Guideline sources The following summarized guidelines for the evaluation and management of fecal incontinence are prepared by our editorial team based on guidelines from the American Society of Colon and Rectal Surgeons (ASCRS 2023), the American College of Gastroenterology (ACG 2021), the American College of Obstetricians and Gynecologists (ACOG 2019), and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK 2015). 1 2 3 4 Calculator Wexner/Cleveland Clinic Fecal In Guidelines 1. Screening and diagnosis Indications for screening: Obtain screen for fecal incontinence in female patients with risk factors, such as: age > 50 years residence in long-term care facilities https://web.pathway.md/diseases/recfTssZTNoahWkPe 1/5 6/29/23, 4:03 AM Fecal incontinence Pathway residence in long term care facilities pelvic floor disorders history of obstetric anal sphincter injuries history of pelvic irradiation engagement in anal intercourse urinary incontinence chronic diarrhea rectal urgency diabetes obesity. B 2. Diagnostic investigations History and physical examination: As per ASCRS 2023 guidelines, elicit a history to help determine the etiology of incontinence, including specific risk factors for incontinence, and characterize the duration and severity of symptoms. E Show 2 more As per ACOG 2019 guidelines, elicit a complete medical history, assess symptoms and perform physical examination of the rectal, vaginal and perineal areas in female patients reporting fecal incontinence symptoms. B Anorectal physiology testing: As per ASCRS 2023 guidelines, consider obtaining anorectal physiology testing (manometry, anorectal sensation, volume tolerance, and compliance) to help define the elements of dysfunction and guide management. C As per ACOG 2019 guidelines, do not obtain anorectal manometry during routine evaluation of female patients with fecal incontinence. D Pudendal nerve conduction studies: As per ASCRS 2023 guidelines, do not obtain pudendal nerve terminal motor latency testing routinely in patients with fecal incontinence. D As per ACOG 2019 guidelines, do not obtain pudendal nerve terminal motor latency testing during routine evaluation of female patients with fecal incontinence. D Diagnostic imaging: As per ASCRS 2023 guidelines, consider obtaining endoanal ultrasound to evaluate sphincter anatomy when planning a sphincter repair. C As per ACOG 2019 guidelines, do not obtain anal sphincter imaging or defecography during routine evaluation of female patients with fecal incontinence. D Laboratory tests: do not obtain specific laboratory tests during initial evaluation of fecal incontinence in female patients unless diarrheal infectious processes are suspected. D 3. Diagnostic procedures https://web.pathway.md/diseases/recfTssZTNoahWkPe 2/5 6/29/23, 4:03 AM Fecal incontinence Pathway Lower gastrointestinal endoscopy: As per ASCRS 2023 guidelines, perform endoscopy according to established screening guidelines and in patients presenting with symptoms warranting further evaluation (changes in bowel habits, bleeding). B As per ACOG 2019 guidelines, consider performing colonoscopy in female patients presenting with fecal incontinence and a change in bowel habits, especially if accompanied by any "red flag" symptoms, such as unexplained weight loss, abdominal pain, rectal bleeding, melena, or anemia. C 4. Medical management Conservative management: As per ASCRS 2023 guidelines, offer dietary and medical management as first-line therapy in patients with fecal incontinence. B As per ACG 2021 guidelines, offer antidiarrheal drugs (such as loperamide, diphenoxylate with atropine, bile salt binding agents, anticholinergic agents, and clonidine) when fecal incontinence is accompanied by diarrhea. B As per ACOG 2019 guidelines: Consider offering conservative measures, such as dietary modifications, bowel scheduling, fiber supplementation, and stool-modifying agents (including antimotility agents and laxatives) in female patients with fecal incontinence. C Offer non-surgical treatments for initial management of female patients with fecal incontinence due to the modest short-term efficacy and a low risk of adverse events, except for patients with fistulae or rectal prolapse. B 5. Nonpharmacologic interventions Dietary modifications: Consider advising fiber supplementation in female patients with fecal incontinence. C Offer dietary manipulation (food diaries and dietary changes) and bowel schedules (regular toileting) in conjunction with other treatment in female patients with fecal incontinence. B Pelvic floor exercises: consider offering pelvic floor muscle exercises, with or without biofeedback, to strengthen the anal sphincter and levator ani muscles in female patients with fecal incontinence. C Bowel training: consider offering bowel training programs to improve rectal evacuation in selected patients with fecal incontinence. C Anal and vaginal mechanical inserts: As per ASCRS 2023 guidelines, do not offer vaginal or anal mechanical insert devices routinely for fecal incontinence. D As per ACG 2021 guidelines, consider offering anal plugs, vaginal balloons, and other devices to impede defecation in selected patients not responding to conservative measures and biofeedback. C https://web.pathway.md/diseases/recfTssZTNoahWkPe 3/5 6/29/23, 4:03 AM Fecal incontinence Pathway 6. Therapeutic procedures Biofeedback therapy: As per ASCRS 2023 guidelines, consider offering biofeedback therapy in patients with fecal incontinence. C As per ACG 2021 guidelines, offer biofeedback (pelvic floor rehabilitative techniques with visual or auditory feedback) in patients with fecal incontinence not responding to education and conservative measures. B Perianal injection of bulking agents: As per ASCRS 2023 guidelines, do not offer injections of biocompatible bulking agents into the anal canal routinely for the treatment of fecal Incontinence. D As per ACG 2021 guidelines, consider offering injection of bulking agents such as dextranomer sodium in selected patients with fecal incontinence not responding to conservative measures or biofeedback. C As per ACOG 2019 guidelines, consider offering injection of anal spicter bulking agents as a short-term treatment option to decrease fecal inconinence episodes in female patients with fecal incontinence failed more conservative treatments. C Sacral nerve stimulation: As per ASCRS 2023 guidelines, consider performing sacral neuromodulation as a first-line surgical option in patients with fecal incontinence with or without sphincter defects. C As per ACG 2021 guidelines, offer sacral nerve stimulation in patients with moderate-to- severe fecal incontinence failed conservative measures, biofeedback, and other low-cost, low-risk techniques. B As per ACOG 2019 guidelines, consider offering sacral nerve stimulation as a surgical treatment option in female patients with fecal incontinence with or without anal sphincter disruption failed conservative treatments. C Transanal radiofrequency: do not offer temperature-controlled radiofrequency energy applied to the sphincter complex for the treatment of fecal incontinence. D 7. Surgical interventions Indications for surgery: As per ASCRS 2023 guidelines, consider performing anal sphincteroplasty in patients with a defect in the external anal sphincter, recognizing that clinical results often deteriorate over time. C Show 3 more As per ACG 2021 guidelines: Consider performing anal sphincteroplasty in patients with acute injuries to the anal sphincters. C Consider offering an end stoma surgery in patients with severe fecal incontinence not responding to other treatments. C https://web.pathway.md/diseases/recfTssZTNoahWkPe 4/5 6/29/23, 4:03 AM Fecal incontinence Pathway As per ACOG 2019 guidelines, offer further evaluation and treatment by a healthcare provider with expertise in pelvic surgery in female patients being candidates for surgical therapy (such as patients with rectovaginal fistulas or rectal prolapse) or if not responding to conservative treatments. B Show 2 more References 1. Arnold Wald, Adil E Bharucha, Berkeley Limketkai et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021 Oct 1;116 10 1987 2008. Open 2. Bordeianou, Liliana G M.D., M.P.H. et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2023 Feb 14. Open 3. No authors listed. ACOG Practice Bulletin No. 210 Fecal Incontinence. Obstet Gynecol. 2019 Apr;133 4):e260-e273. Open 4. William E Whitehead, Satish S C Rao, Ann Lowry et al. Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Am J Gastroenterol. 2015 Jan;110 1 138 46; quiz 147. Open 5. Expert Panel on GYN and OB Imaging: Gaurav Khatri, MD, Priyadarshani R. Bhosale et al. American College of Radiology ACR Appropriateness Criteria Pelvic Floor Dysfunction in Females. ACR. 2021. Open 6. Ian M Paquette, Madhulika G Varma, Andreas M Kaiser et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2015 Jul;58 7 623 36. Open 7. Raimund Stein, Guy Bogaert, Hasan S Dogan et al. EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part II operative management. Neurourol Urodyn. 2020 Feb;39 2 498 506. Open 8. J M Jorge, S D Wexner. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993 Jan;36 1 77 97. Open https://web.pathway.md/diseases/recfTssZTNoahWkPe 5/5