Fecal Incontinence in a 56-Year-Old Female Executive

A 56-year-old woman (president of her company) presents with a 2-year history of intermittent fecal incontinence. She reports 3–5 episodes of stool leakage per week. She is frustrated by her inability to keep travel engagements or attend board meetings because of the unpredictable and precipitous nature of her bowel function. She reports at least 1 formed stool per day. However, a second bowel movement occurs often with urgency and leading to soiling. There is no blood or mucus in her stool. She denies any nocturnal incontinence. She also reports incontinence of flatus that is often embarrassing. Her obstetric history is significant for 3 vaginal deliveries; one was a forceps-assisted delivery with perineal tear that required stitches. She has no other relevant history. In particular, she denied any history of back injury, neurologic problems, or anorectal surgery. She takes calcium and estrogen supplements. Three years ago she reported this symptom to her family physician. A colonoscopy was normal, and she was prescribed psyllium without relief. She tried over-the-counter loperamide, which helps but does not stop the incontinence. On physical examination she appeared well-nourished with no abnormality in the abdomen. Perianal inspection revealed a thin perineum with perianal excoriation. The anocutaneous reflex was absent in 2 quadrants, and digital rectal examination revealed a weak resting and a weak squeeze sphincter tone and a small amount of stool that was negative on guaiac test.