What are the causes and treatments of fecal (bowel) and urinary incontinence?

From the Guidelines

Fecal and urinary incontinence should be managed with a stepwise approach, starting with conservative therapies such as dietary modifications, pelvic floor exercises, and bowel training programs, as these can benefit approximately 25% of patients. For fecal incontinence, conservative therapies, including diet, fluids, and techniques to improve evacuation, should be tried first 1. Pelvic floor retraining with biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative measures 1.

Key Considerations for Fecal Incontinence

• Dietary modifications, such as increasing fiber intake and avoiding trigger foods, can help manage symptoms
• Pelvic floor exercises, like Kegel exercises, can strengthen relevant muscles
• Medications like loperamide can reduce stool frequency and increase consistency

For urinary incontinence, pelvic floor muscle training (PFMT) is an effective nonpharmacologic management option 1. Bladder training, which involves scheduled voiding and gradually increasing intervals, can also be beneficial. Medications such as oxybutynin, tolterodine, or mirabegron may be considered for urge incontinence.

Key Considerations for Urinary Incontinence

• PFMT is a recommended first-line treatment for stress urinary incontinence
• Bladder training can help manage urgency urinary incontinence
• Medications like oxybutynin, tolterodine, or mirabegron can be used to treat urge incontinence, but may have adverse effects 1

Sacral nerve stimulation should be considered for patients with moderate or severe fecal incontinence who do not respond to conservative measures and biofeedback therapy 1. For urinary incontinence, more invasive treatments like intraurethral bulking agents, autologous fascial slings, or artificial urinary sphincters may be necessary for severe cases, but high-quality data on comparative effectiveness are limited 1.

It is essential to seek medical evaluation if symptoms persist, as more advanced treatments, including biofeedback therapy, sacral nerve stimulation, or surgical interventions, may be necessary for severe cases. Absorbent products and protective undergarments can provide immediate management while working on underlying causes. These conditions often result from weakened pelvic floor muscles, nerve damage, or sphincter dysfunction, which can occur due to childbirth, surgery, neurological conditions, or aging.

From the FDA Drug Label

Oxybutynin chloride thus decreases urgency and the frequency of both incontinent episodes and voluntary urination. Loperamide increases the tone of the anal sphincter, thereby reducing incontinence and urgency.

Fecal and Urine Incontinence:

• Oxybutynin decreases the frequency of incontinent episodes and voluntary urination.
• Loperamide reduces incontinence and urgency by increasing the tone of the anal sphincter. 2 3

From the Research

Fecal Incontinence

• Fecal incontinence is a common condition that affects approximately 9% of adult women, with a higher prevalence in older women and those with chronic bowel disturbances, diabetes, obesity, prior anal sphincter injury, or urinary incontinence 4.
• The condition can have a significant impact on quality of life and mental health, and is associated with an increased risk of nursing home placement 4.
• The initial clinical evaluation of fecal incontinence requires a focused history and physical examination, and recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment 4.

Urine Incontinence

• Urge urinary incontinence and overactive bladder are common conditions that can have a profound impact on a patient's health and quality of life 5.
• Oxybutynin is a widely used antimuscarinic agent for the treatment of urge urinary incontinence and overactive bladder, with an extended-release form and transdermal transport system available to improve tolerability and safety profile 6, 5.
• The efficacy and safety of oxybutynin in its various delivery forms have been extensively studied, with results showing significant reduction in incontinence episodes and improvement in quality of life 6, 5.

Diagnosis and Treatment

• The diagnosis and treatment of fecal incontinence have been outlined in a joint European clinical practice guideline, which provides an up-to-date comprehensive evidence-based framework for the diagnosis and management of adult patients with fecal incontinence 7.
• The guideline contains 45 recommendations on the classification, diagnosis, and management of fecal incontinence, and provides a systematic quality assessment using the GRADE approach 7.
• Treatment options for fecal incontinence include optimized stool consistency and medications, pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and colonic diversion 4.