Fecal incontinence (FI) is a frequently occcurring, distressing condition that has a devastating impact on the lives of patients. However, patients are typically embarrassed and reluctant to acknowledge this disability, so they do not seek a cure and remain socially isolated. The exact incidence of FI is not known, because of the reluctance of patients to seek help from their physicians. Most epidemiological studies suggest a prevalence of as high as 2% of the general population; however, when patient interviews ask specific questions about FI, the rate is usually significantly higher. Women seem to be at higher risk of FI, mostly because of obstetric damage to anal sphincters; however, during the last decade there has been increasing interest in types of FI with nontraumatic causes, as these have been shown to occur in significant numbers. Older subjects are at a very high risk of FI, especially those that present with disabilities or are institutionalized. Young patients are also often affected. This results in a significant economic impact for society because of the direct and indirect costs, and also for intangible reasons. Since FI can be the result of various pathophysiological conditions, and a variety of risk factors can cause a wide range of ways in which patients develop the inability to control the passage of feces, an accurate diagnostic work-up of each patient is fundamental. Although not fully accepted, a multimodal diagnosis, using a multiparametric evaluation, seems to allow a better understanding of FI pathophysiology and address the optimal treatment. Optimal treatment is the most important challenging aspect of FI management. Indeed, there is currently a wide range of therapeutic options available, including conservative, rehabilitative, and surgical procedures. The aim of surgery might be correction of a defect, or improvement of a dysfunction in continence control when the sphincter complex is intact, or replacement of a largely fragmented or non-functioning sphincter. Making the correct choice is pivotal to the successful management of this condition. Although a number of reports are available regarding results of different surgical procedures, there is a lack of evidence from randomized controlled studies, making the choice of procedure very difficult.

Anal continence is maintained by the activity of complex anatomic and physiologic structures (anal sphincters, pelvic floor musculature, rectal curvatures, transverse rectal folds, rectal reservoir, and rectal sensation). It is also dependent on numerous other factors, such as stool consistency, the mental faculties and mobility of the patient, available facilities, and social convenience. Only if there is effective coordinated integration of these factors can defecation proceed normally. FI is the result of disruption of one or a few of these different entities: it can have a multifactorial pathogenesis, and in many cases it is not secondary to a sphincter tear. The disruption can lie in alterations that are intrinsic to the anorectal neuromuscular structures of continence control, or extrinsic to them, also involving extrapelvic control mechanisms. The primary aim of an effective therapeutic approach is the improvement, or better still the resolution, of this distressing condition. Different forms of therapy are currently available, so physicians have to select the most appropriate treatment for each patient. Consequently, the diagnostic work-up is fundamental in order to assess the functional condition of every part involved in the continence mechanism, and identify the presumed cause(s) of incontinence. Several specific tests have been designed that are instrumental in FI diagnosis; these are available in a clinical setting for investigational purposes. However, there is disagreement among clinicians on the choice and timing of diagnostic procedures.