What is the most appropriate management for a 90-year-old woman with worsening fecal incontinence, residual memory loss, dysphasia, and right-sided muscle weakness due to a previous stroke, with medical history including hyperlipidemia, hypothyroidism, and chronic constipation, currently taking atorvastatin and levothyroxine?

From the Guidelines

The most appropriate management for this 90-year-old woman with fecal incontinence is a stepwise approach starting with conservative therapies, including diet, fluids, and techniques to improve evacuation, as well as management of diarrhea and constipation with diet and medications if necessary, as recommended by the 2017 study 1. This patient has multiple risk factors for fecal incontinence, including advanced age, history of stroke with residual neurological deficits, and chronic constipation.

Key Considerations

• The patient's cognitive impairment and inability to follow commands make biofeedback therapy inappropriate, as it requires active patient participation and understanding 1.
• Loperamide therapy could be considered but may worsen her underlying constipation, and its use should be carefully weighed against potential benefits.
• Surgical interventions like overlapping sphincteroplasty or sacral nerve stimulation are too invasive for this elderly patient with multiple comorbidities and would likely provide minimal benefit given her overall condition.

Management Approach

• The patient should start with a soluble fiber supplement like psyllium (Metamucil) at a dose of 1 tablespoon mixed in water once daily, gradually increasing to twice daily as tolerated, to help regulate bowel movements and add bulk to the stool, making it easier to control defecation.
• Adequate hydration should accompany fiber supplementation to prevent worsening constipation.
• Addressing the perianal skin irritation with barrier creams and ensuring proper hygiene will improve her comfort while the fiber supplementation takes effect.

Additional Considerations

• The patient's medical history, including hyperlipidemia, hypothyroidism, and chronic constipation, should be taken into account when managing her fecal incontinence, and medications like atorvastatin and levothyroxine should be continued as prescribed.
• The patient's right-sided muscle weakness due to the previous stroke should be considered when developing a bowel training program, and assistance may be needed to ensure proper toileting and hygiene. As recommended by the 2017 study 1, a stepwise approach should be followed for the management of fecal incontinence, starting with conservative therapies, and progressing to more invasive treatments only if necessary and if the patient is a suitable candidate.

From the Research

Management of Fecal Incontinence

The management of fecal incontinence in a 90-year-old woman with a history of stroke, hyperlipidemia, hypothyroidism, and chronic constipation requires a comprehensive approach. The following steps can be considered:

• A thorough diagnostic workup, including patient history, daily stool protocol, and digital rectal investigation, as well as additional investigations such as anorectal manometry, anal sphincter EMG, and defecography, to characterize the different manifestations of fecal incontinence 2
• Conservative therapeutic interventions, including nutritional training, food fibre content, pharmacological treatment of diarrhea/constipation, toilet training, pelvic floor gymnastic, anal sphincter training, and biofeedback, provided in close cooperation with gastroenterologists, surgeons, gynecologists, urologists, physiotherapists, and psychologists 2, 3
• Sacral nerve stimulation, which has emerged as a treatment of choice for patients with fecal incontinence who have failed conservative management, with beneficial effects substantiated by multiple studies 4, 5, 6
• Consideration of surgical therapy, such as the STARR operation for rectoanal prolapse, only after a complete diagnostic workup and failure of all conservative treatment options 2

Considerations for the Patient's Medical History

The patient's medical history, including hyperlipidemia, hypothyroidism, and chronic constipation, should be taken into account when managing her fecal incontinence. The following considerations can be made:

• The patient's current medications, including atorvastatin and levothyroxine, should be reviewed to ensure they are not contributing to her fecal incontinence 2
• The patient's chronic constipation should be managed with dietary modifications, medications, and bowel habits training to prevent worsening of fecal incontinence 5, 3
• The patient's right-sided muscle weakness due to a previous stroke should be considered when developing a pelvic floor exercise program or biofeedback therapy 3

Treatment Options

The following treatment options can be considered for the patient:

• Biofeedback therapy, which has been shown to be effective in managing fecal incontinence and defecatory disorders 5, 3
• Sacral nerve stimulation, which has been shown to be effective in managing fecal incontinence in patients who have failed conservative management 4, 5, 6
• Pelvic floor physical therapy, which can help improve pelvic floor muscle strength and coordination 3
• Pharmacological treatment of diarrhea/constipation, which can help manage bowel disturbances and prevent worsening of fecal incontinence 2, 5