Summary
Definition
History and exam
Key diagnostic factors
- obstetric trauma
- presence of other risk factors
- patulous anus
- weak squeeze pressure
Other diagnostic factors
- constipation
- urinary incontinence
- urgency
- passive leakage
- faecal seepage
- perineal scarring
- perianal fistulae
- rectal mass
- rectal prolapse
- abnormal perianal sensation
Risk factors
- female sex
- older age
- nursing home resident
- forceps delivery
- third- or fourth-degree perineal laceration
- episiotomy
- baby >4 kg or delayed second stage of labour
- occipitoposterior presentation
- iatrogenic sphincter injury
- multiple sclerosis/stroke/pudendal neuropathy/spinal injury
- infectious diarrhoea or inflammatory bowel disease
- constipation/impaction
- rectal prolapse
- third-degree haemorrhoids
- congenital abnormalities of the anorectum
- dementia/learning difficulties
- pelvic radiotherapy
- diabetes mellitus
- central neurological disease
Diagnostic investigations
1st investigations to order
- examination plus sigmoidoscopy
Investigations to consider
- anorectal manometry
- endoanal ultrasound
- endoanal MRI
- pudendal motor nerve latency test
- proctography
- stool culture
- rectal biopsy
- FBC
- CRP
Emerging tests
- transvaginal/transperineal ultrasound
Treatment algorithm
symptomatic but cause undetermined
symptomatic with contributing condition
constipation with overflow
spinal cord damage or neurogenic bowel disorder
external sphincter deficiency
internal sphincter dysfunction
intact sphincter complex
severe incontinence refractory to other treatments
Contributors
Authors
Steven Brown, MBChB, BmedSci, FRCS, MD
Consultant Surgeon
Department of Surgery
Sheffield Teaching Hospitals
Sheffield
UK
Disclosures
SB is an author of a reference cited in this topic.
Peer reviewers
Andrew Miller, MD
Consultant Colorectal/General Surgeon
Leicester Royal Infirmary
Leicester
UK
Disclosures
AM declares that he has no competing interests.
Steven Wexner, MD, FACS, FRCS, FRCS Ed, FASCRS, FAC
Chief of Staff
Chairman
Department of Colorectal Surgery
Cleveland Clinic
Weston
FL
Disclosures
SW was a member of the Scientific advisory board, has received honoraria, and is a consultant for GlaxoSmithKline.
David Hackam, MD, PhD
Assistant Professor of Surgery
Children's Hospital of Pittsburgh
Pittsburgh
PA
Disclosures
DH declares that he has no competing interests.
Differentials
- Colorectal cancer
- Cauda equina syndrome
- Crohn's disease
More DifferentialsGuidelines
- Peristeen transanal irrigation system for managing bowel dysfunction
- Prevention and management of obstetric lacerations at vaginal delivery
More GuidelinesPatient leaflets
Faecal incontinence
More Patient leafletsLog in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer