Fecal incontinence in adults

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 2 Apr 2025

Last updated: 24 Aug 2023

Fecal incontinence is often multifactorial with local, anatomic, or systemic disorders potentially contributing.

There is a significant response to conservative therapy and appropriate support.

For those who do not respond to conservative treatment, specialist investigation is recommended to determine underlying etiology.

Surgical options include anterior sphincter repair and neosphincter formation.

Definition

Fecal incontinence is the involuntary passage of flatus or feces. The underlying etiology is often complex with multiple possible contributing factors including anorectal structural abnormalities, neurologic disorders, cognitive or behavioral dysfunction, stool consistency, or general disability (particularly age). Sometimes no cause can be found. It is extremely common, affecting up to 10% of adults, but the true prevalence remains hidden due to the associated stigma.[1][2]

History and exam

Key diagnostic factors

obstetric trauma
patulous anus
weak squeeze pressure

Full details

Other diagnostic factors

constipation
urinary incontinence
urgency
passive leakage
fecal seepage
perineal scarring
perianal fistulae
rectal mass
rectal prolapse
abnormal perianal sensation

Full details

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 labor
occipitoposterior presentation
iatrogenic sphincter injury
multiple sclerosis/stroke/pudendal neuropathy/spinal injury
infectious diarrhea or inflammatory bowel disease
constipation/impaction
rectal prolapse
third-degree hemorrhoids
congenital abnormalities of the anorectum
dementia/learning difficulties
pelvic radiation therapy
diabetes mellitus
central neurologic disease

Full details

Diagnostic tests

1st tests to order

examination plus endoscopy

Full details

Tests to consider

anorectal manometry
endoanal ultrasound
endoanal MRI
pudendal motor nerve latency test
proctography
stool culture
rectal biopsy
CBC
CRP

Full details

Emerging tests

transvaginal/transperineal ultrasound

Treatment algorithm

INITIAL

symptomatic but cause undetermined

symptomatic with contributing condition

ACUTE

constipation with overflow

spinal cord damage or neurogenic bowel disorder

external sphincter deficiency

internal sphincter dysfunction

intact sphincter complex

ONGOING

severe incontinence refractory to other treatments

Contributors

Authors

Steven Brown, MBChB, BmedSci, FRCS, MD

Consultant Surgeon

Department of Surgery

Sheffield Teaching Hospitals

Sheffield

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

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

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

Disclosures

DH declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

National Institute for Health and Care Excellence. Faecal incontinence in adults: management. Jun 2007 [internet publication].Full text

Bordeianou LG, Thorsen AJ, Keller DS, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of fecal incontinence. Diseases of the Colon & Rectum. 2023 May;66(5):647-61.Full text

Arasaradnam RP, Brown S, Forbes A, et al. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut. 2018 Aug;67(8):1380-99.Full text Abstract

Thaha MA, Abukar AA, Thin NN, et al. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev. 2015 Aug 24;(8):CD004464.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Colorectal cancer
- Cauda equina syndrome
- Crohn disease
More Differentials
Guidelines
- Management of fecal incontinence
- Fecal Incontinence
More Guidelines
Patient information
Fecal incontinence
More Patient information
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Fecal incontinence in adults

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

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

Disclosures

Peer reviewers

Andrew Miller, MD

Disclosures

Steven Wexner, MD, FACS, FRCS, FRCS Ed, FASCRS, FAC

Disclosures

David Hackam, MD, PhD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice