From the Guidelines
The best next step in management for this 28-year-old woman with fecal incontinence following a third-degree perineal laceration during vaginal delivery is to follow a stepwise approach, starting with conservative therapies such as diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary, as approximately 25% of patients may benefit from these measures 1.
Initial Management
The patient is experiencing postpartum fecal and flatal incontinence due to injury to the anal sphincter complex during delivery. Given the recent study from 2024, it is essential to consider the severity of perineal damage and the technique used for repair, as these factors can impact the risk of wound complications and long-term morbidity 1.
- The initial management should focus on conservative measures to improve symptoms and prevent further complications.
- The patient should be advised to maintain adequate fiber intake and consider stool softeners to prevent constipation, which could exacerbate her symptoms.
Pelvic Floor Rehabilitation
If conservative measures are insufficient, pelvic floor retraining with biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative measures 1.
- This therapy typically includes biofeedback techniques, electrical stimulation, and targeted exercises to rehabilitate the pelvic floor muscles.
- The goal of pelvic floor physical therapy is to strengthen the damaged muscles and improve sphincter function, which can help alleviate symptoms of fecal and flatal incontinence.
Further Interventions
If conservative management fails after several months, sacral nerve stimulation should be considered for patients with moderate or severe fecal incontinence 1.
- Other options, such as perianal bulking agents or surgical repair of the sphincter (secondary sphincteroplasty), may also be considered in selected cases.
- The patient should be reassured that postpartum fecal incontinence often improves with time and appropriate therapy, though complete resolution may take several months.
From the Research
Management of Fecal and Flatal Incontinence
The management of fecal and flatal incontinence in a 28-year-old postpartum woman following a spontaneous vaginal delivery complicated by a third-degree perineal laceration can be approached through various methods, including:
- Biofeedback therapy
- Anal sphincter exercises (pelvic floor muscle training)
- Electrical stimulation
- Sacral nerve stimulation
Biofeedback Therapy and Anal Sphincter Exercises
Studies have shown that biofeedback therapy and anal sphincter exercises may be effective in improving fecal incontinence symptoms 2, 3, 4. However, the evidence is limited by the small number of trials and methodological weaknesses. Some studies suggest that rectal volume discrimination training improves continence more than sham training, and that anal biofeedback combined with exercises and electrical stimulation provides more short-term benefits than vaginal biofeedback and exercises for women with obstetric-related fecal incontinence 2, 3, 4.
Sacral Nerve Stimulation
Sacral nerve stimulation has been shown to be effective in treating fecal incontinence, with improvement of quality of life in over 80% of patients treated 5. This technique has a screening phase with a high predictive value and is associated with minimal complications. However, most published reports of sacral nerve stimulation for treatment of fecal incontinence were case studies, and criteria for patient selection are evolving and yet to be defined.
Effectiveness of Biofeedback and Exercises
A systematic review of 46 studies on the effectiveness of biofeedback as a treatment for fecal incontinence in adults found that 49% of patients were cured of symptoms of fecal incontinence following biofeedback therapy, and 72% of patients were reported to be cured or improved 6. However, the studies varied in method, criteria for success, and outcome measures, and only eight of the 46 studies employed a control group.
Next Steps
Based on the available evidence, the next steps in managing the patient's fecal and flatal incontinence could include: