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Editor – Samantha Morris

Date of Last Edit – 14-Mar-17

Current Definition
Post-defaecatory soiling is defined as “soiling occurring after defaecation”. [1] It is thought to be stool that was not successfully emptied on defaecation and remaining in the rectum (i.e. the case of incomplete defaecation) rather than a separate incontinence episode.

Old Definition(s)
Post-defaecatory soiling has only recently been recognised as being its own separate condition, having been previously included under the banner of passive faecal incontinence.

Perspectives and Controversies
Firstly, for a long time this has not been considered as its own condition, with only one article appearing on Pubmed when using the search term “post-defaecatory soiling” [2] and this is discussing haemorrhoids and rectal prolapse, rather than the condition itself. This means that it may not have been assessed appropriately, and patients may have been treated for faecal incontinence, rather than viewing the symptom as an aspect of incomplete defaecation.

Secondly, there does not seem to be a consensus of time point for when a condition changes from being post-defaecatory soiling to faecal incontinence. Is this 30 minutes, 1 hour, 2 hours or more after defaecation? There does not appear to be any evidence for this.

Mechanism
Post-defaecatory soiling can be caused by poor or difficult (perhaps due to haemorrhoids) hygiene, meaning the patient hasn’t successfully cleaned themselves on wiping, and have experienced subsequent soiling and staining from this.


It can also be caused by incomplete defaecation combined with a weak pelvic floor. Incomplete defaecation can be caused by behaviour (e.g. anismus, toilet positioning) or an anatomical problem (e.g. rectocoele, perineal descent or intussusception) causing the stool to become trapped rather than be adequately passed on defaecation. Stool remaining then leaks out passively in the short time after leaving the bathroom. This can be due to rectal prolapse, weak pelvic floor or a defect to the anal sphincters, preventing continence to be maintained.

Therapies
Conservative therapies for treating post-defaecatory soiling focus on getting the patient to successfully empty their rectum on defaecation. The simplest include correct toilet positioning, perineal support and vaginal splinting. By changing the patient’s position to having their feet on a stool and elbows on their knees (i.e. a squatting position), they create a large anorectal angle, allowing successful and easier defaecation. [3-5]. Perineal support involves the patient putting a gloved hand on their perineum and pressing upwards during defaecation, whilst vaginal splitting involves the patient places their gloves thumb inside the vagina, pressing against the back wall during defaecation. Both help to eliminate the effect of the rectocoele or perineal descent, enabling successful emptying.


Devices can also be used to enable complete emptying, including enemas, suppositories and rectal irrigation. Glycerine suppositories and docusate enemas soften the stool in the rectum and stimulate the defaecation reflex [6] enabling complete emptying of the rectum. Rectal irrigation acts to flush out any stool remaining in the rectum post-defaecation, allowing successful emptying and improve the post-defaecatory soiling [7]. The mini systems only use a small volume of water, so are ideal for these patients who do not require full rectal irrigation, but need help with incomplete emptying.


Finally, if the cause of the post-defaecatory soiling is anatomical, e.g. a rectocoele or intussusception, and the conservative methods have not been successful, surgical methods can be used. These include transvaginal rectocoele repair and laparoscopic ventral mesh rectopexy (VMR). A transvaginal rectocoele repair aims to fix the rectocoele, thus preventing trapping of stool in the rectocoele on defaecation, allowing successful defaecation and preventing post-defaecatory soiling [9-9]. A VMR treats posterior compartment pelvic organ prolapse, fixing both a rectocoele and intussusception, again allowing complete defaecation and preventing post-defaecatory soiling [10].

References and Resources
1. Sultan A. H., Monga A., Lee J., Emmanuel A., Norton C., Santoro G., Hull T., Berghmans B., Brody S., Haylen B. T. 2017 “An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female anorectal dysfunction” Neurourology and Urodynamics 36: 10-34

2. Sammarco G., Ferrari F., Carpino A., Russo E., Vescio G., Ammendola M., Sacco R. 2013 “PPh vs Milligan-Morgan: early and late complications in the treatment of haemorrhoidal disease with circumferential prolapse” Ann Ital Chir 84 (ePub) pii: S2239253X1302130

3. Costilla V. C., Foxx-Orenstein A. E. 2014 “Constipation in adults: diagnosis and management” Current Treatment Options in Gastroenterology 12(3): 310-32

4. Takano S., Sands D. R. 2016 “Influence of body posture on defecation: a prospective study of “the thinker” position” Tech Coloproctol 20(2): 117-21

5. Bladder and Bowel Community Resource on Toilet Positions https://www.bladderandbowelfoundation.org/resources/toilet-positions/ Accessed on 15-Feb-1

6. Bove A., Bellini M., Battaglia E., Bocchini R., Gambaccini D., Bove V., Pucciani F., Altomare D. F., Dodi G., Sciaudone G., Falletto E., Piloni V. 2012 “Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)” World Journal of Gastroenterology 18(36): 4994-501

7. Collins B., Norton C. 2013 “Managing passive incontinence and incomplete evacuation” Br J Nurs 22(10): 575-9

8. Ellis C. N., Essani R. 2012 “Treatment of obstructed defecation” Clin Colon Rectal Surg 25(1): 24-33

9. Beck D. E., Allen N. L. 2010 “Rectocoele” Clin Colon Rectal Surg 23(2): 90-98

10. Alam N. N., Narang S. K., Köckerling F., Daniels I. R., Smart N. J. 2015 “Rectopexy for rectal prolapse” Front Surg 2: 54.