How to manage fecal incontinence in patients with urinary incontinence?

Management of Fecal Incontinence in Patients with Urinary Incontinence

A comprehensive bowel management program should be implemented for patients with concurrent fecal and urinary incontinence, including assessment of underlying causes, dietary modifications, scheduled toileting, and appropriate use of medications and pelvic floor exercises. 1

Assessment of Underlying Causes

• Medical history assessment:

  • Previous bowel habits (frequency, consistency, timing)
  • Prior bowel care practices
  • Cognitive awareness of bowel signals
  • Mobility status and ability to reach toilet
  • Medications that may contribute to incontinence

• Physical examination:

  • Assess for fecal impaction (a common cause of overflow incontinence)
  • Evaluate rectal tone and sphincter function
  • Check for neurological deficits affecting bowel control

Management Algorithm

Step 1: Address Modifiable Factors

• Optimize stool consistency:

  • Ensure adequate fluid intake (1.5-2L daily)
  • Provide sufficient dietary fiber (15g daily)
  • Consider bulk-forming agents for loose stools
  • Use stool softeners for constipation

• Medication management:

  • Review and adjust medications that may cause diarrhea
  • Consider loperamide for loose stools and urgency 2
  • Use appropriate laxatives for constipation (osmotic agents or stimulants based on individual needs)

Step 2: Implement Behavioral Interventions

• Establish a regular toileting schedule:

  • Offer toilet access every 2 hours while awake and every 4 hours at night 1
  • Schedule toileting after meals to take advantage of the gastrocolic reflex
  • Ensure toilet accessibility and adequate time for elimination

• Prompted voiding techniques:

  • Implement for both urinary and fecal incontinence 1
  • Train caregivers to recognize and respond to patient cues

Step 3: Physical Rehabilitation

• Pelvic floor muscle training:
  • Implement exercises for both anal and urinary sphincter control 1
  • Consider biofeedback therapy for patients with dyssynergic defecation patterns 3, 4
  • Combine rapid squeeze exercises with sustained submaximal contractions 4

Step 4: Assistive Devices and Advanced Interventions

• For refractory cases:
  • Consider anal plugs or vaginal devices for mechanical support 5
  • Evaluate for sacral neurostimulation in appropriate candidates
  • Surgical options (sphincteroplasty) for severe cases unresponsive to conservative measures 6

Special Considerations

• Post-stroke patients:

  • Fecal incontinence affects 30-40% of hospitalized stroke patients but decreases to 7-9% by 6 months 1
  • The strongest risk factor for persistent fecal incontinence is inability to access the toilet independently 1
  • Assess cognitive awareness of bowel function 1

• Elderly patients:

  • Higher prevalence of both urinary and fecal incontinence
  • Often have multiple contributing factors including decreased rectal sensation and reduced sphincter function 6
  • May require more intensive support for toileting

Monitoring and Follow-up

• Use standardized assessment tools to document baseline severity and track improvement
• Reassess effectiveness of interventions regularly
• Adjust management plan based on response

Pitfalls to Avoid

• Failing to identify fecal impaction - Always check for this as it can cause overflow incontinence that mimics diarrhea
• Focusing only on urinary incontinence - Both conditions require simultaneous management for optimal outcomes
• Overlooking dyssynergic defecation - Present in up to 89% of nursing home residents with fecal incontinence 3
• Inadequate fluid intake - Restricting fluids to manage urinary incontinence can worsen constipation and fecal incontinence

By implementing this structured approach to managing concurrent fecal and urinary incontinence, clinicians can significantly improve patient outcomes, reduce complications, and enhance quality of life.