Treatment Options for Fecal Urgency
Loperamide is the first-line pharmacological treatment for fecal urgency, starting at 2 mg taken 30 minutes before breakfast and titrated as necessary up to 16 mg daily to reduce urgency and improve stool consistency. 1
First-Line Treatments
Dietary and Lifestyle Modifications
- Perform a careful dietary history to identify and eliminate poorly absorbed sugars (e.g., sorbitol, fructose) and caffeine that may contribute to urgency 1
- Fiber supplementation can improve stool consistency and reduce diarrhea-associated urgency 1
- Scheduled toileting and bowel training programs can help manage urgency symptoms 1
Pharmacological Management
Antidiarrheals:
- Loperamide (2-16 mg daily) is the most effective first-line medication for urgency, with many patients learning to use it prophylactically before situations where urgency would be problematic 1
- Start with 2 mg taken 30 minutes before breakfast and titrate as needed 1
- Can be given as divided doses throughout the day or as a single 4 mg dose at night 1
- Reduces stool frequency and urgency by slowing intestinal transit 1, 2
Bile Acid Sequestrants:
- Cholestyramine or colesevelam should be considered when bile salt malabsorption is suspected, which is common in patients with idiopathic diarrhea 1
- Particularly effective for patients with a history of ileal resection or cholecystectomy 1
- About 10% of diarrhea-predominant IBS patients show evidence of bile salt malabsorption 1
- Note that tolerability of cholestyramine is poor, and many patients prefer loperamide which is equally effective 1
Second-Line Treatments
Antispasmodics
- Anticholinergics (dicyclomine, hyoscine) or direct smooth muscle relaxants (mebeverine, alverine citrate) can reduce urgency related to intestinal spasms 1
- Most effective when urgency is associated with abdominal pain and cramping 1
- Anticholinergics may cause dry mouth which can limit their use 1
Antidepressants
- Tricyclic antidepressants (TCAs) like imipramine normalize rapid small bowel transit in diarrhea-predominant conditions 1
- Low doses (50 mg) or higher doses (150 mg) of TCAs (trimipramine, amitriptyline) can be effective, with nocturnal dosing producing the best response 1
- Be aware that constipation is a common side effect of TCAs 1
5-HT Receptor Antagonists
- Alosetron (5-HT3 antagonist) is effective for diarrhea-predominant IBS with urgency 1, 3
- In clinical trials, 50% of patients with urgency on 5+ days per week had urgency reduced to no more than 1 day in the last week of treatment (vs. 29% on placebo) 3
- 12% of patients on alosetron had urgency no more than 2 days per week throughout the 12-week treatment period (vs. 1% on placebo) 3
Advanced Treatments
Biofeedback Therapy
- Pelvic floor retraining with biofeedback therapy can improve pelvic floor strength, sensation, and contraction 1
- Particularly useful for patients with fecal urgency related to pelvic floor dysfunction 1
Combination Therapy
- For persistent symptoms, combining treatments may be necessary:
Special Considerations
Underlying Conditions
- Fecal urgency may be a symptom of irritable bowel syndrome, inflammatory bowel disease, or post-surgical complications 6
- A meticulous characterization of bowel habits and circumstances surrounding urgency (e.g., relationship to meals and activity) is essential for targeted treatment 1
Diagnostic Testing
- For refractory cases, consider anorectal manometry to identify anal weakness, altered rectal sensation, or impaired rectal balloon expulsion 1
- Imaging with ultrasound or MRI may be needed to identify structural issues contributing to urgency 1
Common Pitfalls
- Failing to provide an adequate trial of conservative therapy before moving to advanced treatments 1
- Not recognizing that urgency with constipation may represent overflow incontinence requiring different management 1
- Withholding treatment based on the misconception that diarrhea is a defense mechanism that should not be treated 1