From the Guidelines
Patients with anal sphincter weakness and fecal incontinence should initially be managed with conservative measures, including dietary modifications and pelvic floor muscle training with biofeedback therapy, as these approaches can benefit approximately 25% of patients and should be tried first 1.
Treatment Options
Treatment for anal sphincter weakness and fecal incontinence involves a stepwise approach, starting with conservative therapies and progressing to more invasive options if necessary. The key is to improve quality of life and prevent social isolation by addressing the condition promptly.
- Conservative measures:
- Dietary modifications (avoiding caffeine, alcohol, and spicy foods)
- Fiber supplementation to bulk stool
- Anti-diarrheal medications like loperamide (2-4 mg before meals or activities)
- Pelvic floor muscle training with biofeedback therapy:
- Typically conducted over 6-8 weekly sessions
- Can strengthen the sphincter muscles and improve coordination
Advanced Options
For patients who do not respond to conservative measures and biofeedback therapy, more advanced options can be considered:
- Sacral nerve stimulation:
- Involves implanting a small device that delivers electrical impulses to improve sphincter function
- Should be considered for patients with moderate or severe fecal incontinence who have not responded to conservative measures and biofeedback therapy 1
- Injectable bulking agents:
- Can be administered around the anal canal to enhance closure
- Perianal bulking agents such as intraanal injection of dextranomer may be considered when conservative measures and biofeedback therapy fail 1
Surgical Options
Surgical options are available for patients who do not respond to conservative and advanced treatments:
- Sphincteroplasty:
- Should be considered in postpartum women with fecal incontinence and in patients with recent sphincter injuries 1
- Artificial bowel sphincter implantation:
- May be considered for patients with medically-refractory severe fecal incontinence who have failed treatment or are not candidates for other options 1
- Colostomy:
- Should be considered in patients with severe fecal incontinence who have failed conservative treatment and have failed or are not candidates for other options 1
From the FDA Drug Label
Loperamide increases the tone of the anal sphincter, thereby reducing incontinence and urgency.
Treatment Options: Loperamide may be used to treat anal sphincter weakness and fecal incontinence by increasing the tone of the anal sphincter and reducing incontinence and urgency 2.
- Key Benefits: Reduces incontinence and urgency, increases the tone of the anal sphincter.
- Important Considerations: Loperamide should be used under medical supervision, as it can have adverse effects, such as constipation, and interact with other medications 2.
From the Research
Treatment Options for Anal Sphincter Weakness and Fecal Incontinence
- First-line therapy for fecal incontinence typically includes conservative measures such as dietary adjustments, fiber supplements, constipating agents, or mini-enemas 3
- Biofeedback therapy can be offered to improve external anal sphincter function, although the evidence for long-term effects is poor 3, 4
- Colonic irrigation has been shown to reduce symptoms and improve quality of life, especially in patients with neurogenic fecal incontinence 3
- Sacral nerve stimulation is a minimally invasive procedure with a high rate of success and can be considered if conservative measures fail 3, 4, 5, 6
- Anal sphincter exercises (pelvic floor muscle training) can be effective in treating fecal incontinence, with some studies suggesting that "good" in-home practice makes perfect 7
- Surgical interventions, such as anal sphincteroplasty, can be considered for patients with severe fecal incontinence, but are typically reserved for those who have failed other treatments 3, 5, 6
- Devices placed anally or vaginally, as well as colonic diversion, may be considered for severely affected individuals for whom other interventions fail 6
Factors Influencing Treatment Outcomes
- "Good" anal sphincter exercise technique and longer in-home practice have been associated with improved response to biofeedback therapy 7
- Dropout rates can be high, with reasons for dropout including lack of improvement or dissatisfaction with treatment 7
- Customizing biofeedback therapy intensity based on predictive factors and encouraging in-home practice may optimize outcomes and reduce dropout rates 7
Diagnostic Evaluation
- A focused history and physical examination are essential for the initial clinical evaluation of fecal incontinence 6
- Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment 6
- Invasive diagnostic testing and imaging are generally not needed to initiate treatment but may be considered in complex cases 6