MDCalc

Rome IV Diagnostic Criteria for Fecal Incontinence

Official Rome IV criteria for the diagnosis of fecal incontinence.

Use in patients with recurrent fecal staining or uncontrolled passage of stool for the past 3 months.

Do NOT use in patients with:

  • Clear mucous secretion alone.

  • Remote, isolated episodes of fecal incontinence.

  • Developmental age <4 years old or before toilet training has occurred.

Must have the following:

For 3 months prior

Diagnostic Result

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Advice

  • Passive incontinence suggests internal anal sphincter pathology.

  • Urge incontinence suggests external anal sphincter pathology.

If diagnosis confirmed, consider multifactorial causes:

  • Anal sphincter weakness:

    • Traumatic: obstetric, surgical.

    • Non-traumatic: scleroderma, internal sphincter degeneration.

  • Neuropathy: peripheral (pudendal nerve) or generalized (diabetes).

  • Pelvic floor disorder: rectal prolapse, descending perineum syndrome.

  • Decreased rectal capacity:

    • Inflammatory: radiation proctitis, Crohn’s, ulcerative colitis.

    • Anorectal surgery (pouch, anterior resection).

  • Central nervous system disease: dementia, stroke, tumors, multiple sclerosis, spinal cord lesions.

  • Bowel disturbances:

    • Irritable bowel syndrome, functional diarrhea.

    • Constipation with overflow incontinence, especially when associated with fecal impaction.

Management

If symptoms mild/limited impact on quality of life:

Consider conservative measures:

  • Avoid reversible factors (laxatives, artificial sweeteners, certain medications etc).

  • Dietary trial to reduce diarrhea (psyllium-based fiber, diet low in lactose or fermentable oligo-, di-, monosaccharides and polyols [FODMAPs]).

  • Loperamide 2-4 mg as needed 30 minutes before meals or social occasions where bathroom access limited, up to 16 mg/day.

  • Low dose tricyclic antidepressant (e.g. 25 to 50 mg/day), improves continence in patients with diarrhea-associated incontinence.

  • For Incontinence-Associated Dermatitis (IAD) avoiding soap and application of leave-on products (moisturizers, skin protectants, or a combination) seems to be more effective than withholding these products.

If fecal retention and overflow:

  • Empty the colon and place patient on a regular bowel regimen. 

If symptoms are moderate/severe and impact quality of life or not responding to symptomatic treatment:

Frequently requires more diagnostic testing:

  • Flexible sigmoidoscopy or colonoscopy (i.e. microscopic colitis, Ulcerative Proctitis).

  • Anorectal manometry +/- rectal sensation testing.

  • Anal ultrasound: can guide surgical repair.

  • Pelvic MRI: especially if possible rectovaginal pathology.

  • Defecography (Conventional, MRI): useful in select patients with fecal incontinence if structural cause of outlet obstruction suspected (e.g. large rectocele, rectal prolapse, or excessive perineal descent).

  • Electromyography (EMG): especially urge incontinence.

Often requires multidisciplinary management approach:

  • Pelvic floor physical therapy: biofeedback therapy.

  • Minimally invasive techniques: sacral nerve stimulation, anal submucosal injection of bulking agent.

  • Colorectal surgery: reconstruction of anal sphincter defects or colostomy (last resort).

Critical Actions

Assessment and diagnosis of fecal incontinence requires careful history taking, careful digital rectal exam and often further testing. Management plan should be directed through addressing the underlying etiology in conjunction with addressing the severity of symptoms and impact on quality of life.

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