Evaluating a 72-year-old woman with faecal incontinence for one year

Faecal incontinence (Rome IV) means repeated, uncontrolled loss of faecal material over at least 3 months, so one year qualifies; mucus or flatus alone does not count. Prevalence reaches 16% at 70 years or older.

Shame delays disclosure, so ask directly and sensitively; she may present instead with abdominal pain, perianal itching or skin irritation.

Type: urgency (feels stool, cannot hold it), passive (leaks unknowingly) or seepage after normal bowel movements. Passive leakage points to the internal sphincter and urgency to the external.

Pattern: frequency, stool consistency and volume, day or night, triggers. Severity: the Wexner score is most used but ignores urgency; St Mark's (Vaizey) adds urgency and constipating drugs.

Bowel habit: is diarrhoea or constipation with overflow the real cause? In one tertiary unit (ages 18–80 years) over 40% of those referred for refractory incontinence and/or constipation had both, usually unrecognised at referral.

Obstetric and surgical: instrumental delivery, perineal tears; haemorrhoidectomy, fistulotomy, sphincterotomy, low anterior resection; pelvic radiotherapy.

Drugs: laxatives, opioids, anti-diarrhoeals (can cause impaction with overflow), and anticholinergic drugs (may contribute to impaction).

Red flags: weight loss, rectal bleeding, sudden change in stool consistency. With her age, these guide exclusion of colorectal cancer, inflammatory bowel disease and coeliac disease.

Impact: social and psychological effects, earlier treatments, whether she or a carer can manage a treatment, and her expectations. Also ask about urinary incontinence and vaginal bulge.

General appearance, mental distress, abdomen, pads in use, and a focused neurological examination. Perianal inspection: leaked stool, skin irritation, haemorrhoids, fistulas, fissures, scars. Vaginal examination where appropriate for prolapse.

Digital rectal examination: resting tone, squeeze, bearing down, impaction, masses. Anoscopy can show anorectal lesions.

Impaction with overflow: older people are a main risk group. Liquid stool leaks around the mass (paradoxical diarrhoea), aided by weaker sphincter tone in older people and pudendal neuropathy. A rectal examination does not exclude a mass higher up; an abdominal series or CT can show it. Peritonism needs surgical assessment.

Structural: sphincter injury from vaginal delivery (the leading cause in women, not age-specific) or anorectal surgery; rectal prolapse or rectocele.

Diarrhoeal disease: inflammatory bowel disease, microscopic colitis, malabsorption, radiation proctitis; diabetes can cause anal neuropathy and chronic diarrhoea.

Neurological and functional: stroke, Parkinson's disease, dementia. Cognitive impairment may stop her recognising the urge, so assess cognition and function: can she reach the toilet and undress? Nursing home data, which may not apply if she lives at home, link incontinence (42.3% of residents) with inability to use the toilet (OR 7.37), diarrhoea (OR 7.33) and dementia (OR 2.17).

The 2022 European guideline says further tests could be considered if first-line treatment gives inadequate relief, and found no reviews, trials or controlled studies of whether the tests it reviewed change treatment decisions.

Colonoscopy or similar when red flags or her age raise concern about malignancy. Usual in practice, though not in these sources: a bowel diary or stool chart, blood count, thyroid function, glucose, and stool examination if there is diarrhoea.

Anorectal manometry shows resting and squeeze pressures and rectal sensation, which predicts response to biofeedback. One review makes it the first test; another says most centres use it.

Sphincter imaging when pressures are low, especially if surgery is considered: endoanal ultrasound first (best for internal sphincter tears, operator dependent); MRI is better for external sphincter atrophy and scars, but unsuitable with pacemakers or metal implants.

Defecography for suspected prolapse, rectocele or obstructed defecation. Pudendal nerve latency lengthens with age regardless of continence and is mainly of research interest.

Treat any cause found and discuss expectations; start first-line measures, with testing and second-line options if relief is inadequate.