Although anorectal function is transiently somewhat impaired after restorative proctocolectomy, the impairment is not an age-related phenomenon.

Fecal incontinence (FI) is defined as involuntary or uncontrollable loss of feces. Gas incontinence is defined as involuntary or uncontrollable loss of flatus, while anal incontinence is defined as the involuntary loss of feces or flatus. The prevalence of FI in people over 65 in Japan is 8.7% in the male population and 6.6% among females. The etiology of FI is usually not limited to one specific cause, with risk factors for FI including physiological factors, such as age and gender; comorbidities, such as diabetes and irritable bowel syndrome; and obstetric factors, such as multiple deliveries, home delivery, first vaginal delivery, and forceps delivery. In the initial clinical evaluation of FI, the factors responsible for individual symptoms are gathered from the history and examination of the anorectal region. The evaluation is the basis of all medical treatments for FI, including initial treatment, and also serves as a baseline for deciding the need for a specialized defecation function test and selecting treatment in stages. Following the general physical examination, together with history taking, inspection (including anoscope), and palpation (including digital anorectal and vaginal examination) of the anorectal area, clinicians can focus on the causes of FI. For the clinical evaluation of FI, it is useful to use Patient-Reported Outcome Measures (PROMs), such as scores and questionnaires, to evaluate the symptomatic severity of FI and its influence over quality of life (QoL).

Examination for fecal incontinence is performed in order to evaluate the condition of each patient. As there is no single method that perfectly assesses this condition, there are several tests that need to be conducted. These are as follows: anal manometry, recto anal sensitivity test, pudendal nerve terminal motor latency, electromyogram, anal endosonography, pelvic magnetic resonance imaging (MRI) scan, and defecography. In addition, the mental and physical stress most patients experience during all these examinations needs to be taken into consideration. Although some of these examinations mostly apply for patients with constipation, we hereby describe these tests as tools for the assessment of fecal incontinence. Conservative therapies for fecal incontinence include diet, lifestyle, and bowel habit modification, pharmacotherapy, pelvic floor muscle training, biofeedback therapy, anal insert device, trans anal irrigation, and so on. These interventions have been identified to improve the symptoms of fecal incontinence by determining the mechanisms resulting in firmer stool consistency; strengthening the pelvic floor muscles, including the external anal sphincter; normalizing the rectal sensation; or periodic emptying of the colon and rectum. Among these interventions, diet, lifestyle, and bowel habit modifications and pharmacotherapy can be performed with some degree of knowledge and experience. These two therapies, therefore, can be conducted by all physicians, including general practitioners and other physicians not specializing in fecal incontinence. However, patients with fecal incontinence who did not improve following these initial therapies should be referred to specialized institutions. Contrary to the initial therapies, specialized therapies, including pelvic floor muscle training, biofeedback therapy, anal insert device, and trans anal irrigation, should be conducted in specialized institutions as these require patient education and instructions based on expert knowledge and experience. In general, conservative therapies should be performed for fecal incontinence before surgery because its pathophysiologies are mostly attributed to benign conditions. All Japanese healthcare professionals who take care of patients with fecal incontinence are expected to understand the characteristics of each conservative therapy, so that appropriate therapies will be selected and performed. Therefore, in this chapter, the characteristics of each conservative therapy for fecal incontinence are described.