What are the treatment options for fecal incontinence?

Treatment Options for Fecal Incontinence

A stepwise approach should be followed for the management of fecal incontinence, beginning with conservative therapies before progressing to more invasive interventions. 1

First-Line Conservative Therapies

Conservative measures should be tried first and will benefit approximately 25% of patients:

• Dietary modifications to identify and eliminate poorly absorbed sugars (sorbitol, fructose) and caffeine that may contribute to diarrhea 1, 2
• Fiber supplementation to improve stool consistency and reduce diarrhea-associated incontinence 1
• Scheduled toileting and bowel training programs to establish regular bowel habits 1
• Pelvic floor exercises to strengthen musculature 1
• Medications for diarrhea management:
  • Loperamide (2-16 mg daily) - first-line medication, starting with 1 tablet 30 minutes before breakfast and titrating as needed 1, 3
  • Bile acid sequestrants (cholestyramine, colesevelam) for suspected bile salt malabsorption 1
  • Anticholinergic agents and clonidine as alternative options 1
• Laxatives and rectal cleansing for patients with constipation and overflow incontinence 1

Second-Line Therapy

• Pelvic floor retraining with biofeedback therapy is recommended for patients who don't respond to conservative measures 1, 4
  • Works by improving pelvic floor strength, sensation, contraction, and rectal tolerance 1, 4
  • Can identify and address underlying rectal evacuation disorders 1

Diagnostic Testing for Refractory Cases

For patients who don't respond to conservative measures and biofeedback:

• Anorectal manometry to identify anal weakness, altered rectal sensation, or impaired rectal balloon expulsion 1
• Anal imaging (ultrasound or MRI) to identify sphincter defects, atrophy, and patulous anal canal 1

Minimally Invasive Interventions

• Perianal bulking agents (dextranomer microspheres) may be considered when conservative measures and biofeedback therapy fail 1

  • FDA-approved for fecal incontinence 1
  • 52% of patients showed ≥50% improvement in incontinence episodes at 6 months 1
  • Common side effects include proctalgia (14%), fever (8%), and rectal bleeding (7%) 1

• Sacral nerve stimulation for moderate to severe FI after failed conservative and biofeedback therapy 1

  • Involves continuous pulsed electrical stimulation of sacral nerves 1
  • Initially provided by external stimulator; if 50% or more reduction in FI occurs, permanent implantation is performed 1

• Barrier devices for patients who have failed conservative or surgical therapy 1

Surgical Options

• Anal sphincter repair (sphincteroplasty) for:

  • Postpartum women with FI 1
  • Patients with recent sphincter injuries 1
  • Patients with sphincter damage unresponsive to conservative and biofeedback therapy 1

• Artificial anal sphincter or dynamic graciloplasty for severe, medically-refractory FI who have failed other treatments 1

• Surgical correction for major anatomic defects (rectovaginal fistula, rectal prolapse, etc.) 1

• Colostomy as a last resort for severe FI who have failed all other interventions 1

Common Pitfalls to Avoid

• Inadequate trial of conservative therapy - Many patients considered refractory have not received an optimal trial of conservative measures 1

• Failure to identify underlying causes - A meticulous characterization of bowel habits and circumstances surrounding FI is essential 1

• Overlooking overflow incontinence - Patients with fecal seepage may have evacuation disorders with overflow of retained stool 1

• Not recognizing the impact on quality of life - FI can have devastating effects on daily functioning, confidence, and social interactions 1, 5

• Premature progression to invasive treatments - The stepwise approach should be followed diligently before considering surgical options 1