What are the treatment options for fecal incontinence?

Treatment of Fecal Incontinence

All patients with fecal incontinence should begin with a rigorous trial of conservative therapies—including dietary modifications, antidiarrheal medications (particularly loperamide), fiber supplementation, and scheduled toileting—before considering any invasive interventions, as this stepwise approach restores continence in up to 25% of patients. 1, 2

Step 1: Conservative Medical Management (First-Line)

Dietary and Lifestyle Modifications

• Eliminate poorly absorbed sugars (sorbitol, fructose) and caffeine through careful dietary history and trial elimination, which benefits approximately 25% of patients 1
• Add fiber supplementation to improve stool consistency and reduce diarrhea-associated incontinence 3, 1
• Implement scheduled toileting and bowel training programs to establish regular bowel habits 1

Pharmacological Management

• Start loperamide 2 mg taken 30 minutes before breakfast, titrating up to 16 mg daily as needed for diarrhea control 3, 4
• Loperamide works by slowing intestinal motility, increasing anal sphincter tone, prolonging intestinal transit time, and reducing urgency and incontinence 4
• For patients with suspected bile-salt malabsorption (common in idiopathic diarrhea), trial cholestyramine or colesevelam 3
• Consider anticholinergic agents or clonidine as alternative options for diarrhea-associated fecal incontinence 3

Pelvic Floor Exercises

• Implement pelvic floor exercises to strengthen musculature in all appropriate patients 1

Step 2: Biofeedback Therapy (Second-Line)

• Pelvic floor retraining with biofeedback therapy should be offered when conservative measures fail, using electronic and mechanical devices to improve pelvic floor strength, sensation, and rectal tolerance 3
• Biofeedback produces satisfaction with treatment in up to 76% and continence in 55% of patients, though outcomes depend heavily on therapist skill 2

Step 3: Diagnostic Testing for Refractory Cases

Before proceeding to invasive interventions, perform targeted testing:

• 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

Step 4: Minimally Invasive Interventions

Perianal Bulking Agents

• Dextranomer microspheres may be considered when conservative measures and biofeedback fail, with 52% of patients showing ≥50% improvement in incontinence episodes at 6 months 1

Sacral Nerve Stimulation

• Sacral nerve stimulation is recommended for moderate to severe fecal incontinence after failed conservative and biofeedback therapy, producing ≥50% reduction in fecal incontinence frequency in a median 73% of patients 1, 2
• This minimally invasive procedure has a high success rate and should be prioritized over more invasive surgical options 5

Step 5: Surgical Options (Last Resort)

Sphincter Repair

• Anal sphincter repair (sphincteroplasty) is recommended for postpartum women with fecal incontinence, patients with recent sphincter injuries, and patients with sphincter damage unresponsive to conservative therapy 1
• Note that sphincteroplasty produces short-term clinical improvement in a median 67%, but 5-year outcomes are poor 2

Advanced Surgical Procedures

• Artificial anal sphincter or dynamic graciloplasty for severe, medically-refractory fecal incontinence who have failed other treatments, restricted to highly selected patients at specialist centers 1, 5
• Colostomy should be considered as a last resort if all other treatment modalities fail 5

Critical Pitfalls to Avoid

• Do not prematurely progress to invasive treatments without an adequate trial of conservative therapy, which must include meticulous characterization of bowel habits, circumstances surrounding fecal incontinence episodes (relationship to meals and activity), and prior treatments 3, 1
• Do not overlook underlying causes such as evacuation disorders with overflow of retained stool, which require laxatives and anorectal testing 3, 1
• Do not assume conservative therapy has failed unless the patient has received optimal trials of dietary elimination, appropriate antidiarrheal medications at adequate doses, and structured behavioral interventions 3