How to manage fecal incontinence in a 71-year-old male?

From the Guidelines

Managing fecal incontinence in a 71-year-old male should start with a stepwise approach, beginning with conservative therapies such as dietary changes, bowel training, and management of diarrhea and constipation, as these can benefit approximately 25% of patients 1.

Initial Management

• Dietary changes to increase fiber intake gradually to 20-30 grams daily through foods or supplements like psyllium (Metamucil, 1 tablespoon 1-3 times daily) can help regulate bowel movements.
• Establishing a regular bowel routine, preferably after meals when the gastrocolic reflex is strongest, can improve bowel habits.
• Pelvic floor exercises (Kegel exercises) performed 3 times daily with 10-15 repetitions can strengthen relevant muscles and improve continence.
• For skin protection, using barrier creams containing zinc oxide or petroleum jelly after each bowel movement is essential to prevent irritation.

Medications and Further Interventions

• Medications may include loperamide (Imodium) starting at 2mg after each loose stool, up to 8mg daily, or fiber supplements like methylcellulose to help manage diarrhea and constipation.
• Absorbent products such as adult briefs can help manage accidents and improve quality of life.
• For patients who do not respond to conservative measures, pelvic floor retraining with biofeedback therapy is recommended 1.
• Further interventions such as perianal bulking agents, sacral nerve stimulation, or surgical options like sphincter repair or colostomy may be considered for refractory cases, based on the severity of symptoms and patient eligibility 1.

Investigation and Follow-Up

• Investigating the underlying cause of fecal incontinence is crucial, as it may result from neurological conditions, sphincter damage, rectal prolapse, or medication side effects.
• Regular follow-up is essential to adjust the management plan as needed and to address any complications or side effects of treatments.

From the FDA Drug Label

Loperamide increases the tone of the anal sphincter, thereby reducing incontinence and urgency. Loperamide prolongs the transit time of the intestinal contents It reduces daily fecal volume, increases the viscosity and bulk density, and diminishes the loss of fluid and electrolytes.

Management of Fecal Incontinence: Loperamide may be used to manage fecal incontinence in a 71-year-old male by increasing the tone of the anal sphincter and reducing incontinence and urgency.

• The drug works by slowing intestinal motility and affecting water and electrolyte movement through the bowel.
• It is essential to follow the recommended dosage and administration instructions for loperamide to ensure effective management of fecal incontinence 2.

From the Research

Management of Fecal Incontinence

The management of fecal incontinence in a 71-year-old male involves a multi-faceted approach, including medical, surgical, and lifestyle modifications.

• Medical Management: The first line of treatment for fecal incontinence includes the use of antidiarrheal medications such as loperamide and diphenoxylate, as well as fiber supplements 3, 4, 5. These medications can help to decrease intestinal motility and stool frequency, resulting in more formed stools and improved continence.
• Surgical Options: For patients who fail medical management or have evidence of sphincter weakness, surgical options such as anorectal manometry and endoanal ultrasound may be recommended 3. Biofeedback is also a harmless and inexpensive treatment that can benefit approximately 75% of patients, although it may only cure about 50% 3.
• Lifestyle Modifications: Lifestyle modifications, such as increasing fluid intake and dietary fiber, improving mobility, and eliminating the concurrent use of constipating drugs, can also help to improve fecal incontinence 5.
• Investigational Treatments: Investigational treatments, such as implanted nerve stimulators, artificial sphincters, and anal plugs, may also be considered for patients who do not respond to traditional treatments 3.
• Individualized Treatment: It is essential to note that individualized treatment is crucial, as some patients may respond better to more fiber, while others may respond better to less fiber 6.

Treatment Considerations

When considering treatment options for fecal incontinence, it is essential to take into account the patient's mental status, mobility impairment, and typical bowel habits 3. Additionally, the patient's age and overall health status should also be considered, as these factors can impact the effectiveness and safety of various treatments.

Diagnostic Evaluation

A thorough diagnostic evaluation, including a physical examination, medical history, and diagnostic tests such as anorectal manometry and endoanal ultrasound, is necessary to determine the underlying cause of fecal incontinence and to guide treatment decisions 3, 7.

Updated Treatment Strategies

Recent studies have updated our understanding of the treatment strategies for fecal incontinence, including the use of sacral nerve stimulation and anal sphincter augmentation 7. These treatments may be considered for patients who do not respond to traditional medical and surgical treatments.