A 78-year-old woman is brought to the office from a nursing home for evaluation of urinary and fecal incontinence. She has longstanding, episodic urinary incontinence but started to also have fecal incontinence over the last week. The stool is described as loose and moderate in volume. The patient has chronic constipation treated with a stable dose of laxatives, but these were discontinued at the onset of fecal incontinence. Her other medical problems include moderate dementia, hypertension, type 2 diabetes mellitus, osteoporosis, and well-controlled congestive heart failure. The patient is in a wheelchair for about 4 hours daily, but otherwise remains in bed. No new medications have been added recently.
Vital signs are stable and unchanged from baseline. The abdomen is soft and nontender with distant but normoactive bowel sounds.
Which of the following is the most likely mechanism of fecal incontinence in this patient?

Question

A 78-year-old woman is brought to the office from a nursing home for evaluation of urinary and fecal incontinence.  She has longstanding, episodic urinary incontinence but started to also have fecal incontinence over the last week.  The stool is described as loose and moderate in volume.  The patient has chronic constipation treated with a stable dose of laxatives, but these were discontinued at the onset of fecal incontinence.  Her other medical problems include moderate dementia, hypertension, type 2 diabetes mellitus, osteoporosis, and well-controlled congestive heart failure.  The patient is in a wheelchair for about 4 hours daily, but otherwise remains in bed.  No new medications have been added recently.
Vital signs are stable and unchanged from baseline.  The abdomen is soft and nontender with distant but normoactive bowel sounds.
Which of the following is the most likely mechanism of fecal incontinence in this patient?

Quizplus · Accepted Answer

11ec193a_97f2_0248_853d_7b81d99a1b60_MD0002_00 This elderly patient with a history of dementia, relative immobility, and chronic constipation is likely experiencing overflow fecal incontinence due to fecal impaction. Fecal impaction is common in the elderly and is associated with impaired mental function, immobility, inadequate fluid/dietary fiber intake, decreased sensation of stool in the vault, and chronic constipation. Impacted stool can apply pressure to the bladder and contribute to urinary incontinence. Fecal overflow incontinence occurs when loose or liquid stool flows around the impaction in the rectum. Evaluation of fecal incontinence begins with a perineal inspection and digital rectal examination. Patients with fecal impaction should undergo manual disimpaction and be placed on a chronic bowel regimen to prevent recurrence. (Choices A and E) Diabetic autonomic neuropathy can cause weakness of the anal sphincter and lead to fecal incontinence. Other causes of anal sphincter weakness include trauma (eg, operative vaginal delivery, anal surgery), spinal cord injury, and atrophy (eg, age-related, infiltration with systemic sclerosis). Although this patient has diabetes, diabetic autonomic neuropathy more commonly affects the upper gastrointestinal tract (eg, gastroparesis). When fecal incontinence does occur in autonomic neuropathy, it is typically associated with chronic, painless, watery diarrhea and the inability to retain stool in the rectum, rather than chronic constipation. (Choice B) Decreased rectal compliance results in the reduced ability to store fecal matter, leading to an increase in stool frequency, urgency, and fecal incontinence. However, it is most common in patients with a history of ulcerative or radiation proctitis. This patient's lack of prior diarrhea or history of radiation makes this unlikely. (Choice D) Rectal prolapse is associated with chronic constipation but usually presents with an anal mass, abdominal pain, blood and mucus in the stool, and a sensation of incomplete rectal emptying, which are not seen in this patient. Educational objective: Fecal impaction is common in elderly patients and can lead to stool overflow incontinence. Evaluation of fecal incontinence should begin with a perineal inspection and digital rectal examination. Management includes manual disimpaction and a chronic bowel regimen to prevent recurrence. __________ References: Fecal incontinence in the elderly. (http://www.ncbi.nlm.nih.gov/pubmed/19699410) Approach to fecal incontinence and constipation in older hospitalized patients. (http://www.ncbi.nlm.nih.gov/pubmed/21441765)

A 78-Year-Old Woman Is Brought to the Office from a Nursing