Anorectal Disorders

This report defines criteria and reviews the epidemiology, pathophysiology, and management of the following common anorectal disorders: fecal incontinence (FI), functional anorectal pain, and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals, and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into 3 subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome and unspecified anorectal pain, the pain lasts more than 30 minutes, but in levator ani syndrome there is puborectalis tenderness. Functional defecation disorders are defined by ≥2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with ≥2 features of impaired evacuation, that is, abnormal evacuation pattern on manometry, abnormal balloon expulsion test, or impaired rectal evacuation by imaging. It includes 2 subtypes: dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating levator ani syndrome and defecatory disorders. This report defines criteria and reviews the epidemiology, pathophysiology, and management of the following common anorectal disorders: fecal incontinence (FI), functional anorectal pain, and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals, and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into 3 subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome and unspecified anorectal pain, the pain lasts more than 30 minutes, but in levator ani syndrome there is puborectalis tenderness. Functional defecation disorders are defined by ≥2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with ≥2 features of impaired evacuation, that is, abnormal evacuation pattern on manometry, abnormal balloon expulsion test, or impaired rectal evacuation by imaging. It includes 2 subtypes: dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating levator ani syndrome and defecatory disorders. Anorectal disorders are defined by specific symptoms and, in the case of functional disorders of defecation, also with abnormal diagnostic tests. Our understanding of these disorders continues to evolve with the availability of newer techniques to characterize anorectal structure and function.1Bharucha A.E. Rao S.S.C. An update on anorectal disorders for gastroenterologists.Gastroenterology. 2014; 146: 37-45Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 2Bharucha A.E. Fletcher J.G. Melton 3rd, L.J. et al.Obstetric trauma, pelvic floor injury and fecal incontinence: a population-based case-control study.Am J Gastroenterol. 2012; 107: 902-911Crossref PubMed Scopus (28) Google Scholar, 3Shorvon P.J. McHugh S. Diamant N.E. et al.Defecography in normal volunteers: results and implications.Gut. 1989; 30: 1737-1749Crossref PubMed Google Scholar Consequently, the distinction between “organic” and “functional” anorectal disorders may be difficult in individual patient.1Bharucha A.E. Rao S.S.C. An update on anorectal disorders for gastroenterologists.Gastroenterology. 2014; 146: 37-45Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 2Bharucha A.E. Fletcher J.G. Melton 3rd, L.J. et al.Obstetric trauma, pelvic floor injury and fecal incontinence: a population-based case-control study.Am J Gastroenterol. 2012; 107: 902-911Crossref PubMed Scopus (28) Google Scholar, 3Shorvon P.J. McHugh S. Diamant N.E. et al.Defecography in normal volunteers: results and implications.Gut. 1989; 30: 1737-1749Crossref PubMed Google Scholar Anorectal disorders, such as fecal incontinence, are usually defined by specific symptoms, but functional disorders of defecation require symptoms and anorectal physiological testing.4Bharucha A.E. Wald A. Enck P. Rao S. Functional anorectal disorders.Gastroenterology. 2006; 130: 1510-1518Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar While bowel symptoms recorded by questionnaires and bowel diaries are correlated,5Bharucha A.E. Seide B.M. Zinsmeister A.R. et al.Insights into normal and disordered bowel habits from bowel diaries.Am J Gastroenterol. 2008; 103: 692-698Crossref PubMed Scopus (15) Google Scholar some patients may not accurately recall bowel symptoms6Ashraf W. Park F. Lof J. Quigley E.M. An examination of the reliability of reported stool frequency in the diagnosis of idiopathic constipation.Am J Gastroenterol. 1996; 91: 26-32PubMed Google Scholar; hence, symptom diaries may be more reliable. In this report, we examine the prevalence and pathophysiology of anorectal disorders, listed in Table 1, and provide recommendations for diagnostic evaluation and management. These supplement practice guidelines recommended by the American Gastroenterological Association7Diamant N.E. Kamm M.A. Wald A. et al.AGA technical review on anorectal testing techniques.Gastroenterology. 1999; 116: 735-760Abstract Full Text Full Text PDF PubMed Google Scholar and American College of Gastroenterology.8Wald A. Bharucha A.E. Cosman B.C. et al.ACG Clinical guidelines: management of benign anorectal disorders.Am J Gastroenterol. 2014; 109: 1141-1157Crossref PubMed Scopus (20) Google Scholar We will not address anorectal symptoms secondary to a neurologic or systemic disorder. The revised diagnostic criteria include a minimum duration of symptoms that were selected arbitrarily to avoid the inclusion of self-limited conditions.Table 1Functional Anorectal DisordersF. Functional anorectal disorders F1. Fecal incontinence F2. Functional anorectal painF2a. Levator ani syndromeF2b. Unspecifed functional anorectal painF2c. Proctalgia fugax F3. Functional defecation disordersF3a. Dyssynergic defecationF3b. Inadequate defecatory propulsion Open table in a new tab Fecal incontinence (FI) is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. We recognize that fecal staining of underwear may reflect poor hygiene, prolapsing hemorrhoids, or rectal prolapse rather than true FI, but for practical purposes it is included in the definition of FI. Clear mucus secretion must be excluded by careful questioning. Flatus incontinence is often included in the definition of anal incontinence but not in the current diagnosis of FI because it is difficult to define when isolated passage of flatus is abnormal. FI is often multifactorial and occurs in conditions that cause diarrhea, impair colorectal storage capacity, and/or weaken the pelvic floor (Table 2). FI is considered abnormal after toilet training has been achieved, generally around 4 years of age.9Bongers M.E.J. Tabbers M.M. Benninga M.A. Functional nonretentive fecal incontinence in children.J Ped Gastroenterol Nutr. 2007; 44: 5-13Crossref PubMed Scopus (0) Google ScholarTable 2Common Causes of Fecal IncontinenceAnal sphincter weakness Traumatic: obstetric, surgical (eg, hemorrhoidectomy, internal sphincterotomy, fistulectomy) Nontraumatic: scleroderma, idiopathic internal sphincter degeneration Neuropathy Peripheral (eg, pudendal) or generalized (eg, diabetes mellitus)Pelvic floor disorders Rectal prolapse, descending perineum syndromeDisorders affecting rectal capacity and/or sensationaThese conditions may also be associated with diarrhea. Inflammatory conditions: radiation proctitis, Crohn’s disease, ulcerative colitisAnorectal surgery (pouch, anterior resection)Rectal hyposensitivityRectal hypersensitivityCentral nervous system disorders Dementia, stroke, brain tumors, multiple sclerosis, spinal cord lesionsPsychiatric diseases, behavioral disordersBowel disturbances Irritable bowel syndrome, post-cholecystectomy diarrhea Constipation and fecal retention with overflowa These conditions may also be associated with diarrhea. Open table in a new tab Several large community-based studies10Bharucha A.E. Zinsmeister A.R. Locke G.R. et al.Prevalence and burden of fecal incontinence: a population based study in women.Gastroenterology. 2005; 129: 42-49Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 11Melville J.L. Fan M.Y. Newton K. et al.Fecal incontinence in US women: a population-based study.Am J Obstet Gynecol. 2005; 193: 2071-2076Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 12Quander C.R. Morris M.C. Melson J. et al.Prevalence of and factors associated with fecal incontinence in a large community study of older individuals.Am J Gastroenterol. 2005; 100: 905-909Crossref PubMed Scopus (59) Google Scholar, 13Varma M.G. Brown J.S. Creasman J.M. et al.Reproductive Risks for Incontinence Study at Kaiser Research GroupFecal incontinence in females older than aged 40 years: who is at risk?.Dis Colon Rectum. 2006; 49: 841-851Crossref PubMed Scopus (116) Google Scholar, 14Siproudhis L. Pigot F. Godeberge P. et al.Defecation disorders: a French population survey.Dis Colon Rectum. 2006; 49: 219-227Crossref PubMed Scopus (70) Google Scholar, 15Nygaard I. Barber M.D. Burgio K.L. et al.Pelvic Floor Disorders NetworkPrevalence of symptomatic pelvic floor disorders in US women.JAMA. 2008; 300: 1311-1316Crossref PubMed Scopus (456) Google Scholar, 16Whitehead W.E. Borrud L. Goode P.S. et al.Pelvic Floors Disorders NetworkFecal incontinence in US adults: epidemiology and risk factors.Gastroenterology. 2009; 137: 512-517Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar, 17Matthews C.A. Whitehead W.E. Townsend M.K. et al.Risk factors for urinary, fecal, or dual incontinence in the nurses' health study.Obstet Gynecol. 2013; 122: 539-545Crossref PubMed Scopus (13) Google Scholar have suggested that FI is common, with a prevalence ranging from 7% to 15% in community-dwelling women, 18% to 33% in hospitals, and 50% to 70% in nursing homes.18Nelson R. Furner S. Jesudason V. Fecal incontinence in Wisconsin nursing homes: prevalence and associations.Dis Colon Rectum. 1998; 41: 1226-1229Crossref PubMed Scopus (152) Google Scholar, 19Bliss D.Z. Harms S. Garrard J.M. et al.Prevalence of incontinence by race and ethnicity of older people admitted to nursing homes.J Am Med Dir Assoc. 2013; 14: 451.e1-451.e7Abstract Full Text Full Text PDF Google Scholar The prevalence is either comparable16Whitehead W.E. Borrud L. Goode P.S. et al.Pelvic Floors Disorders NetworkFecal incontinence in US adults: epidemiology and risk factors.Gastroenterology. 2009; 137: 512-517Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar, 20Perry S. Shaw C. McGrother C. et al.Prevalence of faecal incontinence in adults aged 40 years or more living in the community.Gut. 2002; 50: 480-484Crossref PubMed Scopus (320) Google Scholar or lower in men than women.21Landefeld C.S. Bowers B.J. Feld A.D. et al.National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults.Ann Intern Med. 2008; 148: 449-458Crossref PubMed Google Scholar, 22Ditah I. Devaki P. Luma H.N. et al.Prevalence, trends, and risk factors for fecal incontinence in United States adults, 2005−2010.Clin Gastroenterol Hepatol. 2014; 12 (e1−e2): 636-643Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Some11Melville J.L. Fan M.Y. Newton K. et al.Fecal incontinence in US women: a population-based study.Am J Obstet Gynecol. 2005; 193: 2071-2076Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 13Varma M.G. Brown J.S. Creasman J.M. et al.Reproductive Risks for Incontinence Study at Kaiser Research GroupFecal incontinence in females older than aged 40 years: who is at risk?.Dis Colon Rectum. 2006; 49: 841-851Crossref PubMed Scopus (116) Google Scholar, 17Matthews C.A. Whitehead W.E. Townsend M.K. et al.Risk factors for urinary, fecal, or dual incontinence in the nurses' health study.Obstet Gynecol. 2013; 122: 539-545Crossref PubMed Scopus (13) Google Scholar, 23Markland A.D. Goode P.S. Burgio K.L. et al.Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study.J Am Geriatr Soc. 2010; 58: 1341-1346Crossref PubMed Scopus (39) Google Scholar but not all16Whitehead W.E. Borrud L. Goode P.S. et al.Pelvic Floors Disorders NetworkFecal incontinence in US adults: epidemiology and risk factors.Gastroenterology. 2009; 137: 512-517Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar, 24Goode P.S. Burgio K.L. Halli A.D. et al.Prevalence and correlates of fecal incontinence in community-dwelling older adults.J Am Geriatr Soc. 2005; 53: 629-635Crossref PubMed Scopus (95) Google Scholar studies reported a lower prevalence in African-American than white women, but similar prevalence across races in men.24Goode P.S. Burgio K.L. Halli A.D. et al.Prevalence and correlates of fecal incontinence in community-dwelling older adults.J Am Geriatr Soc. 2005; 53: 629-635Crossref PubMed Scopus (95) Google Scholar Interestingly, the majority of patients seen in clinical practice are women. Variations in the prevalence of FI among studies may reflect differences in survey methods, screening questions, reference time frame10Bharucha A.E. Zinsmeister A.R. Locke G.R. et al.Prevalence and burden of fecal incontinence: a population based study in women.Gastroenterology. 2005; 129: 42-49Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 16Whitehead W.E. Borrud L. Goode P.S. et al.Pelvic Floors Disorders NetworkFecal incontinence in US adults: epidemiology and risk factors.Gastroenterology. 2009; 137: 512-517Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar, 25Bharucha A.E. Outcome measures for fecal incontinence: anorectal structure and function.Gastroenterology. 2004; 126: S90-S98Abstract Full Text Full Text PDF PubMed Google Scholar (1 year or past month), and definition of incontinence. Two studies evaluated the incidence of FI.23Markland A.D. Goode P.S. Burgio K.L. et al.Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study.J Am Geriatr Soc. 2010; 58: 1341-1346Crossref PubMed Scopus (39) Google Scholar, 26Rey E. Choung R.S. Schleck C.D. et al.Onset and risk factors for fecal incontinence in a US community.Am J Gastroenterol. 2010; 105: 412-419Crossref PubMed Scopus (32) Google Scholar In a community study (65 years and older), the incidence of FI at 4 years was 17%, with 6% having FI at least monthly.23Markland A.D. Goode P.S. Burgio K.L. et al.Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study.J Am Geriatr Soc. 2010; 58: 1341-1346Crossref PubMed Scopus (39) Google Scholar In a follow-up community study (50 years and older), the incidence of FI was 7.0%.26Rey E. Choung R.S. Schleck C.D. et al.Onset and risk factors for fecal incontinence in a US community.Am J Gastroenterol. 2010; 105: 412-419Crossref PubMed Scopus (32) Google Scholar Persons with FI report that poor bowel control restricts their social life; other issues pertain to toilet location, hygiene/odor issues, coping strategies, fear, physical activities, embarrassment, and unpredictability of bowel habits.27Cotterill N. Norton C. Avery K.N.L. et al.A patient-centered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence.Dis Colon Rectum. 2008; 51: 82-87Crossref PubMed Scopus (35) Google Scholar Co-existent psychological problems may include anxiety and depression,28Maeda Y. Vaizey C.J. Hollington P. et al.Physiological, psychological and behavioural characteristics of men and women with faecal incontinence.Colorectal Dis. 2009; 11: 927-932Crossref PubMed Scopus (9) Google Scholar, 29Koloski N.A. Jones M. Kalantar J. et al.Psychological impact and risk factors associated with new onset fecal incontinence.J Psychosom Res. 2012; 73: 464-468Abstract Full Text Full Text PDF PubMed Google Scholar poor self-esteem, and problems with sexual relationships.30Visscher A.P. Lam T.J. Hart N. et al.Fecal incontinence, sexual complaints, and anorectal function after third-degree obstetric anal sphincter injury (OASI): 5-year follow-up.Int Urogynecol J. 2014; 25: 607-613Crossref PubMed Google Scholar Quality of life issues can be evaluated by generic or disease-specific instruments, such as the Rockwood Fecal Incontinence Quality of Life Scale, modified Manchester Health Questionnaire, Fecal Incontinence and Constipation Assessment Quality of Life scale. FI symptoms can also be assessed by Pelvic Organ Prolapse/Incontinence Sexual Questionnaire−IUGA (International Urogynecology Association).31Bharucha A.E. Zinsmeister A.R. Locke G.R. et al.Symptoms and quality of life in community women with fecal incontinence.Clin Gastroenterol Hepatol. 2006; 4: 1004-1009Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 32Rockwood T.H. Church J.M. Fleshman J.W. et al.Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence.Dis Colon Rectum. 2000; 43 (discussion 16−17): 9-16Crossref PubMed Google Scholar, 33Kwon S. Visco A.G. Fitzgerald M.P. et al.Pelvic Floor Disorders NetworkValidity and reliability of the Modified Manchester Health Questionnaire in assessing patients with fecal incontinence.Dis Colon Rectum. 2005; 48 (discussion 331−334): 323-331Crossref PubMed Scopus (49) Google Scholar, 34Rogers R.G. Rockwood T.H. Constantine M.L. et al.A new measure of sexual function in women with pelvic floor disorders (PFD): the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR).Intern Urogyn J. 2013; 24: 1091-1103Crossref PubMed Scopus (0) Google Scholar There is a significant correlation between symptom severity and QOL in FI.31Bharucha A.E. Zinsmeister A.R. Locke G.R. et al.Symptoms and quality of life in community women with fecal incontinence.Clin Gastroenterol Hepatol. 2006; 4: 1004-1009Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 35Rockwood T.H. Church J.M. Fleshman J.W. et al.Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index.Dis Colon Rectum. 1999; 42: 1525-1532Crossref PubMed Google Scholar FI was associated with increased mortality in some, but not all studies.36Chassagne P. Landrin I. Neveu C. et al.Fecal incontinence in the institutionalized elderly: incidence, risk factors, and prognosis.Am J Med. 1999; 106: 185-190Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 37Nakanishi N. Tatara K. Shinsho F. et al.Mortality in relation to urinary and faecal incontinence in elderly people living at home.Age Ageing. 1999; 28: 301-306Crossref PubMed Scopus (40) Google Scholar, 38Alameel T. Basheikh M. Andrew M.K. Digestive symptoms in older adults: prevalence and associations with institutionalization and mortality.Can J Gastroenterol. 2012; 26: 881-884Crossref PubMed Google Scholar but whether it is due to FI per se or conditions associated with FI (age and comorbidity) is unknown.16Whitehead W.E. Borrud L. Goode P.S. et al.Pelvic Floors Disorders NetworkFecal incontinence in US adults: epidemiology and risk factors.Gastroenterology. 2009; 137: 512-517Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar The etiology of incontinence is often multifactorial. Therefore, it is more appropriate to focus on associated conditions, especially when they precede the onset of FI, and on risk factors for FI. In community surveys, bowel disturbances, especially diarrhea and rectal urgency, and the burden of chronic illness were more important and independent risk factors for FI than obstetric-related pelvic floor injury (eg, forceps use, complicated episiotomy).2Bharucha A.E. Fletcher J.G. Melton 3rd, L.J. et al.Obstetric trauma, pelvic floor injury and fecal incontinence: a population-based case-control study.Am J Gastroenterol. 2012; 107: 902-911Crossref PubMed Scopus (28) Google Scholar, 16Whitehead W.E. Borrud L. Goode P.S. et al.Pelvic Floors Disorders NetworkFecal incontinence in US adults: epidemiology and risk factors.Gastroenterology. 2009; 137: 512-517Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar, 26Rey E. Choung R.S. Schleck C.D. et al.Onset and risk factors for fecal incontinence in a US community.Am J Gastroenterol. 2010; 105: 412-419Crossref PubMed Scopus (32) Google Scholar, 39Bharucha A.E. Zinsmeister A.R. Locke G.R. et al.Risk factors for fecal incontinence: a population based study in women.Am J Gastroenterol. 2006; 101: 1305-1312Crossref PubMed Scopus (67) Google Scholar, 40Bharucha A.E. Seide B. 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Schleck C.D. et al.Bowel disturbances are the most important risk factors for late onset fecal incontinence: a population-based case-control study in women.Gastroenterology. 2010; 139: 1559-1566Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Smoking, external sphincter atrophy, and obesity are also risk factors for FI.2Bharucha A.E. Fletcher J.G. Melton 3rd, L.J. et al.Obstetric trauma, pelvic floor injury and fecal incontinence: a population-based case-control study.Am J Gastroenterol. 2012; 107: 902-911Crossref PubMed Scopus (28) Google Scholar, 11Melville J.L. Fan M.Y. Newton K. et al.Fecal incontinence in US women: a population-based study.Am J Obstet Gynecol. 2005; 193: 2071-2076Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 13Varma M.G. Brown J.S. 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Newton K. et al.Fecal incontinence in US women: a population-based study.Am J Obstet Gynecol. 2005; 193: 2071-2076Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 16Whitehead W.E. Borrud L. Goode P.S. et al.Pelvic Floors Disorders NetworkFecal incontinence in US adults: epidemiology and risk factors.Gastroenterology. 2009; 137: 512-517Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar, 17Matthews C.A. Whitehead W.E. Townsend M.K. et al.Risk factors for urinary, fecal, or dual incontinence in the nurses' health study.Obstet Gynecol. 2013; 122: 539-545Crossref PubMed Scopus (13) Google Scholar, 42Nelson R. Norton N. Cautley E. et al.Community-based prevalence of anal incontinence.JAMA. 1995; 274: 559-561Crossref PubMed Google Scholar, 43Rommen K. Schei B. Rydning A. et al.Prevalence of anal incontinence among Norwegian women: a cross-sectional study.BMJ Open. 2012; 2Crossref PubMed Scopus (12) Google Scholar Several diseases that affect anorectal sensorimotor dysfunctions and/or alter bowel habits are also associated with FI in clinical practice (Table 2). Some of these conditions do not emerge as risk factors in community studies, possibly because their prevalence is relatively low. Consistent with the findings of community-based studies, the vast majority of women with FI who consult a physician might not have a neurologic or inflammatory disorder, but rather have bowel disturbances, typically diarrhea, often associated with a history of obstetric risk factors. However, neurologic deficit can only be identified with neurophysiological tests, and these are not widely available. The incidence of FI after vaginal delivery was 8% in a recent series.44Rogers R.G. Leeman L. Borders A. et al.Does cesarean delivery protect against pelvic floor dysfunction at 6 months postpartum?.Female Pelvic Med Reconstruct Surg. 2012; 18: S73Google Scholar This may reflect improvements in obstetrical practices, including decreased use of instrumented vaginal delivery (eg, forceps), less frequent and more selective use of episiotomy, and increased use of cesarean sections, although a Cochrane review showed no demonstrable difference between cesarean sections and vaginal deliveries.45Nelson R.L. Furner S.E. Westercamp M. et al.Cesarean delivery for the prevention of anal incontinence.Cochrane Database Syst Rev. 2010 Feb 17; : CD006756PubMed Google Scholar Third-degree (ie, involving the external anal sphincter) and fourth-degree lacerations (ie, extending through the external and internal anal sphincters) are strong risk factors for anal and fecal incontinence.46Bols E.M.J. Hendriks E.J.M. Berghmans B.C.M. et al.A systematic review of etiological factors for postpartum fecal incontinence.Acta Obstet Gynecol Scand. 2010; 89: 302-314Crossref PubMed Scopus (31) Google Scholar A prospective National Institutes of Health trial identified a nearly 2-fold increased OR of FI for women with sphincter injury during childbirth compared with a control group.47Borello-France D. Burgio K.L. et al.Pelvic Floor Disorders NetworkFecal and urinary incontinence in primiparous women.Obstet Gynecol. 2006; 108: 863-872Crossref PubMed Scopus (137) Google Scholar The risk is highest for instrument-assisted deliveries, with increased odds of 1.5 for anal incontinence and a higher risk with forceps than vacuum extraction.48Pretlove S.J. Thompson P.J. Toozs-Hobson P.M. et al.Does the mode of delivery predispose women to anal incontinence in the first year postpartum? 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Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence.Dis Colon Rectum. 1999; 42: 1306-1310Crossref PubMed Scopus (206) Google Scholar Impaired rectal compliance, as can occur with proctitis or after creation of a pouch, and fecal impaction with overflow diarrhea, can all cause FI.50Buchmann P. Mogg G.A. Alexander-Williams J. et al.Relationship of proctitis and rectal capacity in Crohn's disease.Gut. 1980; 21: 137-140Crossref PubMed Google Scholar, 51Read N.W. Abouzekry L. Read M.G. et al.Anorectal function in elderly patients with fecal impaction.Gastroenterology. 1985; 89: 959-966Abstract Full Text PDF PubMed Google Scholar, 52Varma J.S. Smith A.N. Busuttil A. Correlation of clinical and manometric abnormalities of rectal function following chronic radiation injury.Br J Surg. 1985; 72: 875-878Crossref PubMed Google ScholarF1. Diagnostic Criteriaa for Fecal Incontinence1.Recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least 4 yearsaCriteria fulfilled for the last 3 months. For research studies, consider onset of symptoms for at least 6 months previously with 2−4 episodes of FI over 4 weeks. F1. Diagnostic Criteriaa for Fecal Incontinence1.Recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least 4 years aCriteria fulfilled for the last 3 months. For research studies, consider onset of symptoms for at least 6 months previously wit