KNGF Evidence Statement Royal Dutch Society for Physical Therapy

Anal incontinence

Methodical approach Red flags*

• (recent) trauma
• pre-existing (unexplained) fever
Direct Access to Physical Therapy • recent unexplained weight loss (> 5 kg/month)
recommendation: contact family • prolonged use of corticosteroids
physician/specialist (with patient’s permission) • constant pain that does not decrease at rest or after changing position
• history of cancer
• general malaise
• nocturnal pain
Referral • extensive neurological signs and symptoms
• inability to urinate/defecate
• blood and mucus in stools
• pain during defecation
• acute loss of stools
• abnormal color of stools not related to food consumed
• brief anemia episode

* Attention to red flags is required throughout the diagnostic and therapeutic process for physical
therapy.

(Supplementary) history • reason for contact and patient’s presenting problem

• nature (underlying cause/condition) and severity of anal incontinence (in ICF terms) and
modifiability (impeding factors, general and local)
• proctological, gynecological, obstetrical, urological and sexological history in relation to the
musculoskeletal system
• comorbidity
• coping strategies
• psychosocial problems
• defecation and micturition patterns
• nutrient and fluid intake
• status of components of continence system (muscle function, reservoir function, consistency of
stools, awareness and acknowledgment of health problem; interactions between these)
• patient’s pattern of expectations

Physical examination General inspection

• inspecting breathing, spinal column, pelvis, hips, gait analysis

Local inspection of vagina/anus/perineum

• inspecting pelvic floor at rest (introitus, perineum, vagina, anus)
• inspecting pelvic floor during contraction (contraction strength, performance, co-contractions and
breathing)
• inspecting pelvic floor during coughing
• inspecting pelvic floor during straining

Supplementary functional examination

• palpation at rest, anorectal
• palpation during contraction, anorectal
• palpation during straining, Valsalva, coughing (involuntary) rectal
• rectal balloon and electromyography

Measurement instruments
• Wexner score
• Global Perceived Effect
• defecation diary

Physical therapy analysis/diagnosis identification of impairments (nature, severity), limitations and participation restrictions
(consequences of anal incontinence)

V-25/2013 The full-text Evidence Statement is available from www.fysionet-evidencebased.nl © KNGF

KNGF Evidence Statement Royal Dutch Society for Physical Therapy
Anal incontinence
Identification of problem category:
I, II, III en IV

Treatment plan for patients with anal incontinence

I-II
anal incontinence with pelvic floor dysfunction III IV
anal incontinence anal incontinence (I/II/III) + general
I II without pelvic floor factors impeding recovery or adjustment
with awareness of loss of stools (urgency): without awareness of loss of stools dysfunction processes
external anal sphincter + m. puborectalis/levator ani (passive): internal anal sphincter

neurological problema neurological problemb

yes (local/central) yes (local/central)

no no

anorectal sensation normal anorectal sensation abnormal

3rd/4th degree tear peripheral dysfunction
traumas spinal cord S2-S4

IA IB IC ID IIA IIB III IVA IVB

• without voluntary • without • with voluntary • plus negative anorectal sensation anorectal sensation • reduced rectal without with comorbidities
control of pelvic involuntary control of pelvic effects on pelvic normal abnormal capacity comorbidity • increased
floorc control of pelvic floorc floor muscle • 3rd/4th degree • peripheral • intestinal • diet sensitivity
Disorder floor function from tear dysfunction system function • medication for (chronic fatigue,
respiratory • traumas • spinal cord S2-S4 problemse constipation chronic stress,
problems, • overflow diarrhea • pelvic organ • fecal consistency (incl. difficulty
musculoskeletal • paradoxical prolapse (POP)d • soiling antimuscarinic concentrating)
problems and/or straining • loss of drugs M3/ • neurological,
toileting posture, discrimination M4), diarrhea, urological,
regime and/or between flatus sensitivity, gynecological,
behavior and feces cognition, muscle endocrinological,
relaxants psychological
and cognitive
problems
• connective tissue
diseases
• chronic
obstructive
pulmonary
disease (COPD)
• morbid obesity
• eating disorders
• panic/anxiety/
psychosis
• functional
problems relating
to toileting

improving components of continence :

1. muscle function: basic activity, timing, coordination, relaxation, duration, reflex activity (fast-twitch/slow-twitch)
2. reservoir function (perception of filling sensation): first sensation, first feeling of urgency, maximum tolerable volume, appropriate reaction of pelvic floor to rectal filling (= being continent)
Goal
3. fecal consistency: from loose to soft shapeds
4. recognition of health problem, acknowledgement of health problem, expression (uttering, setting in motion) and letting go*
5. interaction between the above continence components

Strategy optimizing one continence component → optimizing the complex mechanism of continence components → making ADL tasks become automatic

Therapy providing education and advice

IA IB IC ID IIA IIB III IVA IVB

• verbal instruction • training to reduce • PFMT • exercises • PFMT • PFMT • PFMT • addressing • addressing
• ES for PFMT (m. anorectal angle to address impeding factors impeding factors
puborectalis / • training pelvic • BFf unfavorable • BFf • BFf Note: complete where possible where possible
external anal floor during trunk factors recovery unlikely • informing patient • informing patient
sphincter) stabilization about what about what
• ES separate • PFMT exercise therapy exercise therapy
• BF can and cannot can and cannot
• BFf achieve achieve
when in doubt • PFMT • PFMT
about pelvic floor
contraction capacity • BFf • BFf

• voluntary control
present PFMT

• voluntary control
absent refer to
family doctor/
medical specialist

Evaluation evaluating the outcome: Wexner score, Global Perceived Effect, defecation diary

Follow-up checkup at predefined moment(s) → brief reminder therapy (if necessary)

ES = electrostimulation; PFMT = pelvic floor muscle training; BF = biofeedback (electromyogram, pressure and rectal balloon).

a. without neurological problem (motor); local neurological problem (motor): n. pudendus lesion (S2-S4), iatrogenic; central neurological problem: coordination problem.
b. without neurological problem: 3rd/4th degree tear, traumas, overflow diarrhea, paradoxical straining; local or central neurological problem (sensory): n. pudendus lesion (S2-S4), iatrogenic.
c. voluntary control, i.e. ‘awareness’.
d. pelvic organ prolapse (POP).
e. overflow diarrhea, irritable bowel syndrome, Morbus Crohn, colitis ulcerosa.
f. biofeedback (EMG/pressure/rectal balloon training): if insufficient progress and to speed up results.

*Dutch acronym HEEL: Herkennen van gezondheidsprobleem, Erkennen van gezondheidsprobleem, Expressie (uiten, in beweging brengen) en Loslaten (eigen maken)

V-25/2013 The full-text Evidence Statement is available from www.fysionet-evidencebased.nl © KNGF