Fecal Incontinence - Essay Example

Fecal Incontinence: A Research Proposal on Diagnosis and Management Introduction The anorectum is the caudal end of the gastrointestinal tract, and is responsible for fecal continence and defecation. In humans, defecation is a viscerosomatic reflex that is often preceded by several attempts to preserve continence. Continence has been defined as the ability to retain a bodily discharge voluntarily. Fecal incontinence (FI) is a frequent, distressing condition that has a devastating impact on patients' lives. However, patients are typically embarrassed and reluctant to acknowledge this disability, so they relinquish the possibility of being cured and remain socially isolated. They become housebound and prefer to pass the day very close to the toilet to avoid losing feces. The exact incidence of FI is uncertain because of patients' hesitation to seek help from their physicians. Women seem to be at higher risk, mostly due to obstetric damage to the anal sphincters; however, during the last decade, an increasing interest has been dedicated to those forms of FI related to nontraumatic factors, which reach a relevant incidence (Bharucha, 2003). Older subjects are at very high risk, especially those with disabilities and those who are institutionalized. Moreover, young people are often affected. These factors create a significant economic impact for society, not only due to direct and indirect costs, but also due to intangible costs. FI may result from a variety of pathophysiological situations, and various risk factors can cause a wide range of inability to control feces passage. Therefore, an accurate diagnostic workup of each patient is fundamental. Although not fully agreed upon by all physicians, a multimodal diagnosis, using a multiparametric evaluation, seems to allow the most thorough understanding of FI pathophysiology and to indicate optimal treatment. These are really the most important and challenging aspects of FI management. Indeed, a wide range of therapeutic options is available, including conservative, rehabilitative, and surgical procedures. Highly variable rates of defecatory dysfunction and fecal incontinence have been reported, which most likely reflects the heterogeneity of the populations studied, the use of non-standardized questionnaires, a variety of definitions in terms of frequency of defecation or fecal loss, and patient reluctance to disclose these potentially embarrassing problems. Aging has been consistently identified as a major risk factor for the development of fecal incontinence, and the prevalence has been reported to approach 50% in nursing home residents (Cook and Mortensen 2002). A recent study of more than 3,000 community-dwelling women found a population-adjusted prevalence of 7.7% when fecal incontinence was defined as loss of liquid or solid stool at least monthly. The prevalence of fecal incontinence increased linearly with age (Melville et al., 2005). Many patients are reluctant to seek medical attention for bowel disorders because of embarrassment and social stigma. Primary care providers, including obstetricians and gynecologists, are therefore integral to the successful disclosure of such problems by routinely inquiring about bowel function during periodic health care visits. The Research Problem The problem with fecal incontinence is that it often goes undiagnosed and untreated in elderly patients mainly due to the social stigma attached to it. Not only are the patients reluctant to admit the problem, the physicians often fail to ask about the problem due to similar embarrassment that the patients feel or due to the fact that they think the problem to be insignificant. In the older age groups this is particularly significant since it is common in them. Large population surveys have revealed that above age 65, the prevalence is 3% to 7%. Many elderly people are forced to get admitted into nursing homes due to this problem so much so that the prevalence is as high as 50% (Perry et al., 2002). As highlighted by Bharucha et al. (2005), the financial impact on families, patients, and the healthcare system is enormous. It not only speaks about the cost of management, fecal incontinence has been acknowledged to be one of the most common causes of the institutionalization with severe and devastating psychosocial impacts that may range from mild embarrassment and nuisance to significant alterations in lifestyle leading even to social isolation eventually intensifying the baseline depression and cognitive impairment in the elderly. This contrasts with the feasibility of effective treatment of this condition provided it is diagnosed. Thus the two pillars of this condition remain the diagnosis and the management. Even today, only a third of patients suffering with the condition discuss it with their physicians. This is particularly unfortunate, as the condition affects a significant portion of the population and is a significant burden to patients, their families, and society. This situation exists for a number of reasons. The social stigma of incontinence of stool is the primary reason. Early on, children are taught to avoid "bathroom talk", and that admonishment continues into adulthood. However, there are other reasons as well. Continence of flatus and stool is an extremely complex process involving feces consistency and transit time, the sensory capability of the rectum, and the neurological and muscular function of the sphincter muscle. Despite years of research on the pathophysiology, it is hard to explain how a patient with an intact sphincter has daily episodes of incontinence (Bharucha et al., 2005). The etiologies of fecal incontinence are many. It is helpful to divide the etiologies between those that start outside or above the pelvis versus those within the pelvis. In many cases, patients will have several abnormalities that lead to fecal incontinence, such as diarrhea-predominant IBS and a chronic third-degree laceration. The etiologies outside the pelvis include all the pathologies that cause diarrhea or increased intestinal motility. Neurologic conditions such as multiple sclerosis, diabetic neuropathy, trauma, or neoplasms in the spinal cord or cauda equina initially begin as pathologies outside the pelvis, and the pelvic floor is presumed normal. As these neuropathies progress, the pelvic floor muscular function or rectal sensation may become impaired, resulting in fecal incontinence. On the contrary, functional fecal incontinence may result from fecal impaction, diarrhea, or nonstructural anal sphincter dysfunction, and it has been defined as recurrent uncontrolled passage of fecal material for >1 month, in an individual with a developmental age of at least 4 years (Lau and Caty 2006). Focus Question From this, it is evident that there are several questions regarding fecal incontinence which remain answered yet, and they cover vast areas of the topic, mainly the diagnosis and management. For this assignment, this author would focus on the following questions 1. What is the true nature of the pathophysiology of fecal incontinence as reflected in the literature 2. As indicated in the literature, what are the current updates on its diagnosis based on current pathophysiologic revelations 3. Based on the newer diagnostic insights, are there any management modalities that can treat fecal incontinence in a better and more effective manner Rationale to Continue the Research There are very few topics in the field of coloproctology like faecal incontinence for which such an impressive progress in understanding pathophysiology and treatment has been achieved in recent years. Significant changing attitudes of outstanding researchers all over the world towards modern treatment of the disorder is the main derivative of the current literature. Whereas a few years ago aggressive surgical treatment was advised not only for patients with proven postobstetric or traumatic sphincter defects but also for neurogenic faecal incontinence, today,more conservative measures are indicated as a consequence of the very good results reported with advanced rehabilitation techniques and sacral neuromodulation. It is becoming clear that the promising results first enthusiastically reported after complex surgical operations such as sphincteroplasty, dynamic graciloplasty or artificial bowel sphincters inevitably deteriorate with longer follow-up. This is not unusual whenever surgery is applied to "functional" disorders. On the other hand, appropriate surgery with skilled operative technique still has an important role in the management of specific conditions. Making the correct choice is pivotal to the successful management of this condition. Although a number of reports are available regarding results of different surgical procedures, the lack of sufficient evidence from randomized controlled studies makes choosing the type of surgery very difficult (Cotterill et al., 2008). This has been confirmed in the very recent Cochrane Review. All randomized or quasirandomized trials of surgery in the management of adult FI, other than surgery for rectal prolapse were analyzed, and nine trials were selected with a total sample size of 264 participants. Brown et al. (2007) concluded "it was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies" (Brown and Nelson, 2007). Ideally, a few written questions should be part of the standard office intake questionnaire. Several reports have shown that twice the number of patients complain of fecal or flatal incontinence when given written questionnaires than when answering verbal questions. If an affirmative response if obtained, then further quantification of the problem is obviously required. The Wexner fecal incontinence scale is a quick and simple questionnaire that has been validated to track changes in symptoms and is a useful tool to assess and track patient progress. A review of literature suggests that there are many routes to becoming a patient with faecal incontinence (FI), many aetiologies of the disorder, and many personal histories. The "meaning" of the FI will be different for each patient, and his or her way of managing it will depend not only on aetiology but also on a number of personal, social and medical factors. On the whole, this is an important area of study since the implications of this problem are far reaching. People with FI have been found to live in a restricted world, often describing it as being similar to imprisonment. The limits to their world are often dictated by access to toilets, the need to carry a change of clothing with them at all times, and attempts to conceal the problem from family and friends alike. The initial moments in the assessment may involve understanding something of the FI-its origins, its aetiology and the impact on the various spheres of the patient's life (Norton 2004). Following the assessment, management strategies can be devised. This depends not only on the patient's psychological state but also on the availability of treatments in each particular case. Research Hypothesis Based on research and literature, this author believes that a conservative approach involving a total bowel management program can be the most suitable management modality for fecal incontinence management. This proposal will also review the available research to determine the incidence, prevalence, causes, diagnostic modalities, and management strategies for fecal incontinence. Therefore, this proposal will attempt to answer the following main and sub-questions. Research Questions 1. Epidemiologically, what are the incidence and prevalence of fecal incontinence 2. What are the causes of fecal incontinence 3. How best fecal incontinence can be diagnosed 4. What are the management modalities of fecal incontinence 5. What are the medical managements of fecal incontinence 6. What are the adverse effects of therapeutic agents 7. How do the patients handle fecal incontinence 8. What are the expected outcomes of the treatment regimens Of these questions, questions 1, 2, 3, 4 are main questions, and questions 5, 6, 7, and 8 are the sub-questions. Significance of the Problem Given the psychological, social, and functional impacts that fecal incontinence (FI) has on an individual, the assessment of health-related quality of life (HRQoL) is an important consideration when evaluating the efficacy of treatment. An individual with FI faces a serious set of challenges in living life, and as a result, providers are also faced with consideration of these issues in providing treatment (Wilson 2007). Besides physiologic investigations and radiology imaging, diagnosis of fecal incontinence requires accurate clinical assessment. By means of a structured scheme, clinical assessment aims to evaluate the whole picture: whether the patient is really incontinent, the etiology of the incontinence, and the nature and severity of the problem. One must keep in mind that when treating an individual patient, these data may not be enough to define the pathophysiology of the symptom. Once fecal incontinence has been established, the next step to investigate is the nature of the incontinence: passive or stress incontinence. Passive incontinence 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. Fecal incontinence is a consequence of functional disturbances in the mechanisms that regulate continence and defecation. In addition to normal anorectal function, there are other factors that preserve continence. These include normal stool consistency, intact mental faculties, and adequate physical mobility. All these must be kept in mind while designing the management strategy in such patients (Bharucha et al., 2004). Research Design Fecal incontinence is a multifactorial problem, where apart from organic and anatomical malfunctions, other salient factors are involved in the etiopathologic mechanism. This also includes the functional aspects, where patients' descriptions about their experiences occupy a major area. Traditionally interview or structured questionnaire has been used to determine the very existence of this disorder. This points to the need of a qualitative research design to emulate the factors and answer the questions enumerated above. Naturalistic methods of inquiry attempt to deal with the issue of human complexity by exploring it directly. Researchers in the naturalistic tradition emphasize the inherent complexity of humans, their ability to shape and create their own experiences, and the idea that truth is a composite of realities. Consequently, naturalistic investigations place a heavy emphasis on understanding the human experience as it is lived, usually through the careful collection and analysis of qualitative materials that are narrative and subjective. Therefore, in this proposed design, the collection of information and its analysis will occur in the natural setting to result in rich in-depth information that has the potential to elucidate varied dimensions of a complicated phenomenon, namely, fecal incontinence. This would have another benefit. The findings can be communicated at ease to the lay people so the findings can be incorporated in to the healthcare concerning fecal incontinence. Naturally, human beings suffering from this problem will be directly used as instruments. In qualitative studies, the tasks of sampling, data collection, data analysis, and interpretation typically take place iteratively. Qualitative researchers begin by talking with or observing a few people who have first-hand experience with the phenomenon under study. The discussions and observations are loosely structured, allowing for the expression of a full range of beliefs, feelings, and behaviors. Analysis and interpretation are ongoing, concurrent activities that guide choices about the kinds of people to sample next and the types of questions to ask or observations to make. The actual process of data analysis involves clustering together related types of narrative information into a coherent scheme. As analysis and interpretation progress, researchers begin to identify themes and categories, which are used to build a rich description or theory of the phenomenon. Therefore, in this study, data in detail will be gathered through open-ended questions that can provide direct quotations, which will be analyzed thematically to classify them into themes. This proposal also contains that this will be a nonstatistical method of inquiry and analysis of the social phenomenon surrounding fecal incontinence. The samples therefore will be small and purposive in that through an inductive process, themes and categories of findings will emerge. Specific issues and problems related to fecal incontinence as guided by the research questions will as expected emerge through the perspectives of the participants (Polit and Beck 2005). Organization of the Study In chapter 2, a critical review of literature will be presented in order to establish the baseline knowledge and to identify the gap in the current knowledge. Comprehensive knowledge on the topic of fecal incontinence will be gathered from the research literature, so the need of pursuing the research is definitively established. In chapter 3, the problem of fecal incontinence will be talked about. This chapter will focus on the focus questions based on the problem of fecal incontinence. In chapter 4, based on the research questions, the tools to investigate them will be discussed. This would actually provide the different tools such as indexes, abstracts, internet, research literature, and text books will be dealt with. In chapter 5, the fecal incontinence project will be discussed, and the planning will be elaborated and evaluated so the intervention program is effective. This will also look forward to finding and segregating different information in order to formulate the plan. Chapter 6 will be all about writing the proposal and the different steps of writing it. This would also hint towards writing a timeline. Literature Review Search Strategy Two recent reviews provide perspective on the prevalence of faecal incontinence. Matibag et al. (2003) suggest a range of 1%-11% in population-based studies and 4%-50% in other, mainly clinic-based studies (Matibag et al. 2003). Harrari (2002) suggests a range of 2%-18% in the community as distinct from 13%-54% in long-term care (Harrari 2002). The issues raised by these and other reviews (Tariq et al. 2003) include a lack of definition of concepts and indicators, inconsistent age and gender relationships, lack of information on social groups and differences in health-related risk factors identified. The search strategy included electronic search of Medline and Embase for English language papers concerning 'faecal incontinence'. Separate searches were carried out for 'prevalence' and 'risk factors', 'correlates' or 'predictors'. Exclusion criteria for prevalence studies were: non-population-based; response rate of less than 60%; data collection from third parties; and lack of definition of faecal incontinence as a whole and as distinct from anal incontinence. Studies concerning risk factors were excluded if they concerned selected groups such as clinical series and long-term care, local conditions affecting the pelvic floor such as obstetric factors and cancer, or children. All eligible studies were methodologically evaluated for potential biases. Information on prevalence and risk correspond to levels of evidence II-3 and II-2, respectively. For the purposes of this review, faecal incontinence (FI) was conceptualized as involuntary leakage of liquid or solid from the bowel, and severity as frequency volume (Kalantar et al. 2002). Reported definitions were rated into thresholds of minor, moderate or major incontinence based on the implicit and explicit severity of the wording. Descriptors such as 'leakage' and 'staining' were rated as similar and less severe than 'difficulty in control' and 'soiling'. This approach was based on experience with piloting and interviewing in a variety of population groups using such terms (Lam et al., 1999). Anatomical Considerations Recent imaging utilizing direct coronal and sagittal images, as well as reconstructed axial anatomical images, has largely clarified the disposition of the sphincters in humans and the relevant gender differences. Despite these studies, there is no uniform consensus regarding their anatomic nomenclature. Recent attempts to incorporate matched images obtained by three-dimensional (3D) reconstructions of the anal canal with attendant level-orientated physiologic readings, where morphologically demonstrable and separable recognizable muscle groups have been equated with resting and squeeze contributions to recorded pressures, have provided results that are somewhat contradictory to manometric reports, particularly in what is represented by the anal high-pressure zone (Gold et al., 1999). Historically, there have been many conflicting anatomical reports of the internal anal sphincter and its relationship to the external anal sphincter. Prior to 1950, it was believed that the internal anal sphincter was the main contributing influence to resting continence, although subsequently it had been suggested that preservation of the external anal sphincter was critical in the maintenance of overall continence (Ihre, 1974). The anal canal is surrounded by the internal and external anal sphincters. The internal sphincter is a thickened extension of the circular smooth muscle layer surrounding the colon that contains discrete muscle bundles separated by large septa. In the rectum, the interstitial cells of Cajal (ICC) are organized in dense networks along the submucosal and myenteric borders. In the internal anal sphincter, the ICCs are located along the periphery of the muscle bundles within the circular layer. The external sphincter is composed of superficial, subcutaneous, and deep portions; the deep portion blends with the puborectalis. In men, this trilaminar pattern is preserved around the sphincter circumference. In contrast, the anterior portion of the external sphincter in women is a single muscle bundle. External sphincter fibers are circumferentially oriented, very small, and separated by profuse connective tissue. The internal sphincter is primarily responsible for ensuring that the anal canal is closed at rest. The other contributors to anal resting tone include the external anal sphincter, the anal mucosal folds, and the puborectalis muscle. Penninckx et al. (2004) estimated that anal resting tone was generated by nerve-induced activity in the internal sphincter (45% of anal resting tone), myogenic tone in the internal sphincter (10%), the external sphincter (35%), and the anal hemorrhoidal plexus (15%). These figures should be regarded as estimates, because they were obtained, in part, from complex studies in which anal resting pressure was sequentially recorded before surgery, after curarization, and in the resected specimen before and after verapamil. Moreover, the relative contributions of these factors to anal resting tone are influenced by several factors, including the size of the probe and the location at which pressure was measured (Penninckx et al., 2004). Frenckner and Ihre investigated the contribution of myogenic tone and the extrinsic, that is, sympathetic and parasympathetic nerves to anal resting tone by assessing anal pressure at rest and in response to rectal distention under baseline conditions after low spinal anesthesia (L5-S1), and after high spinal anesthesia (T6-T12). A separate study assessed anal pressures before and after pudendal nerve blockade. The decline in anal resting pressure was significantly greater after high (323.2 mm Hg) than low (117.1 mm Hg) anesthesia or after pudendal nerve blockade (103.9 mmHg), suggesting there is a tonic excitatory sympathetic discharge to the internal anal sphincter in humans (Frenckner and Ihre 1976). Incidence A total of 15 eligible population-based studies were identified. These 15 studies provided 21 prevalence estimates for individual thresholds. The overall range of prevalence was 0.7%-13.1% for adults of various ages. Full ranges for specific thresholds were: minor, 6.2%-13.1%; moderate, 2.8%-10%; and major, 0.7%-3.8%. Overall, there was good correlation between threshold rating and prevalence. There was evidence of correlation with age within the major threshold, but no suggestion of any correlation with either place or time of reporting studies. Among those studies that considered age, all described some degree of increase in prevalence with age. All but one study (Roberts et al. 1999) showed a continuing increase with advancing age. The increase was present to a slightly greater extent for women compared to men. Some apparent decline in prevalence in extreme old age was reported (Talley et al. 1992), but the estimate was based on very small numbers. Among studies that considered gender, the overall range of female : male ratios was 0.36-4.0. In the majority (85%) of studies, the range was considerably narrower, 0.73-1.43, and consistent with no difference between the two. Other than sampling error, there was no clear explanation for the variation. Taking into account issues of sample size and type, it seems likely that the prevalence in elderly women exceeds that in men slightly in the total population (Talley et al., 1992) FI has an understandably profound impact on a patient's quality of life, leading to major social and psychologic impact in many cases. As a stigmatized condition, it leads to embarrassment and shame, often combined with reluctance to admit the problem and present for help from health care professionals. Some people lack a vocabulary with which to explain their symptoms, or assume that FI is an inevitable consequence of childbirth, diarrheal disease, or anal surgery. The impact seems to be very individual, and some cope well, but others live in fear of being caught out in public and map all activities around the likely availability of easy access to toilet facilities. Increasing recognition of the importance of the patient perspective and impact on quality of life has led to recent efforts to develop standardized and validated tools to add this dimension to outcome measures for FI, in addition to the somewhat simplistic ''scores'' that presume that number of episodes equate to ''severity''. Those patients with the most severe symptoms and impact on quality of life are the most likely to seek help (Norton 2004). FI is a symptom arising from diverse etiologies, which often coexist in the same individual. Typically, patients complain of urgency and urge incontinence, often indicating external sphincter weakness or damage, or passive soiling secondary to internal anal sphincter disruption or atrophy. Both symptoms can be present in the same individual. Stool consistency, bowel motility, sensation, completeness of evacuation, and physical or mental abilities for self-care may each have an impact. It is this multiple pathology that often enables FI symptoms to be reversed by conservative means. Even in patients with sphincter trauma, there may well be an element of residual function that can be improved, or other factors, such as stool consistency, toilet habit, complete evacuation, psychologic coping, and toilet access, can be optimized. In practice, although sphincter damage is commonly found when these patients are imaged, careful history often reveals that the patient has not been symptomatic continuously following the trauma incident. Other factors have contributed to symptom development, and these can be modified (Maeda et al., 2008). The internal anal sphincter is responsible for maintaining approximately 70% of the resting anal tone, and this is largely due to tonic sympathetic excitation. The external anal sphincter, which is mostly made up of striated muscle, contributes to the remaining component of the resting tone. The external anal sphincter, the puborectalis, and the levator ani contract further when necessary to preserve continence but relax nearly completely during evacuation. External sphincter contraction may be voluntary or reflexive. Anal resting and/or squeeze pressures are generally reduced in patients with fecal incontinence, suggesting sphincter weakness. Inward traction exerted by the puborectalis is reduced in fecal incontinence and is correlated more closely with symptoms than with squeeze pressures, and improves after biofeedback. Fecal incontinence occurs when one or more mechanisms that maintain continence are disrupted to an extent that another mechanism(s) is unable to compensate. Thus the cause of fecal incontinence is often multifactorial. In a prospective study, 80% of patients had more than one pathogenic abnormality (Wald 2007). While interviewing a patient, both from the medical or social points of views, the literature has revealed that there are certain important parameters that need to be elucidated. These are, onset and precipitating event(s); duration, severity, and timing; stool consistency and urgency; coexisting problems/surgery/urinary incontinence/back injury; obstetrical history such as forceps delivery, tears, breech presentation, repair; history of drugs, such as, caffeine; diet; clinical subtypes: passive or urge incontinence or fecal seepage; clinical grading of severity; and history of fecal impaction. The precise role of obstetric trauma and fecal incontinence is unclear, although a clinically overt anal tear occurred in approximately 3.3% of women after vaginal delivery. Endoanal ultrasound identified anal sphincter defects in 35% of women after their first vaginal delivery. Other important risk factors include forceps delivery, prolonged second stage of labor, large birth weight, and occipitoposterior presentation. Perineal tears, even when carefully repaired, can be associated with incontinence, and patients may present with incontinence either immediately following delivery or several years later. Clinical evaluation, along with the formulation of a diagnostic strategy is essential in for establishing an accurate diagnosis. Many patients who suffer with fecal incontinence inadvertently refer to this condition as "diarrhea" or "urgency." Thus, the very first step is to establish a rapport with the patient and carefully inquire about the presence of fecal incontinence. Also, it is important to identify whether the patient has passive or urge incontinence or fecal seepage and to grade its severity based on a prospective stool diary. This in combination with physiological testing and imaging will help to determine the underlying pathophysiology and facilitate optimal treatment (Engel et al., 1995) Because FI is a symptom of multiple etiologies, it is highly unlikely that the same treatment suits all patients. For this reason, careful assessment of history, symptoms, and contributing factors is mandatory as is a basic physical assessment including anal, abdominal, and rectal examination. Various investigations are commonly used, including manometry, electrophysiologic tests to assess reflexes and sensory function, and imaging of the sphincters using anal ultrasound or MRI. There is almost no evidence that the results of these tests change management or influence patient outcomes, however, and expert opinion suggests that evaluation of FI does not necessarily include manometry and imaging in the first instance for all patients. As suggested in literature, a step-wise approach to patients would be prudent except in acute cases. Patients should normally have a targeted history and physical examination and then consideration of a range of conservative options, which can be combined according to individual need (Norton 2008). Medical management without any exercises or biofeedback has been found to improve symptoms in one third to one half of patients. The treatment of fecal incontinence includes medications, biofeedback, electrical stimulation, and surgery. In every patient, regardless of the integrity of the sphincter complex, maintaining normal stool consistency and frequency is the first step in management. The goal for every patient is to have a predictable bowel movement every morning that is the size of a six-inch log and of moderately firm consistency. Soft, mushy stools can be very difficult for patients to control and evacuate completely, a problem that leads to constant seepage and the inability to ever wipe clean. If patients are having several bowel movements throughout the day, this implies rapid colonic motility or an enhanced gastrocolic reflex, both of which can create symptoms of fecal urgency and incontinence. The successful evacuation of a formed, bulked stool every morning can be achieved by taking a fiber supplement at night such as methylcellulose or psyllium. High-fiber cereals and a hot beverage for breakfast the next morning will usually prompt the gastrocolic reflex, and before leaving the comfortable home environment, patients will typically experience a defecatory urge (Bliss et al., 2005). Conclusion Fecal continence is maintained in healthy individuals by various physiological factors, and disruption of these factors may result in fecal incontinence. Fecal incontinence is often multifactorial, and a systematic approach is required to make a correct diagnosis. This includes a thorough history, physical examination, selective laboratory testing, endoscopy, and specific physiological testing. These specific tests are often complementary, and the diagnostic information obtained can influence the management and outcome of patients with fecal incontinence. Meanwhile, there can be little doubt that conservative interventions improve many patients with FI to the point where most report satisfaction with treatment and do not wish to consider more invasive options, such as surgery. Reference List Bharucha AE (2003) Fecal Iincontinence. Gastroenterology 124(6):1672-1685 Bharucha AE, Locke GR, Seide BM, et al. (2004). A new questionnaire for constipation and faecal incontinence. Aliment Pharmacol Ther;20:355-64. Bharucha AE, Zinsmeister AR, Locke GR, et al. (2005). 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