Introduction
Besides physiologic investigations and radiology imaging, diagnosis of fecal incontinence requires accurate clinical assessment. By means of a struc- tured scheme, clinical assessment aims to evaluate the whole picture: whether the patient is really incon- tinent, the etiology of the incontinence, and the nature and severity of the problem. Nevertheless, we must keep in mind that when treating an individual patient, these data may not be enough to define the pathophysiology of the symptom and, therefore, we need the investigations we mentioned initially.
The first goal is to determine whether the patient is incontinent. Many patients will not easily admit the symptom. On the one hand, incontinence repre- sents a social stigma and, on the other hand, patients may feel distressed by realizing their physical deteri- oration reaches the point of not being able to main- tain fecal continence. Avoiding the term itself, patients will frequently use other terms, such as diar- rhea, fecal urgency, etc. This was shown in a classical study [1] in which data showed how half of the patients referred with chronic diarrhea actually pre- sented incontinence, and less than half of them pro- vided that information to the doctor.
At the same time, we can find continent patients who seem to be incontinent. Physically handicapped patients may find difficulty in entering the bath- room, sitting on the toilet or device for defecation, or even cleaning themselves properly after defeca- tion. Psychiatric patients may feel an inadequate need to defecate even if they are not incontinent.
Lastly, we must differentiate between incontinence and soiling due to inadequate hygiene or hemor- rhoid prolapse.
Once fecal incontinence has been established, the next step to investigate is the nature of the inconti- nence: passive or stress incontinence. Passive incon- tinence deals with patients who are not aware of the leak of gases or feces, while stress incontinence means the impossibility of stopping the leak of gases or feces even if attempting to do so. It also must be
ascertained what kind of incontinence (gas, liquid, or solid feces) and the frequency of the episodes.
Physical Examination
Assessment must begin with a general examination to investigate possible underlying systemic illness- es that can cause incontinence. Therefore, it should include a neurologic assessment. Anorectal exami- nation must be undertaken in the most comfort- able position for the patient. Different options have been described, but the suitable one is the left lat- eral position, with flexed thighs and knees and with the buttocks slightly out of the limit of the table.
This position usually allows a satisfactory inspec- tion of the perineum. Before the examination starts, it is advisable to inspect the underclothes of the patient to check for soiling and the use of pro- tective pads. Anorectal examination should include inspection, palpation, digital examination, and proctoscopy.
Inspection
Severe incontinence, particularly to liquid feces, can cause erosion and erythema of the perianal skin.
Those lesions, as well as scratching erosions that may accompany them, can present signs of infection, fre- quently due to streptococcus and fungi. In that case, specimen cultures may be taken.
Perineum inspection helps identify scarring from previous trauma, episiotomy, or anal surgery that may indicate the etiology of incontinence. External fistula-in-ano openings or inflammatory areas that can explain the feeling of soiling must also be identi- fied. Multiple external openings lead to the suspicion of inflammatory bowel disease.
It is very important to evaluate the anus by sepa- rating the buttocks and checking whether it remains completely closed or becomes patulous and opens easily. In that case, a low resting pressure can be sus-
Clinical Assessment of the Incontinent Patient
Héctor Ortiz, Mario De Miguel, Miguel A. Ciga
8
pected, suggesting a sphincter gap, occult rectal pro- lapse, or neuropathy (Fig. 1). Anal deformities, such as key-hole anus, frequently caused after posterior sphincterotomy or fistulotomy, prevent the anus from closing properly and can explain the leak of feces and mucus. The patient should be asked to squeeze so the symmetry and quality of closure can be assessed. Asymmetric collapse of the sphincter ring may reveal a unilateral gap in the sphincter as well as bilateral defects in a different area.
The anus and the perineal area should also be evaluated under the Valsalva maneuver. Under these conditions, rectal prolapse with concentric folds will differ from mucosa prolapse that shows radial folds and is rarely responsible for severe incontinence, although it can explain minor mucus leak. This is
also the time to look for third- and fourth-degree hemorrhoids, as well as perineal descent, which is clear when the perineum descends below the level of the ischial tuberosities line. Perineal descent indi- cates weakness of the pelvic floor and is frequently observed in patients with neuropathic fecal inconti- nence. Sometimes, the patient’s straining permits the observer to see the leak of gas or feces. This maneu- ver is enhanced by asking the patient to sit in special devices that simulate a toilet and that include a mir- ror in its inferior plane, allowing a better view of the investigated area with less discomfort for the patient (Fig. 2).
When examining women, the vagina must also be evaluated. Presence of feces in the vagina suggests anovaginal or rectovaginal fistula probably due to obstetric trauma. When large rectoceles are found, it will be observed whether the posterior vaginal wall reaches the vaginal opening during straining.
Palpation
Palpation allows evaluation of sensibility of the peri- anal area as well as the anal cutaneous reflex. The loss of sensibility in the perianal area suggests a denerva- tion lesion, although it can also be the consequence of surgery. The anal cutaneous reflex (or “wink”
reflex) is triggered by stroking the perianal skin (Fig. 3).
If present, a sphincter contraction will be observed after stimulation. This spinal reflex finds its afferent and efferent tracts in the pudendal nerves. Its loss suggests pudendal injury.
Fig. 1.Patulous anus in a patient with previous anal surgery and neuropathy
Fig. 2.Special device that simulates a toilet and that includes a mirror in its inferior plane, allowing a better view of the anal and perianal area
Fig. 3. Anal cutaneous reflex is triggered by stroking the perianal skin. If reflex is present, a sphincter contraction will be observed after stimulation
Digital Examination
When palpating the anal canal in its entire length and circumference, gaps can be observed indicating the presence of sphincter defects. However, the absence of these gaps does not exclude the presence of sphincter defects. Digital examination permits evalu- ation of the sphincter tone at rest and during squeeze. The positive predictive value of this exami- nation to detect low pressure at rest or during con- traction is high [2]. In any case, the perceived tone by digital examination must be considered only as a first approach because it is dependent on multiple factors, including the surgeon’s experience, finger measure- ment of the observer, patient position and coopera- tion, and coexistence of other illness. As an example, neurologic diseases, even after spinal or cauda equina injuries, may present with an apparently nor- mal sphincter tone, while radial traction at the anal margin or separating the buttocks may show an anal
“wink” that normal individuals would not present [3]. Therefore, the assessment of sphincter pressure should rely on anorectal manometry, although this test also has some disadvantages [4].
Digital examination can also evaluate the anal canal length, the integrity of the puborectalis sling, or the anorectal angle by curving the finger above the posterior puborectalis sling at the level of the anorec- tal junction. Elevation of pelvic floor and perineum can be determined by requesting the patient to pro- vide a voluntary contraction.
The anal canal is most often empty of feces. Find- ing fecal bolus after digital examination suggests overflow incontinence, which is usually seen in elder- ly patients or in patients who present a megarectum.
Fecal bolus is the most frequent cause of inconti- nence in the elderly. Nevertheless, in up to 30% of elderly patients who present with large quantity of stool in the upper rectum and sigmoid colon–seen by radiological imaging-feces will not descend to the low rectum and, thus, will not be detected by digital examination [5].
Bimanual examination of the rectovaginal septum helps evaluate the thickness and integrity of the per- ineal body. This structure is usually involved in obstetric injuries. The Valsalva maneuver during
bimanual examination will help detect intussuscep- tion, rectocele, cystocele, and enterocele.
Endoscopy
Endoluminal examination is needed to evaluate the lumen and mucosa of the rectum and distal colon and to exclude problems such as proctitis, cancer, and benign secretor tumors, such as villous adeno- mas, solitary rectal ulcer, or inflammatory bowel dis- ease. It is not necessary to perform a full examination of the colon unless incontinence coexists with diar- rhea.
Severity Scores
As opposed to other diseases in which it is possible to establish severity scores from clinical investigation, laboratory tests, or radiology imaging-assessment of severity for incontinent patients depends on the information the patient provides. The aim of severity scores is two fold: they help determine symptom severity and allow comparison of results of the dif- ferent available treatments. Even if the International Foundation for Functional Gastrointestinal Disor- ders [6] and the American College of Gastroenterolo- gy [7] recommend the use of severity scores, their clinical usefulness has not been demonstrated apart for research purposes.
Two kinds of scores have been proposed to assess severity for incontinence: grading scales and summa- ry scales. Grading scales determine severity by assigning sequential punctuation to incontinent syn- dromes depending on the type of rectal content the patient is incontinent to, and by considering inconti- nence to gas; the least important is the latter, and incontinence to solid feces the most important. The most popular grading scale is the Browning and Parks [8] scale (Table 1). This particular score assumes that the more consistent the leaked material is, the greater the damage that can be expected in the sphincter structures. This is the reason that leakage of solid feces is considered more severe than leakage of gas. However, assessment of incontinence severity provided by physicians seems not to be coincident
Table 1.Browing and Parks Scale
Category 1 Category 2 Category 3 Category 4
Normal Difficult control of flatus & No control of No control of solid
diarrhea diarrhea stool
with patients’ perceptions [9]. Besides, grading scales have the disadvantage of not taking into considera- tion the frequency of leakage episodes. These scales are not subtle enough to discriminate among minor differences in incontinence severity and, therefore, to assess slight changes in continence achieved after treatment, which can be of clinical interest. However, grading scales are still used indirectly in studies that review long-term results of incontinence surgery, as such scales assess the kind of rectal content to which the patient is incontinent [10]. Summary scales take into consideration the kind of content and frequency of leakage. Ten scales that consider only clinical data have been proposed. Among them, the Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS) [11] and those by Pescatori et al. [12], Rockwood et al. [9], and Vaizey et al. [13] have gained greater acceptance. These scales share more similarities than differences. However, the main differences concern the evaluation of quality of life items [11, 13], consid- eration of constipating treatment, the definition of urgency as the impossibility to defer defecation more than 15 min [13], the fact that it is the patient who
punctuates himself or herself [9], and the fact that only the frequency of the most severe type of incon- tinence is weighted [12]. Even if the scales that use ordinal values seem more perfect, their design pres- ents some weaknesses:
– None of these scales take into consideration defe- cation frequency, and therefore, in patients with low defecation frequency, incontinence can be underestimated.
– Considering quality of life items may induce errors in the assessment of incontinence severity, as quality of life can depend on the patient’s situa- tion totally unrelated to incontinence.
– Considering the use of pads is an error factor, as patients can wear them continuously to prevent soiling in case of leakage, even if leakage is actual- ly not occurring frequently.
– The difference between liquid and solid leakage has not been validated as a factor influencing severity of incontinence.
– The difference between scales where point assign- ment is made by the physician and those where it is made by the patient has not been assessed. Dis- Table 2.Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS)
Frequency
Type of incontinence Never Rarely Sometimes Usually Always
Solid 0 1 2 3 4
Liquid 0 1 2 3 4
Gas 0 1 2 3 4
Wears pads 0 1 2 3 4
Lifestyle alteration 0 1 2 3 4
Never 0, Rarely <1 month, Sometimes <1 week to ⱖ1 month, Usually <1 day to ⱖ1 week, Always ⱖ1 day
Table 3.Vaizey Score: the need to wear a pad or plug, taking constipating medicines, and lack of ability to defer defecation for 15 min
Frequency
Type of incontinence Never Rarely Sometimes Weekly Daily
Incontinence for solid stool 0 1 2 3 4
Incontinence for liquid stool 0 1 2 3 4
Incontinence for gas 0 1 2 3 4
Alteration in lifestyle 0 1 2 3 4
Need to wear a pad or plug 0 2
Taking constipating medicines 0 2
Lack of ability to defer 0 4
defecation for 15 min
Never no episodes in the past 4 weeks, Rarely 1 episode in the past 4 weeks, Sometimes >1 episode in the past 4 weeks but <1 a week, Weekly 1 or more episodes a week but <1 a day, Daily 1 or more episodes a day
tress caused by incontinence can only be reported subjectively, and therefore, it would seem sensible that the patient assign the points. However, this same reason can become a weakness. As refined as the scales can be, they will always be dependent on what the patient reports.
– The attitude of the patient toward incontinence can also alter punctuation if the completely incon- tinent patient avoids moving far from the toilet.
Another controversial issue concerning the use of scoring systems is the method of data collection.
Questionnaires fulfilled in the office and defecation diaries given to the patient can be used. In the first instance, collection depends on the patient’s memo- ry. Concerning the usefulness of the second method, which at first seems more consistent, it can be argued that studies evaluating similar diaries for pain [14]
show how most patients keep the information with- out reporting at least for 1 day. In that case, informa- tion would not be of better quality than that obtained by questionnaires.
It is difficult to say that summary scales are better than grading scales, because studies evaluating relia- bility and validity of severity scores are scarce [13].
Finally, the most popular scale is the CCF-FIS [11]
(Table 2). However, if assessment of urgency is con- sidered important, then the most suitable scale is that by Vaizey et al. [13] (Table 3). It is also interesting to note that population studies that evaluate the use of scores show how they are rarely used except in refer- ral centers [15].
References
1. Leigh RJ, Turnberg LA (1982) Faecal incontinence: the unvoiced symptom. Lancet 1(8285):1349–1351
2. Hill J, Corson RJ, Brandon H et al (1994) History and examination in the assessment of patients with idio- pathic fecal incontinence. Dis Colon Rectum 37:473–477 3. Hardcastle JD, Porter NH (1969) Anal continence. In:
Morson BC, ed. Diseases of the colon, rectum and anus. Appleton-Century-Crofts, New York, p 251 4. Eckhardt VF, Kanzler G (1993) How reliable is digital
examination for the evaluation of anal sphincter tone?
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5. Smith RG, Lewis S (1990) The relationship between digital rectal examination and abdominal radiographs in elderly patients. Age Ageing 19:142–143
6. Norton NJ (2004) The perspective of the patient. Gas- troenterology 126:S175–S179
7. Rao SSC (2004) Diagnosis and management of fecal incontinence. Practice guidelines. Am J Gastroenterol 99:1585–1604
8. Browning G, Parks A (1983) Postanal repair for neuro- pathic faecal incontinence: correlation of clinical results and anal canal pressures. Br J Surg 70:101–104 9. Rockwood TH, Church JM, Fleshman JW et al (1999)
Patient and surgeon ranking of the severity of symp- toms associated with fecal incontinence. The Fecal Incontinence Severity Index. Dis Colon Rectum 42:1525–1532
10. Bravo A, Madoff RD, Lovry AC et al (2004) Long-term results of anterior sphincteroplasty. Dis Colon Rectum 47:727–732
11. Jorge JMN, Wexner SD (1993) Etiology and manage- ment of fecal incontinence. Dis Colon Rectum 36:77–97 12. Pescatori M, Anastasio G, Botíni C et al (1992) New grading system and scoring for anal incontinence.
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13. Vaizey CJ, Carapeti E, Cahill JA, Kamm MA (1999) Prospective comparison of faecal incontinence grad- ing systems. Gut 44:77–80
14. Stone AA, Shiffman S, Schwartz JE et al (2002) Patient non-compliance with paper diaries. BMJ 324:1193–1194 15. Dobben AC, Terra MP, Deutekom M et al (2005) Diag- nostic work-up for faecal incontinence in daily clinical practice in the Netherlands. Neth J Med 63:265–269
