History and exam
Key diagnostic factors
common
history of anorectal, neurologic, or spinal abnormalities, or gastrointestinal surgery
May be associated with organic fecal incontinence; particular diagnosis determines patient's risk of fecal incontinence.
fecal soiling or diarrhea
Required for diagnosis of fecal incontinence. May be related to overflow diarrhea in constipated children or due to increased stool frequency and diarrhea.
constipation
Required for a diagnosis of fecal incontinence associated with chronic constipation.
perianal skin irritation
Due to moisture and fecal enzymes.
uncommon
abnormal rectal examination
May note abnormal tone, large fecal mass in dilated rectum in fecal incontinence associated with chronic constipation, or empty rectal vault in functional nonretentive fecal incontinence.
spinal deformities
Defects of varied severity associated with varied degrees of fecal incontinence.
weakness and decreased or absent reflexes
On neurological examination, weakness and decreased or absent reflexes in lower extremities may be found, indicative of organic or neurogenic bowel disease.
Other diagnostic factors
common
behavior problems
May display anxiety, depression, and social isolation.
Associated with all types of fecal incontinence, perhaps etiologic factor or consequence.
painful bowel movements
Related to fecal incontinence associated with chronic constipation.
abdominal pain/cramping
Related to fecal incontinence associated with chronic constipation.
posturing described as tightening of buttocks
Related to functional fecal incontinence associated with chronic constipation.
enuresis
Associated mostly with functional fecal incontinence with chronic constipation and organic fecal incontinence.
anorectal malformation
Defects of varied severity associated with varied degrees of fecal incontinence.
abnormal abdominal examination
Abdominal examination may reveal the presence of a fecal mass and gas in the lower quadrants.
uncommon
history of underlying medical condition
Hypothyroidism, celiac disease, and cystic fibrosis may present with fecal incontinence.
Risk factors
strong
chronic constipation
Major cause of fecal retention, which causes overflow incontinence.
May be related to an underlying medical condition such as hypothyroidism.
male sex
Boys are generally more affected than girls. In one epidemiology survey of 2686 children ages 10 to 16 years, of the 55 (2.0%) with fecal incontinence, 43 (78.2%) were boys.[6]
age: 5 to 6 years
A study from Amsterdam found fecal incontinence more frequently among 5- to 6-year-olds than 11- to 12-year-olds (4.1 versus 1.6%).[4]
diet lacking in fiber
Can cause constipation.
inadequate fluid intake
Can cause constipation.
delayed or inadequate toilet training
In younger children, particularly boys, a refusal or unwillingness to use the toilet/potty to empty the bowels is not uncommon. Continual "holding on" may ultimately lead to constipation and fecal incontinence.
anorectal malformations
Defects vary from minor to complex, and likelihood of persistent incontinence depends on the defect.
Patients with hypodeveloped sacrum are much more likely to be incontinent.[13]
Approximately 50% of affected children occasionally soil their underwear, and 25% have persistent fecal incontinence that requires daily treatment.[7]
Hirschsprung disease
More than 50% of patients may experience fecal incontinence after surgery, but most are continent by adolescence.[8]
Fecal continence is an important predictor of overall quality of life after surgical repair.
spinal abnormalities
Neural tube defects, specifically spina bifida, occur in about 2500 newborns per year and with an incidence of 1 in 1200 to 1400 live births.[9] Virtually all affected children will experience some degree of fecal incontinence.
Other spinal abnormalities that can lead to fecal incontinence include myelodysplasia and tethered cord.
weak
psychological or behavioral problems due to stressful family events
Significant family events such as divorce of parents, birth of a sibling, or death of a family member may result in psychological stress causing children to regress in their development (including bowel and bladder habits).
psychiatric disorders
It is unknown if a behavioral or psychiatric disorder (i.e., anxiety, depression) is a risk factor for or may result from fecal incontinence.[10]
medication overuse
Fecal incontinence may rarely be due to overuse of medication (i.e., laxatives, orlistat), used mainly by adolescents and adults.
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