What is the treatment for fecal incontinence (incontinence of bowel movements)?

Treatment for Fecal Incontinence

Biofeedback therapy is the first-line treatment for fecal incontinence, with success rates exceeding 70% in patients with defecatory disorders. 1

Initial Assessment and Conservative Management

Step 1: Characterize the Type of Fecal Incontinence

• Urge incontinence: Inability to delay defecation when feeling the urge
• Passive incontinence: Leakage without awareness
• Combined: Features of both types

Step 2: Address Underlying Bowel Disturbances

• For diarrhea-associated incontinence:

  • Identify and eliminate dietary triggers (sorbitol, fructose, caffeine) 1
  • Loperamide (2 mg): Start with 1 tablet 30 minutes before breakfast, titrate up to 16 mg daily 1, 2
    • Acts by slowing intestinal motility and increasing anal sphincter tone 2
  • Fiber supplementation to improve stool consistency 1
  • Consider cholestyramine or colesevelam for bile-salt malabsorption 1

• For constipation with overflow incontinence:

  • Osmotic laxatives (polyethylene glycol 17g daily, milk of magnesia) 1
  • Stimulant laxatives (bisacodyl, glycerol suppositories) 1
  • Small-volume enemas or tap water rectal cleansing to prevent leakage 1

Step 3: Implement Behavioral Techniques

• Scheduled toileting and bowel training program 1
• Pelvic floor exercises to strengthen musculature 1

Advanced Management for Refractory Cases

Step 4: Specialized Testing

For patients who don't respond to conservative measures:

• Anal manometry to identify sphincter weakness 1
• Anal imaging (ultrasound or MRI) to identify sphincter defects 1

Step 5: Biofeedback Therapy

• Improves symptoms in >70% of patients 1
• Uses electronic/mechanical devices to improve:
  • Pelvic floor strength
  • Pelvic floor sensation and contraction
  • Rectal sensation and tolerance of rectal distention 1
• Helps patients learn to relax pelvic floor muscles during straining 1
• Success depends on patient motivation and therapist expertise 1

Step 6: Minimally Invasive Interventions

If biofeedback fails:

• Perianal bulking injection (NASHA Dx) 1
  • 52% of patients show ≥50% improvement in FI episodes
  • Most common side effects: proctalgia (14%) and fever (8%)

Step 7: Surgical Options

Consider only after failure of conservative and minimally invasive approaches:

• Sphincteroplasty for patients with sphincter damage 1
• Sacral nerve stimulation 1
• Magnetic anal sphincter device (limited evidence, high complication rate) 1
• Colostomy as last resort for severe, refractory cases 1

Common Pitfalls to Avoid

1. Inadequate conservative management: Many patients considered "refractory" haven't received optimal trials of conservative therapy 1

2. Missing overflow incontinence: Patients with fecal seepage often have evacuation disorders with overflow of retained stool 1

3. Focusing only on sphincter function: Bowel disturbances, particularly diarrhea, are often the most important risk factors 3

4. Neglecting to ask about symptoms: Many patients don't volunteer information about fecal incontinence due to embarrassment 3

5. Delayed treatment: Early intervention with biofeedback therapy can prevent progression and improve quality of life 1, 3

By following this algorithmic approach and addressing both bowel habits and pelvic floor function, most patients with fecal incontinence can achieve significant improvement in symptoms and quality of life.