Fecal incontinence affects up to 20% of community-dwelling adults and more than 50% of nursing home residents, and is one of the major risk factors for elderly persons in the nursing home. Institutionalization itself is a risk factor (eg, immobility due to physical restraints). Management should focus on identifying and treating underlying causes, such as diet- or medication induced diarrhea, constipation, and fecal impaction. Use of absorbent pads and special undergarments is useful. Anorectal physiologic testing of nursing home residents has revealed an association between constipation, stool retention, and fecal incontinence. Impaired sphincter function (risk factor for fecal incontinence), decreased rectal sensation, and sphincter dyssynergia (risk factor for constipation and impaction) are found in a high proportion of incontinent nursing home residents. Biofeedback and sacral nerve stimulation may be useful in refractory patients and should be considered before colostomy in community-dwelling adults. Despite appropriate management, nursing home residents may remain incontinent because of dementia and health or restraint related immobility.