ACOG PRACTICE BULLETIN

Clinical Management Guidelines for Obstetrician–Gynecologists

NUMBER 210
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Committee on Practice Bulletins—Gynecology. The American Urogynecologic Society endorses this document. This Practice
Bulletin was developed by the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology
in collaboration with Gena C. Dunivan, MD; Chi Chiung Grace Chen, MD, MHS; and Rebecca Rogers, MD.

Fecal Incontinence
Fecal incontinence, or the involuntary leakage of solid or loose stool, is estimated to affect 7–15% of community-
dwelling women (1). It is associated with reduced quality of life, negative psychologic effects, and social stigma (2), yet
many women do not report their symptoms or seek treatment. Less than 3% of women who do self-report fecal
incontinence will have this diagnosis recorded in their medical record (3). Obstetrician–gynecologists are in
a unique position to identify women with fecal incontinence because pregnancy, childbirth, obstetric anal sphincter
injuries (OASIS), and pelvic floor dysfunction are important risk factors that contribute to fecal incontinence in women.
The purpose of this Practice Bulletin is to provide evidence-based guidelines on the screening, evaluation, and
management of fecal incontinence to help obstetrician–gynecologists diagnose the condition and provide conserva-
tive treatment or referral for further work up and surgical management when appropriate. For discussion on fecal
incontinence associated with OASIS, see Practice Bulletin No. 198, Prevention and Management of Obstetric Lacer-
ations at Vaginal Delivery (4).

including age and whether the individuals are community

Background
Definition
Fecal incontinence generally is defined as the recurrent,
involuntary loss of solid or liquid stool or mucus from the
rectum (1, 5, 6). The more encompassing term “anal
incontinence” includes the loss of flatus with or without
the loss of liquid and solid stool (1). Although a survey of
938 women found that the preferred term for anal or fecal
incontinence was “accidental bowel leakage,” (7) the term
“fecal incontinence” is used throughout this document to
be consistent with the published literature. Dyssynergia
results when the anal sphincter, pelvic floor muscles, or
both, do not relax appropriately with attempts at defeca-
tion, and the resultant incomplete emptying and evacua-
tion difficulties lead to overflow incontinence (8, 9).
Epidemiology
The prevalence of fecal incontinence varies based on the
definition used, how frequently the episodes occur, and
the specific characteristics of the population studied,
dwelling or institutionalized. Data from the National
Health and Nutrition Examination Survey (NHANES) of
4,308 community-dwelling adults indicate that the prev-
alence of fecal incontinence, when defined as loss of
solid or liquid stool or mucus at least once in the previous
30 days, is 8.3% (95% CI, 7.1–9.5) (6). Loss of liquid
stool is most common (6.2%), followed by mucus (3.1%)
and solid stool (1.6%). Prevalence increases with age,
from 2.6% among adults aged 20–29 years to 15.3% in
adults aged 70 years and older (10). Although previous
reports indicated that fecal incontinence prevalence rates
were significantly higher among women than men, cur-
rent evidence demonstrates that the rates are similar, with
an estimated prevalence of 8.9% and 7.7%, respectively
(6). Fecal incontinence rates are highest among nursing
home populations, with rates ranging from 40% to 70%
(11–13). Prevalence rates are likely underestimated
because approximately 75–80% of individuals with fecal
incontinence symptoms do not seek help or report them
to their health care provider (14).

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Etiology
The etiology of fecal incontinence is broad and typically
divided into neurologic and nonneurologic causes. The
most common presentations among women are non-
neurologic, particularly fecal incontinence after obstetric
anal sphincter injuries (OASIS), which may occur remote
from delivery. Table 1 lists other common nonneurologic
causes of fecal incontinence. Many commonly used med-
ications also contribute to fecal incontinence symptoms,
particularly medications that are associated with loose
stools, such as metformin (Table 2) (15). Neurologic
causes include spinal cord injury, spina bifida, and cere-
bral vascular accidents. Fecal incontinence that is due to
neurologic causes is beyond the scope of this document.
Risk Factors
Multiple risk factors are associated with fecal incontinence.
Independent risk factors in adult women include loose or
watery stool (odds ratio [OR], 2.82; 95% CI, 1.95–4.08),
increased frequency of stools (more than 21) per week (OR,
2.36; 95% CI, 1.09–5.12), and having two or more chronic
illnesses (OR, 2.20; 95% CI, 1.19–4.05) (6). Other risk
factors include urinary incontinence, obesity, smoking,
increasing age, decreased physical activity, anal intercourse,
history of OASIS, history of pelvic irradiation, and other
medical comorbidities, such as diabetes mellitus and inflam-
matory bowel disease (1, 6, 8, 16, 17). Nursing home res-
idents are at increased risk of fecal incontinence, in part
because of constipation that leads to fecal impaction and
overflow incontinence of feces (18).
Effect on Quality of Life
Fecal incontinence has a significant effect on women’s
quality of life and is associated with depression, social iso-
lation, shame, embarrassment, worsened sexual function,
and increased economic burden (3, 16, 19–29). In focus
groups of women who reported fecal incontinence symp-
toms to their health care providers, patients stated that their
physicians did not provide guidance on how to address the
quality-of-life effects of fecal incontinence (30). Patients
reported that they wanted their health care providers to
counsel them that there was hope for improvement, that
behavioral and lifestyle changes could improve their symp-
toms, and that they should continue their normal activities
despite fecal incontinence symptoms.
Treatment Options
Treatment options for fecal incontinence vary and often are
used in combination. Management typically begins with

Table 1. Examples of Common Nonneurologic Etiologies of Fecal Incontinence

Etiology Characteristic Symptoms Physical Examination Findings

Diarrheal diseases Fecal urgency, loose stools, and abdominal Variable

cramping (eg, irritable bowel syndrome,
infection)

Inflammatory bowel Variable; diarrhea, abdominal cramping, Abdominal tenderness, anal fistula, anal
disease fatigue, weight loss (eg, Crohn’s disease, fissures, extra-intestinal findings (aphthous
ulcerative colitis) stomatitis, erythema nodosum, arthritis)

Fistula Intermittent loss of stool and flatus from the Abnormal communication from the rectum to
vagina, perineum, or (rarely) the bladder the vagina, perineum, or bladder

Severe constipation Constipation followed by liquid stool Variable

with overflow incontinence

Rectal prolapse Rectal bulge (symptoms vary from severe Full-thickness or partial-thickness
incontinence to constipation) and rectal circumferential protrusion of the rectal
bleeding mucosa and muscularis from the anus

Hemorrhoids Perianal itching, perianal discomfort, rectal Variable if internal or external; perianal mass,
bleeding prolapsed rectal vein through anus, swollen
or tender perianal tissue

Sphincter lacerations/ Passive or urgency-associated fecal Disruption of the internal anal sphincter or
anal trauma incontinence the external anal sphincter, or both

Systemic diseases Variable depending on etiology (Parkinson’s Variable

disease, diabetes mellitus, multiple sclerosis,
systemic sclerosis)

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Table 2. Medications Associated With Loose Stool or Fecal Incontinence

Class Examples Mechanism of Action

Antacids Aluminum hydroxide and Magnesium can exert an osmotic effect and draw
magnesium hydroxide water into bowels

Antibiotics (especially with Cephalosporins Disruption to intestinal flora

broad spectrum coverage) Fluoroquinolones
Clindamycin

Antidepressants and mood Citalopram Cholinergic effects or blockage of serotonin

stabilizers Paroxetine receptors that may inhibit water absorption
Lithium
Antihypertensive agents
Beta blockers Propranolol Increased gastrointestinal motility
ACE inhibitors Enalapril

Bile acid sequestrant Cholestyramine Osmotic effect from unabsorbed bile salts

Chemotherapeutic agents Irinotecan Cholinergic properties

5-fluorouracil Disruption of intestinal enterocytes and crypt cells

Diabetic medications Metformin Increased intestinal motility and malabsorption

Laxatives Polyethylene glycol Draw water into colon or promote contractility (or
both) of the bowels

Prostaglandins Misoprostol Impairment of water absorption

Proton pump inhibitors Omeprazole Alterations in gastric acidity with increased

Pantoprazole susceptibility to enteric infections
Abbreviation: ACE, angiotensin-converting enzyme.

nonsurgical interventions (eg, pads and other protective
devices, dietary manipulation, fiber, stool-modifying medi-
cation) before progressing to more intensive interventions
(eg, pelvic floor muscle training with or without biofeed-
back, anal sphincter tissue bulking injections) and ultimately
surgical treatment (Table 3) (5). Most interventions are
aimed at decreasing the frequency and severity of fecal
incontinence, and many patients report short-term improve-
ment with treatment; however, these interventions rarely pro-
vide long-term benefit or cure (5).
Clinical Considerations
and Recommendations
< Which women should be asked about fecal
incontinence symptoms?
Women with risk factors should be screened for fecal
incontinence. Because women are reluctant to reveal
fecal incontinence symptoms (31), proactive screen-
ing is recommended, particularly among women with
other pelvic floor disorders. Additional risk factors
that may prompt screening include age 50 years and
older; residence in a long-term care facility; prior
OASIS; history of pelvic irradiation; engagement in
anal intercourse; or the presence of urinary inconti-
nence, chronic diarrhea, diabetes, obesity, or rectal
urgency (1, 6, 8, 16, 17).
< What is the recommended initial evaluation of
a woman who reports fecal incontinence?
Women who report fecal incontinence symptoms should
undergo a complete medical history, symptoms assess-
ment, and physical examination of the rectal, vaginal,
and perineal areas. No specific laboratory tests are
needed for the initial evaluation of fecal incontinence
unless diarrheal infectious processes are suspected.
Medical History
The medical history should include questions about
underlying neurologic disorders and potentially modifi-
able risk factors for fecal incontinence, such as obesity,

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Table 3. Available Treatments for Fecal Incontinence

Treatment Examples Fecal Incontinence Type/Etiology

Nonsurgical
Protective devices Pads All
Diapers, briefs
Adhesive patches

Dietary manipulations Titrating fiber in diet Loose stools

Managing fluid intake Dietary sensitivity
Food diary to identify
dietary triggers

Anticonstipation medications Laxatives Overflow fecal incontinence

Enema/rectal irrigation Neurogenic bowel dysfunction
Bowel schedules All

Fiber supplementation Psyllium All

Antidiarrheal medications Loperamide Loose stools

Diphenoxylate
Phenylephrine
Amitriptyline
Clonidine

Pelvic floor physical therapy Pelvic floor muscle exercises All

Biofeedback

Devices Anal plugs All

Vaginal bowel control devices

Invasive Nonsurgical
Bulking agents Perianal tissue bulking injection All
 Dextranomer in stabilized
hyaluronic acid (NASHA-Dx)
 Silicon biomaterial
 Carbon-coated beads

Surgical
Neuromodulation Sacral nerve stimulation All

Anal sphincter repair Sphincteroplasty Sphincter disruption

Radiofrequency anal sphincter Radiofrequency procedure All

remodeling

Other surgical treatments Sphincter muscle transposition Failure of other surgical options
 Dynamic graciloplasty
Artificial anal sphincter
Colostomy

diabetes, smoking, engaging in anal sex, use of medi- Symptoms Assessment

cations that are associated with loose stool (15) (Table 2), The symptoms assessment should include questions
and prior anal sphincter surgery or trauma, including about type and timing of accidental bowel leakage (solid,
OASIS. liquid, gas, mucus), frequency, severity (volume of loss,

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including fecal staining), relationship to fecal urgency,
and effect on daily activities and quality of life. Various
validated instruments exist, including the FI Severity
Index (32), FI Quality of Life Scale (33), and Fecal
Incontinence and Constipation Assessment Question-
naire (34). Obstetrician–gynecologists may consider
using the Bristol Stool Form Scale (Table 4) to help
patients identify the consistency of bowel movements
(35). Categorization of stools is important because
treatments should be tailored to normalizing stool con-
sistency (typically type 3 and type 4).
Physical Examination
Clinicians should inspect the appearance of the rectum
to determine if the anal opening is gaping, if there is
fecal material around the rectum or perineum, or if
there are any obvious fistula. The “dovetail” sign—loss
of the normal puckering around the anus anteriorly—may
indicate a disruption of the external anal sphincter. A dig-
ital rectal examination (DRE) should be performed.
Although the sensitivity and specificity of the DRE
is 82% and 32% respectively for detection of complete
anal sphincter disruption confirmed on endoanal ultraso-
nography (36), the DRE also assesses anal sphincter tone
and squeeze, as well as the presence of rectal masses and
fistula. A vaginal and perineal examination to assess for
rectocele, hemorrhoids, and rectal prolapse also should be
performed. If a woman’s history is consistent with a rectal
prolapse but the rectal prolapse is not visualized in the
examination room, it may be helpful to ask the woman
to strain on a toilet in the clinic to facilitate identification
of the rectal prolapse.
< What is the role of ancillary testing in the
evaluation of fecal incontinence?
Ancillary diagnostic testing (such as anal sphincter
imaging, defecography, anorectal mammography, and
Table 4. Bristol Stool Form Scale
Type 1 Separate hard lumps, like nuts
Type 2 Sausage-shaped by lumpy
Type 3 Like a sausage or snake but with cracks on
its surface
Type 4 Like a sausage or snake, smooth and soft
Type 5 Soft blobs with clear-cut edges
Type 6 Fluffy pieces with ragged edges, a mushy
stool
Type 7 Watery, no solid pieces
Reprinted from Lewis SJ, Heaton KW. Stool form scale as
a useful guide to intestinal transit time. Scand J Gastroenterol
1997;32:920–4.
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pudendal nerve terminal motor latency testing), is not
recommended for the routine evaluation of fecal incon-
tinence (37–39). If anatomic defect or dysfunction is
suspected or if clinical examination findings are incon-
clusive, referral for ancillary testing and further evalua-
tion should be considered.
< Who requires evaluation for colon cancer
among women with fecal incontinence?
Any woman presenting with fecal incontinence and
a change in her bowel habits should be considered for
a colonoscopy, especially when accompanied by any
“red flag” symptoms, including unexplained weight loss,
abdominal pain, rectal bleeding, melena, or anemia.
Attention should be paid to changes in bowel habits,
including diarrhea, constipation, or changes in the caliber
of stools (“pencil stools” that are thinner than normal).
< What is the role of obstetrician–gynecologists
in the management of fecal incontinence?
Although management of patients with fecal inconti-
nence may include a multidisciplinary approach involv-
ing referral to specialists in gastroenterology,
urogynecology, and pelvic floor physical therapy, it is
reasonable for obstetrician–gynecologists to initiate
conservative interventions, such as dietary manipulation,
bowel scheduling, fiber supplementation, and stool-
modifying agents. Patients who are candidates for sur-
gical therapy (such as women with rectovaginal fistulas
or rectal prolapse) or who do not respond to conservative
treatments should receive further evaluation and treat-
ment by a health care provider with expertise in pelvic
surgery.
< How effective are nonsurgical interventions
for the treatment of fecal incontinence?
Nonsurgical treatments for fecal incontinence are
associated with modest short-term efficacy and a low
risk of adverse events and are recommended for initial
management, except in cases of fistulae or rectal
prolapse. Many patients with fecal incontinence
(excluding those with fistulas or rectal prolapse) will
receive some benefit from nonsurgical interventions,
such as dietary fiber supplementation, stool-modifying
agents, and pelvic floor muscle exercises with or
without biofeedback. Other available conservative
therapies are listed in Table 3. An Agency for Health-
care Research and Quality (AHRQ) 2016 systematic
review of fecal incontinence treatment concluded that
although only low-level evidence exists for nonsurgi-
cal therapies such as fiber supplementation, pelvic
OBSTETRICS & GYNECOLOGY
floor muscle exercises, and pharmacologic interven-
tions, these therapies demonstrated modest short-term
improvements in fecal incontinence outcomes with
few minor adverse effects (5). Despite short-term effi-
cacy data, evidence is lacking for the effectiveness of
any treatment (nonsurgical or surgical) for fecal incon-
tinence beyond 6 months (5). Comparison of nonsur-
gical and surgical interventions is challenging because
nonsurgical options often are attempted first, and
women undergoing surgical intervention often have
failed conservative management.
Lifestyle Changes
Based on expert opinion, dietary manipulation (ie, food
diaries and dietary changes) and bowel schedules (ie,
regular toileting) should be offered to women with fecal
incontinence in conjunction with other treatments
because these treatments may help improve symptoms
and are associated with few adverse events (8, 40, 41). A
common tool used with dietary manipulation is a food
diary. Food diaries help patients identify and recognize
food triggers that may exacerbate rectal urgency or diar-
rhea, or both. This record allows patients to identify
common food sensitivities, such as dairy products, spicy
foods, caffeine, alcohol, and greasy or fatty foods (40)
that may result in loose stools. Once identified, patients
can avoid certain foods to determine if their fecal incon-
tinence symptoms improve. Food diaries also help pa-
tients record of their fecal incontinence symptoms and
episodes as well as fiber and water intake. Regular toilet-
ing, such as attempting a bowel movement immediately
after waking in the morning and after meals, may
improve rectal emptying and, thereby, decrease fecal
incontinence episodes (42).
Fiber and Stool-Modifying Agents
Based on limited data, fiber, antimotility agents, and
laxatives can be recommended as useful treatments for
fecal incontinence (43–47). For example, psyllium
and loperamide may be offered to patients to decrease
fecal incontinence episodes (46). Many patients with
fecal incontinence report abnormal stool consistency,
such as loose stools, hard, dry stools, or a combination
of the two. Stool-modifying agents can be used to
improve stool consistency because the fecal conti-
nence mechanism works best for patients with formed,
bulky, soft stool.
Dietary fiber affects the function of the gastroin-
testinal tract in a variety of ways and helps to
normalize stool consistency (48). A recent AHRQ
review found short-term efficacy with fiber supple-
mentation (5, 49, 50). A small, randomized controlled
trial of 206 women found that a daily fiber supplement
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of 16 g significantly decreased fecal incontinence fre-
quency by 51% in the exposure group versus 11% in
the placebo group (50). Once a woman determines her
typical daily fiber intake, she can slowly increase die-
tary fiber by 5 g over 1–2 weeks to help avoid adverse
effects associated with rapidly increased fiber intake,
such as flatus, bloating, and abdominal cramping (51).
The 2015–2020 U.S. Department of Agriculture Die-
tary Guidelines recommend that adult women consume
28 g of fiber a day at ages 19–30 years, 25.2 g at ages
31–50 years, and 22.4 g at 51 years and older (52). The
guidelines also provide helpful information about die-
tary sources of fiber (53).
For fecal incontinence associated with diarrhea or
loose stools, constipating medications, such as loper-
amide, diphenoxylate with atropine, and codeine
phosphate, may be helpful (8). A randomized con-
trolled trial of 80 patients compared loperamide with
psyllium and found that both treatment modalities
decreased fecal incontinence episodes; however, more
constipation was reported in the loperamide group
than the psyllium group (29.2% versus 9.7%, respec-
tively; P5.05) (46). In another prospective controlled
study of 69 women, methylcellulose was initiated, and
loperamide added if fecal incontinence persisted, with
a significantly higher cure rate in the treatment group
(46% versus 0%; P,.01) (44). In addition, a random-
ized crossover trial of 63 patients that compared lo-
peramide with a low-residue diet versus loperamide
with a high-fiber diet found similar improvement on
fecal incontinence severity index scores with a nonsig-
nificant difference between treatment arms (45). Thus,
many practitioners recommend that patients who do
not have constipation take loperamide routinely or
episodically when fecal incontinence symptoms are
exacerbated. Dosages can start with as little as one
half a tablet of loperamide by mouth daily and can
be titrated up to 4 mg two to three times daily as
needed (the maximum daily dose is 16 mg per day).
Patients should be counseled to experiment to find
what works best for them and to titrate loperamide
doses to prevent fecal incontinence but not to the point
of causing constipation (54).
Osmotic laxatives, such as lactulose or polyethyl-
ene glycol, are the mainstay medical therapy for
overflow fecal incontinence associated with constipa-
tion or impaction. In a 2010 Cochrane review of 10
randomized controlled trials (N5868), polyethylene
glycol was superior to lactulose for the treatment of
chronic constipation (55). Polyethylene glycol is avail-
able over the counter, and patients can dissolve a capful
into 4–8 oz of a preferred beverage and take it at night
or in the morning.
Practice Bulletin Fecal Incontinence e265
Pelvic Floor Muscle Exercises/
Physical Therapy
Pelvic floor muscle exercises with or without biofeedback
can be recommended for the treatment of fecal incontinence
to strengthen the anal sphincter and levator ani muscles, but
there are insufficient data on the most effective treatment
protocol. Although the AHRQ 2016 (5) review reported
there was insufficient evidence that pelvic floor muscle
exercises with the use of biofeedback were more effective
than other conservative treatments (eg, dietary advice, fiber,
and stool-modifying agents), the exercises are a reasonable
treatment option because most studies report improvement
in symptoms with no adverse events. In addition, expert
guidelines from the American College of Gastroenterology
and a National Institute of Diabetes and Digestive and Kid-
ney Diseases consensus panel recommend pelvic floor mus-
cle exercises with biofeedback for the treatment of fecal
incontinence (8, 41). Exercises may be accomplished with
or without a physical therapist, biofeedback, or electrical
stimulation (56). Biofeedback involves the use of sensors,
such as electromyography patches, to enhance a patient’s
awareness of physiologic sensations, such as rectal disten-
tion, and may improve the ability to isolate and contract
specific muscles, such as the external anal sphincter muscle,
without involving the abdominal musculature (8, 41). Elec-
trical stimulation is used to apply a current to the pelvic
floor musculature so that the muscles contract involuntarily.
In the 2012 Cochrane review of 21 randomized or quasi-
randomized trials (N51,525) comparing pelvic floor mus-
cle training with and without biofeedback, and with and
without electrical stimulation, the authors concluded that
the addition of biofeedback may be more effective than
exercises alone (57). Furthermore, biofeedback with elec-
trical stimulation may be more effective than biofeedback
alone or electrical stimulation alone (57). However, the
AHRQ 2016 review concluded that pelvic floor biofeed-
back with electrical stimulation was no more effective than
pelvic floor biofeedback alone and that up to 9% of partic-
ipants may experience discomfort (5).
Devices
Although limited data support the efficacy of anal plugs
and vaginal bowel control devices, patient tolerability
and product availability limit their use. Newer devices
appear to be better tolerated, but more long-term data are
needed to make a recommendation about their use as
a treatment option for fecal incontinence.
Anal Plug
A systematic review of four randomized and quasi-
randomized trials (N5136) found that although tradi-
tional anal plugs are poorly tolerated, they are effective
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for those who can tolerate them (58). A newer single-use
silicone anal plug that is removed during the process of
normal defecation demonstrated success in a noncompar-
ative trial (N591), in which 77% of patients who com-
pleted 12 weeks of use (n573) achieved a reduction in
fecal incontinence episodes by 50% or more (59). Fifty-
one percent of participants reported adverse effects prob-
ably or possibly related to the device. The most common
adverse effects were rectal urgency (26%), irritation
(13%), pain (7%), and soreness (6%).
Vaginal Bowel Control Device
In 2015, the U.S. Food and Drug Administration cleared
a vaginal bowel control device that has been shown to
reduce fecal incontinence episodes in a noncomparative
trial of 110 women whose fecal incontinence did not
primarily result from chronic watery diarrhea (60). This
device is placed in the vagina and has a balloon that
occludes the rectum and can be deflated for voluntary
bowel movements. More than one half (55.5%) of the
women were successfully fitted with the device. More
than three quarters (78.7%) achieved a 50% or greater
reduction in the number of fecal incontinence episodes.
The most common adverse events reported among pa-
tients who completed the fitting period were pelvic
cramping or discomfort (15%), urinary symptoms (incon-
tinence urgency or frequency) (10%), pelvic pain (8%),
and vaginal spotting (7%) (60).
< How effective are anal sphincter bulking
agents for the treatment of fecal incontinence?
Injections of biocompatible tissue-bulking agents into the
anal canal walls are an invasive nonsurgical procedure
for the treatment of fecal incontinence (5) by health care
providers with the appropriate training. Anal sphincter
bulking agents may be effective in decreasing fecal
incontinence episodes up to 6 months and can be con-
sidered as a short-term treatment option for fecal incon-
tinence in women who have failed more conservative
treatments. Data regarding the long-term effects of
sphincter bulking injections are lacking, with only a sin-
gle study in the AHRQ review that monitored patients for
more than 6 months (5). In one randomized trial, injec-
tions were not more effective than pelvic floor muscle
exercises with biofeedback (61). The AHRQ systematic
review concluded that bulking agents may reduce fecal
incontinence for up to 6 months, but durability decreased
after that time (5).
A variety of agents have been used to increase the
bulk of the anal sphincter. These include collagen
materials, silicone, carbon coated beads, and dextrano-
mer in hyaluronic acid (NASHA-Dx). A 2012
OBSTETRICS & GYNECOLOGY
systematic review (62) of five randomized trials
(N5382) examining injectable bulking agents found
that in one large trial there was a significant reduction
in fecal incontinence episodes with NASHA-Dx, with
more than one half (52%) of the 206 patients having
a 50% or greater reduction in fecal incontinence epi-
sodes at the 6-month follow-up (63). However, approx-
imately 30% of the individuals in the placebo group
noted similar improvements in symptoms, and the treat-
ment and placebo groups had similarly high rates of
requesting retreatment (82% versus 87%, respectively)
(63). A prospective cohort study that monitored the 136
patients who had been randomized to active injection
demonstrated that although 52% of participants main-
tained a more than 50% reduction in fecal incontinence
episodes, only 13% had complete resolution of symp-
toms at 36 months, with 15% reporting worsened symp-
toms (64). The most common adverse events included
proctalgia (14%), rectal hemorrhage (7%), injection site
bleeding (5%), diarrhea (4%), and rectal discharge
(4%). A single case of perirectal abscess, a rare severe
adverse effect, also was reported (64).
< Who is a candidate for surgical treatment of
fecal incontinence? What are the benefits and
risks of surgical treatment?
Surgical treatments should not be considered for the
initial management of fecal incontinence (except in cases
of fistulas or rectal prolapse) because surgical treatments
provide only short-term improvement and are associated
with more frequent and more severe complications
compared with nonsurgical interventions. Patients who
have failed nonsurgical treatments may be candidates for
surgical treatment; however, the AHRQ 2016 systematic
review found insufficient data to support the efficacy
of surgical interventions for fecal incontinence beyond
3–6 months postoperatively (5). Potential candidates for
surgical management of fecal incontinence should be
referred to a urogynecologist or other qualified surgical
specialist for further evaluation and treatment. Because
there is limited evidence to guide the choice of therapy,
the choice of surgical intervention can be based on sur-
geon and patient preference.
Neuromodulation
Neuromodulation includes sacral nerve stimulation and
peripheral tibial nerve stimulation (65). The U.S. Food
and Drug Administration approved sacral nerve stimula-
tion for the treatment of urinary incontinence in 1998 and
fecal incontinence in 2011. Peripheral tibial nerve stim-
ulation is not approved for fecal incontinence.
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and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Sacral nerve stimulation involves the implantation of
a wire electrode near the third sacral nerve root, and if
initial testing is beneficial a permanent battery is attached
to the wire electrode. Sacral nerve stimulation can be
considered as a surgical treatment option for women with
fecal incontinence with or without anal sphincter disrup-
tion who have failed conservative treatments. The AHRQ
2016 systematic review (5) concluded that there was
insufficient evidence supporting the use of sacral nerve
stimulation because the five included studies all had
moderate-to-high risk of bias and different treatment-
outcome combinations. However, guidelines from groups
such as the American Society of Colon and Rectal Sur-
geons and the U.K.’s National Institute for Health and
Care Excellence recommend sacral nerve stimulation as
the first-line surgical treatment for women with fecal
incontinence who have failed conservative treatment ir-
respective of anal sphincter integrity (9, 40). In addition,
a 2013 systematic review of 61 studies examining sacral
nerve stimulation reported a success rate (defined as
a 50% or greater reduction in fecal incontinence epi-
sodes) of 63% in the short term (6–12 months), 58% in
the medium term (17–36 months), and 54% in the long
term (44–118 months). At 56 months, 20% of patients
reported complete continence, with a 10% decrease in
efficacy within 5 years (66). Sacral nerve stimulation
appears to be equally effective in women with anal
sphincter disruption and women with pudendal neuropa-
thy (67). Typical adverse events after sacral nerve stim-
ulation include pain, infection, lead migration,
hematoma, and the need for battery replacement or revi-
sions to the wire or battery pocket site. Reoperation rates
range from 3% to 41%, and rates of device removal
adverse events range from 3% to 24% (5, 68).
Peripheral tibial nerve stimulation involves the place-
ment of a needle electrode near the posterior tibial nerve.
Although there were no serious adverse events reported
with peripheral tibial nerve stimulation, only pain or
bruising noted at the needle site, it should not be offered
routinely to patients with fecal incontinence because the
AHRQ 2016 review found insufficient evidence supporting
its use (5, 69). A randomized controlled trial (N5227) that
compared peripheral tibial nerve stimulation with sham
electrical stimulation found similar outcomes, with 38%
of participants in the peripheral tibial nerve stimulation
group reporting a 50% or greater reduction in fecal incon-
tinence episodes compared with 31% in the sham group
(OR, 1.28; 95% CI, 0.72–2.28) (69).
Anal Sphincter Repair
Sphincteroplasty can be considered in women with anal
sphincter disruption and fecal incontinence symptoms who
have failed conservative treatments. Sphincteroplasty is
Practice Bulletin Fecal Incontinence e267
performed in either an end-to-end or overlapping manner.
Most studies comparing these two techniques at the time
of OASIS have found similar outcomes up to 36 months
postoperatively, with up to 85% of patients reporting
improvement in fecal incontinence symptoms (70). In
addition, although the evidence is limited, long-term stud-
ies have demonstrated significant deterioration in fecal
incontinence over time after either end-to-end or overlap-
ping sphincteroplasty, with one half of women reporting
fecal incontinence symptoms 5–10 years after their repair
(71). Despite less encouraging objective outcomes, most
patients (74%) remained satisfied with their results (72).
Data on the effectiveness of sphincteroplasty compared
with other treatment options, including a stoma or sacral
nerve stimulation, is limited. In addition, it is not known
whether sphincteroplasty alone or sphincteroplasty cou-
pled with postoperative biofeedback therapy results in bet-
ter continence postoperatively (5). Overall rates of surgical
complications after a sphincteroplasty range from 5% to
27%. The most common adverse event after sphinctero-
plasty is wound infection, which occurs in 6–35% of cases
(72). Less common complications include fecal impaction,
wound hematoma, urinary tract infections, and dyspareu-
nia. Patients also may experience defecatory dysfunction,
such as incomplete evacuation, straining, or the need to
manually remove stool (72). For further discussion of anal
sphincter repair, refer to Practice Bulletin No. 198, Pre-
vention and Management of Obstetric Lacerations at Vag-
inal Delivery (4).
Radiofrequency Anal
Sphincter Remodeling
Radiofrequency remodeling of the anal sphincter is a treat-
ment option frequently mentioned in review articles but
infrequently performed in the United States. In this pro-
cedure, radiofrequency energy is directed toward the sub-
mucosa at the anorectal juncture to create scarring and
fibrosis of the anal sphincter. The theory is that this scarring
creates more resistance in the anal canal and aids in the
reduction of fecal incontinence. A review of 10 studies
including 220 patients with limited follow-up data reported
improvement in incontinence scores and quality-of-life
measures (73). Although most adverse events were not
serious (eg, up to 22% of patients reported minor bleeding
at the local site), this procedure should not be offered rou-
tinely to patients because there is currently no data from
high-quality studies to support its use (74).
Other Surgical Treatment Options
Several options exist to augment, replace, or bypass the
anal sphincter for patients with severe fecal incontinence
who have failed other interventions, including those with
neurologically impaired or congenitally absent anal
e268 Practice Bulletin Fecal Incontinence
© 2019 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
sphincters. These options include gracilis muscle trans-
position, artificial anal sphincter placement, and diverting
colostomy. These procedures are rarely performed, have
limited supporting data, are associated with high rates of
perioperative morbidity and, if considered, should be
performed only by urogynecologists or other subspecial-
ists familiar with the procedures (5, 75).
Summary
of Recommendations
The following recommendations are based on limited or
inconsistent scientific evidence (Level B):
< Nonsurgical treatments for fecal incontinence are
associated with modest short-term efficacy and a low
risk of adverse events and are recommended for
initial management, except in cases of fistulae or
rectal prolapse.
< Fiber, antimotility agents, and laxatives can be rec-
ommended as useful treatments for fecal
incontinence.
< Pelvic floor muscle exercises with or without bio-
feedback can be recommended for the treatment of
fecal incontinence to strengthen the anal sphincter
and levator ani muscles, but there are insufficient
data on the most effective treatment protocol.
< Anal sphincter bulking agents may be effective
in decreasing fecal incontinence episodes up to
6 months and can be considered as a short-term
treatment option for fecal incontinence in women
who have failed more conservative treatments.
< Surgical treatments should not be considered for
the initial management of fecal incontinence
(except in cases of fistulas or rectal prolapse)
because surgical treatments provide only short-term
improvement and are associated with more frequent
and more severe complications compared with
nonsurgical interventions.
< Sacral nerve stimulation can be considered as a sur-
gical treatment option for women with fecal incon-
tinence with or without anal sphincter disruption
who have failed conservative treatments.
< Sphincteroplasty can be considered in women with
anal sphincter disruption and fecal incontinence
symptoms who have failed conservative treatments.
The following recommendations are based primarily on
consensus and expert opinion (Level C):
< Women with risk factors should be screened for
fecal incontinence.
OBSTETRICS & GYNECOLOGY
< Women who report fecal incontinence symptoms
should undergo a complete medical history, symp-
toms assessment, and physical examination of the
rectal, vaginal, and perineal areas. No specific lab-
oratory tests are needed for the initial evaluation of
fecal incontinence unless diarrheal infectious pro-
cesses are suspected.
< Ancillary diagnostic testing (such as anal sphincter
imaging, defecography, anorectal mammography,
and pudendal nerve terminal motor latency testing),
is not recommended for the routine evaluation of
fecal incontinence.
< Any woman presenting with fecal incontinence and
a change in her bowel habits should be considered
for a colonoscopy, especially when accompanied by
any “red flag” symptoms, including unexplained
weight loss, abdominal pain, rectal bleeding, mele-
na, or anemia.
< It is reasonable for obstetrician–gynecologists to
initiate conservative interventions, such as dietary
manipulation, bowel scheduling, fiber supplemen-
tation, and stool-modifying agents. Patients who are
candidates for surgical therapy (such as women with
rectovaginal fistulas or rectal prolapse) or who do
not respond to conservative treatments should
receive further evaluation and treatment by a health
care provider with expertise in pelvic surgery.
< Dietary manipulation (ie, food diaries and dietary
changes) and bowel schedules (ie, regular toileting)
should be offered to women with fecal incontinence
in conjunction with other treatments because these
treatments may help improve symptoms and are
associated with few adverse events.
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own internal resources and documents were used to Copyright 2019 by the American College of Obstetricians and
conduct a literature search to locate relevant articles Gynecologists. All rights reserved. No part of this publication
published between January 2000–May 2018. The may be reproduced, stored in a retrieval system, posted on the
search was restricted to articles published in the Internet, or transmitted, in any form or by any means, elec-
English language. Priority was given to articles tronic, mechanical, photocopying, recording, or otherwise,
reporting results of original research, although review without prior written permission from the publisher.
articles and commentaries also were consulted.
Abstracts of research presented at symposia and Requests for authorization to make photocopies should be
scientific conferences were not considered adequate for directed to Copyright Clearance Center, 222 Rosewood Drive,
inclusion in this document. Guidelines published by Danvers, MA 01923, (978) 750-8400.
organizations or institutions such as the National American College of Obstetricians and Gynecologists
Institutes of Health and the American College of 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
Obstetricians and Gynecologists were reviewed, and
additional studies were located by reviewing Fecal incontinence. ACOG Practice Bulletin No. 210. Ameri-
bibliographies of identified articles. When reliable can College of Obstetricians and Gynecologists. Obstet Gyne-
research was not available, expert opinions from col 2019;133:e260–73.
obstetrician–gynecologists were used.
Studies were reviewed and evaluated for quality
according to the method outlined by the U.S.
Preventive Services Task Force:
I Evidence obtained from at least one properly de-
signed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
case–control analytic studies, preferably from
more than one center or research group.
II-3 Evidence obtained from multiple time series with
or without the intervention. Dramatic results in
uncontrolled experiments also could be regarded
as this type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to
the following categories:
Level A—Recommendations are based on good and
consistent scientific evidence.
Level B—Recommendations are based on limited or
inconsistent scientific evidence.
Level C—Recommendations are based primarily on
consensus and expert opinion.

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Unauthorized reproduction of this article is prohibited.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use
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care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
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Unauthorized reproduction of this article is prohibited.