Faecal incontinence (FI) is defined as the involuntary loss of liquid or solid stool. It is used to describe a wide range of symptoms, from occasional soiling, to frequent uncontrolled involuntary bowel motions (1,2). Recent surveys have established a prevalence of FI to be approximately 8.4%, with increased incidence with age but similar distribution between sexes (3).  The aim of this study was to assess characteristics of patients with primary symptoms of faecal incontinence in a tertiary referral centre.

A retrospective review of prospectively collected data was performed for patients presenting to a tertiary referral pelvic floor unit for the assessment of FI over a period of 4 years (2013-2017). All patients underwent a dedicated telephone triage assessment clinic (TTAC), where symptoms severity scores were assessed and completed using ICIQ-BS (International Consultation on Incontinence Modular Questionnaire-Bowel Symptoms) and St Mark’s faecal incontinence grading system. Symptoms have been classified into the following categories: urgency, flatus incontinence, urge faecal incontinence, passive incontinence and soiling. In addition information about difficult defaecation and obstructive defaecation syndrome (ODS) have been recorded to assess the association between various degrees of FI and ODS. 
In all patients, the data collected included demographics, practitioner directed history, risks factors for FI (such as previous pelvic floor surgery, anorectal surgery, number of vaginal deliveries and traumatic vaginal deliveries) and neurological comorbidities. Based on gravity of symptoms at presentation, patients had pelvic floor investigations such us endoanal ultrasound, (EAUS), pelvic floor ultrasound (PFUS), anorectal manometry and defecography. Information about results of these pelvic floor tests have been recorded as well as conservative or surgical treatment received. 
Depending on the symptoms and severity, a decision was made whether the patient would benefit from further investigations, conservative management, consultant clinic or referral to another specialist service.

During the study period, 574 patients were referred to our third referral centre with the main symptoms of FI (16% males and 84% females). The mean age at presentation was 57 years old (Male median age 55, range 17-85; Female median age 58, range 20-93). 
Fourteen percent of females were nulliparous, among the remaining parous females, the median number of vaginal deliveries was 3 (range 1-8). History of episiotomy or traumatic vaginal delivery was recorded in 269 (47%). 237 (41%) of patients who had a previous abdominal and/or transvaginal hysterectomy.
Past surgical events of potential etiological were present in 25% male and 25% female. Males had a lower incidence of previous pelvic floor surgery (M:1.1% vs F:19%, P<0.05). Males had a higher incidence of previous anal surgery (M:25%vs F: 8% p<0.05).
Incontinence symptoms could be divided into, urge faecal incontinence 65%, soiling 17%, passive faecal incontinence 11%, urgency 4% and 3% flatus incontinence. Although patient’s primary complaint was FI, 26% of subjects reported defaecatory difficulties classified as ODS. 
Interventions are summarized in table 1. 81% have been sent for tests, out of them 98% had EAUS, 39% had PFUS, 97% had anorectal physiology and 82% had proctography. 
Ninety-one percent of patients had conservative treatment, with an average number of biofeedback appointments 3 (range 1-13), which includes dietary advices, pelvic floor exercises, medications to increase stool consistency (41%), use of suppositories (51%) and selective use of low and high volume of irrigation (26%) . 
Nine percent of patients had surgical interventions, in the form of laparoscopic ventral mesh rectopexy to correct high grade intussusception (30%), transvaginal rectocoele repair manage symptomatic rectocoele causing vaginal prolapse symptoms associated with ODS symptoms and soiling (24%), sacral neuromodular implant to improve urge faecal incontinence symptoms (9%), perineal rectopexy (7%), injection of bulking agents (5%), sphincter repair with rectocoele repair and levator-plasty to restore the anatomy of sphincter function and perineal body (4%), perineal rectosigmoidectomy (2%), sutured anopexy (2%), laparoscopic posterior rectopexy (2%), transperineal rectocoele repair (2%). Other procedures were performed for treatment of haemorrhoids in 13% of patients.

An understanding of patients’ faecal incontinence symptoms and the co-existence with defaecation difficulties and their severity is necessary to direct each patient to the most effective treatment pathway. Those patients with ODS are more likely to require surgical intervention to improve both ODS and incontinence symptoms. Sacral nerve neuromodulation plays a role in selected patients with urge faecal incontinence and unsatisfactory improvement to conservative management.
The majority of patients benefit from conservative treatment. This is the primary treatment modality and should be tried before any surgical intervention is attempted. From review of the results, investigations for faecal incontinence are now only performed if conservative treatment fails.
From this review only 9% of patients required surgical intervention. This highlights the important role conservative treatment plays in faecal incontinence. Another factor are the limited successful surgical options as if we did have a cure surgery would be more popular.

Faecal incontinence includes a wide range of symptoms, and may be associated with obstructive defaecation syndrome. An accurate assessment at presentation is fundamental to structure a tailored conservative treatment for individual patients. Conservative treatment is the primary and most successful option for patients with faecal incontinence.

Bordeianou L et al, Colorectal Dis. 2008 Mar;10(3):273-9.
Townsend DC et al, Neurogastroenterol Motil. 2016 Oct;28(10):1580-8.
Prichard D et al, Clin Gastroenterol Hepatol. 2015 Oct;13(10):1793-1800.