How to manage fecal incontinence?

Management of Fecal Incontinence

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

Initial Assessment and Risk Factors

• Identify risk factors including diarrhea (strongest risk factor with OR=53), cholecystectomy, smoking, rectocele, stress urinary incontinence, and higher BMI 2
• Other associated conditions include advanced age, diabetes, anal sphincter trauma (obstetrical injury, prior surgery), decreased physical activity, inflammatory bowel disease, and neurological disorders 2, 3
• Determine the type of incontinence (urge, passive, or combined) to guide treatment approach 3

First-Line Conservative Management

Dietary Modifications

• Conduct a meticulous dietary history to identify and eliminate poorly absorbed sugars (sorbitol, fructose) and caffeine that may contribute to diarrhea 2, 1
• Implement fiber supplementation to improve stool consistency and reduce diarrhea-associated incontinence 2, 1

Behavioral Interventions

• Establish scheduled toileting and bowel training programs to develop regular bowel habits 1
• Implement pelvic floor exercises to strengthen musculature 1

Pharmacological Management

• For diarrhea-associated incontinence, start with loperamide (2 mg) taken 30 minutes before breakfast and titrate as necessary up to 16 mg daily 2, 4
• Loperamide increases anal sphincter tone and reduces urgency while slowing intestinal motility 4
• Consider bile acid sequestrants (cholestyramine or colesevelam) for patients with suspected bile salt malabsorption 2, 5
• Alternative medications include anticholinergic agents and clonidine for diarrhea-related incontinence 2, 6
• For constipation with overflow incontinence, appropriate laxatives should be prescribed 2

Second-Line Interventions

Biofeedback Therapy

• Pelvic floor retraining with biofeedback therapy should be implemented when first-line measures are inadequate 2, 1
• Biofeedback helps improve pelvic floor strength, sensation, contraction, rectal sensation, and tolerance of rectal distention 2, 7

Diagnostic Testing for Refractory Cases

• Perform anorectal manometry to identify anal weakness, altered rectal sensation, or impaired rectal balloon expulsion 2, 1
• Conduct anal imaging with ultrasound or MRI to identify sphincter defects, atrophy, and patulous anal canal, particularly before considering surgical interventions 2, 1

Advanced Interventions for Refractory Cases

Minimally Invasive Procedures

• Consider perianal bulking agents (dextranomer microspheres) when conservative measures fail, with approximately 52% of patients showing ≥50% improvement in incontinence episodes at 6 months 1, 7
• Implement sacral nerve stimulation for moderate to severe fecal incontinence after failed conservative and biofeedback therapy 1, 7

Surgical Options

• Anal sphincter repair (sphincteroplasty) is appropriate for postpartum women with fecal incontinence, patients with recent sphincter injuries, and those with sphincter damage unresponsive to conservative therapy 1, 8
• Consider artificial anal sphincter or dynamic graciloplasty for severe, medically-refractory fecal incontinence in patients who have failed other treatments 1, 7

Special Considerations

For Constipation-Related Incontinence

• Evaluate for evacuation disorders with overflow of retained stool in the rectum, which can be effectively managed with pelvic floor biofeedback therapy 2, 5
• Consider rectal cleansing with small enemas or tap water to reduce stool leakage 2

For Patients with Neurological Conditions

• Implement more aggressive bowel management programs including scheduled defecation and manual disimpaction if necessary 3, 9

Common Pitfalls to Avoid

• Inadequate trial of conservative therapy before progressing to invasive treatments 2, 1
• Failure to identify underlying causes such as evacuation disorders with overflow incontinence 2, 5
• Not recognizing the significant impact of fecal incontinence on quality of life, which may require psychological support 2, 3
• Overlooking medication side effects that may contribute to incontinence 6, 9