scholar
  7. 7.
    Bugg GJ, Kiff ES, Hosker G. A new condition-specific health-related quality of life questionnaire for the assessment of women with anal incontinence. Br J Obstet Gynaecol. 2001;108:1057–67.CrossRefGoogle Scholar
  8. 8.
    Drossman DA, Sandler RS, McKee DC, Lovitz AJ. Bowel patterns among subjects not seeking health care. Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology. 1982;83:529–34.PubMedGoogle Scholar
  9. 9.
    Stewart WF, Liberman JN, Sandler RS, Woods MS, Stemhagen A, Chee E, et al. Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features. Am J Gastroenterol. 1999;94:3530–40.PubMedCrossRefGoogle Scholar
  10. 10.
    D’Hoore A, Penninckx F. Obstructed defecation. Colorectal Dis. 2003;5:280–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Knowles CH, Scott M, Lunniss PJ. Outcome of colectomy for slow transit constipation. Ann Surg. 1999;230:627–38.PubMedCrossRefGoogle Scholar
  12. 12.
    Frank L, Kleinman L, Farup C, Taylor L, Miner Jr P. Psychometric validation of a constipation symptom assessment questionnaire. Scand J Gastroenterol. 1999;34:870–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Knowles CH, Eccersley AJ, Scott SM, Walker SM, Reeves B, Lunniss PJ. Linear discriminant analysis of symptoms in patients with chronic constipation: validation of a new scoring system (KESS). Dis Colon Rectum. 2000;43:1419–26.PubMedCrossRefGoogle Scholar
  14. 14.
    Marquis P, De La Loge C, Dubois D, McDermott A, Chassany O. Development and validation of the patient assessment of constipation quality of life questionnaire. Scand J Gastroenterol. 2005;40:540–51.PubMedCrossRefGoogle Scholar
  15. 15.
    Eckardt VF, Elmer T. Reliability of anal pressure measurements. Dis Colon Rectum. 1991;34:72–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Ryhammer AM, Laurberg S, Hermann AP. Test-retest repeatability of anorectal physiology tests in healthy volunteers. Dis Colon Rectum. 1997;40:287–92.PubMedCrossRefGoogle Scholar
  17. 17.
    Felt-Bersma RJ, Klinkenberg-Knol EC, Meuwissen SG. Anorectal function investigations in incontinent and continent patients. Differences and discriminatory value. Dis Colon Rectum. 1990;33:479–85.PubMedCrossRefGoogle Scholar
  18. 18.
    McHugh SM, Diamant NE. Effect of age, gender, and parity on anal canal pressures. Contribution of impaired anal sphincter function to fecal incontinence. Dig Dis Sci. 1987;32:726–36.PubMedCrossRefGoogle Scholar
  19. 19.
    Jameson JS, Chia YW, Kamm MA, Speakman CT, Chye YH, Henry MM. Effect of age, sex and parity on anorectal function. Br J Surg. 1994;81:1689–92.PubMedCrossRefGoogle Scholar
  20. 20.
    Rao SS, Welcher KD, Leistikow JS. Obstructive defecation: a failure of rectoanal coordination. Am J Gastroenterol. 1998;93:1042–50.PubMedCrossRefGoogle Scholar
  21. 21.
    Masi P, Miele E, Staiano A. Pediatric anorectal disorders. Gastroenterol Clin North Am. 2008;37:709–30.PubMedCrossRefGoogle Scholar
  22. 22.
    Yang YK, Wexner SD. Anal pressure vectography is of no apparent benefit for sphincter evaluation. Int J Colorectal Dis. 1994;9:92–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Gold DM, Halligan S, Kmiot WA, Bartram CI. Intraobserver and interobserver agreement in anal endosonography. Br J Surg. 1999;86:371–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Dobben AC, Terra MP, Slors JF, Deutekom M, Gerhards MF, Beets-Tan RG, et al. External anal sphincter defects in patients with fecal incontinence: comparison of endoanal MR imaging and endoanal US. Radiology. 2007;242:463–71.PubMedCrossRefGoogle Scholar
  25. 25.
    Kiff ES, Swash M. Slowed conduction in the pudendal nerves in idiopathic (neurogenic) faecal incontinence. Br J Surg. 1984;71:614–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Neill ME, Swash M. Increased motor unit fibre density in the external anal sphincter in anorectal incontinence: a single fibre EMG study. J Neurol Neurosurg Psychiatry. 1980;43:343–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Wexner SD, Marchetti F, Salanga VD, Corredor C, Jagelman DG. Neurophysiologic assessment of the anal sphincters. Dis Colon Rectum. 1991;34:606–12.PubMedCrossRefGoogle Scholar
  28. 28.
    Felt-Bersma RJ, Poen AC, Cuesta MA, Meuwissen SG. Anal sensitivity test: what does it measure and do we need it? Cause or derivative of anorectal complaints. Dis Colon Rectum. 1997;40:811–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Gladman MA, Scott MS, Chan CLH, Williams NS, Lunniss PJ. Rectal hyposensitivity prevalence and clinical impact in patients with intractable constipation and fecal incontinence. Dis Colon Rectum. 2003;46:238–46.PubMedCrossRefGoogle Scholar
  30. 30.
    Sun WM, Donnelly TC, Read NW. Utility of a combined test of anorectal manometry, electromyography and sensation in determining the mechanism of idiopathic faecal incontinence. Gut. 1992;33:807–13.PubMedCrossRefGoogle Scholar
  31. 31.
    Bartram CI. Functional anorectal imaging. Abdom Imaging. 2005;30:195–203.PubMedCrossRefGoogle Scholar
  32. 32.
    Williams AB. Anorectal investigation. In: Philips KS, editor. Colorectal surgery: a companion to specialist surgical practice. London: Elsevier/Saunders; 2005. p. 1–23.Google Scholar
  33. 33.
    Rentsch M, Paetzel C, Lenhart JM, Feuerbach S, Jauch KW, Fiirst A. Dynamic magnetic resonance imaging defecography. Dis Colon Rectum. 2001;44:999–1007.PubMedCrossRefGoogle Scholar
  34. 34.
    Rao SS, Ozturk R, Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic review. Am J Gastroenterol. 2005;100:1605–15.PubMedCrossRefGoogle Scholar
  35. 35.
    Duthie HL. Dynamics of the rectum and anus. Clin Gastroenterol. 1975;4:467–77.PubMedGoogle Scholar
  36. 36.
    Hinton JM, Lennard-Jones JE, Young AC. A new method for studying gut transit times using radioopaque markers. Gut. 1969;10:842–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Metcalf AM, Phillips SF, Zinsmeister AR, MacCarty RL, Beart RW, Wolff BG. Simplified assessment of segmental colonic transit. Gastroenterology. 1987;92:40–7.PubMedGoogle Scholar
  38. 38.
    Lin HC, Prather C, Fisher RS, Meyer JH, Summers RW, Pimentel M, et al. Measurement of gastrointestinal transit. Dig Dis Sci. 2005;50:989–1004.PubMedCrossRefGoogle Scholar
  39. 39.
    Lundin E, Karlbom U, Pahlman L, Graf W. Outcome of segmental colonic resection for slow-transit constipation. Br J Surg. 2002;89:1270–4.PubMedCrossRefGoogle Scholar
  40. 40.
    Redmond JM, Smith GW, Barofsky I, Ratych RE, Goldsborough DC, Schuster MM. Physiological tests to predict long-term outcome of total abdominal colectomy for intractable constipation. Am J Gastroenterol. 1995;90:748–53.PubMedGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  1. 1.Pelvic Floor Service, Department of General SurgeryUniversity Hospital South ManchesterManchesterUK

Personalised recommendations