Fecal Incontinence Clinical Practice Guidelines (ASCRS, 2023)

American Society of Colon and Rectal Surgeons

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 06, 2023

Guidelines on the evaluation and management of fecal incontinence were updated from 2007 and published in February 2023 by the American Society of Colon and Rectal Surgeons (ASCRS) in Diseases of the Colon & Rectum. Class I (strong) recommendations are summarized below.

Evaluation and Risk Assessment

Obtain a thorough disease history to identify the cause and specific risk factors for incontinence, delineate the duration and severity of the main symptoms, and gather details about secondary issues and associated pathologies. In addition, a thorough physical examination is essential.

Use validated measures to evaluate how the patient’s quality of life has been affected by the nature, severity, and impact of fecal incontinence.

Consider the use of anorectal physiology testing (manometry, anorectal sensation, volume tolerance, compliance) to delineate the features of dysfunction and guide management.

Pudendal nerve terminal motor latency is an option that can be used but is not routinely recommended due to its limited impact in diagnosing and managing fecal incontinence.

Sphincter defects in the setting of suspected sphincter injury can be confirmed with endoanal sonography.

Conservative Management

First-line therapy for fecal incontinence is the use of conservative measures comprising dietary and medical management.

Perform endoscopic evaluation in patients who fulfill general screening guidelines or who have specific symptoms (ie, diarrhea, bleeding, obstruction) that should be assessed further.

Consider biofeedback as an initial treatment in the setting of incontinence with some preservation of voluntary sphincter contraction.

Surgical Interventions

Correct obvious anatomic defects (eg, rectovaginal fistula, rectal/hemorrhoidal prolapse, fistula in ano, cloaca-like deformity).

Offer sphincter repair (sphincteroplasty) in the setting of symptomatic disease and a defined defect of the external anal sphincter.

In general, avoid repeat anal sphincter reconstruction following failure of overlapping sphincteroplasty—unless other therapeutic modalities are not feasible or have been ineffective.

The ASCRS does not recommend plication of the external anal sphincter (Park postanal repair).

Consider sacral neuromodulation as a first-line surgical option for patients with fecal incontinence, with and without sphincter defects.

Artificial bowel sphincter implantation remains effective for select patients with severe fecal incontinence.

Colostomy creation is an excellent surgical option for those whose fecal incontinence has failed other therapies or who don’t wish to pursue them.

For more information, please go to Fecal Incontinence and Neurogenic Bowel Dysfunction.


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