What are the treatment options for fecal incontinence?

Treatment of Fecal Incontinence

All patients with fecal incontinence must begin with a rigorous trial of conservative therapies before considering any surgical interventions, as many patients referred for surgery have not received adequate conservative management. 1, 2

Initial Conservative Management (First-Line Therapy)

Identify and Treat Underlying Causes

• Bowel disturbances, particularly diarrhea, are the most important risk factor (OR=53) and must be addressed first 1
• Perform meticulous characterization of bowel habits, timing of incontinence episodes relative to meals and activities, and prior treatments 1, 2
• Identify and eliminate poorly absorbed sugars (sorbitol, fructose) and caffeine from the diet—this benefits approximately 25% of patients 2
• Discontinue medications that may worsen diarrhea or affect sphincter function 1

Medical Therapies

• Loperamide is the primary antidiarrheal agent—it slows intestinal motility, increases anal sphincter tone, prolongs intestinal transit time, and reduces fecal volume and urgency 3
• Bile acid sequestrants for bile acid diarrhea 2
• Fiber supplementation to improve stool consistency and bulk 2
• Anticholinergic agents as adjunctive therapy 2

Behavioral Interventions

• Scheduled toileting programs to establish regular bowel habits 2
• Pelvic floor exercises to strengthen musculature 2
• Bowel training programs 1, 2

Second-Line: Biofeedback Therapy

Pelvic floor retraining with biofeedback therapy should be implemented when simple measures fail—this involves working with therapists using electronic and mechanical devices to improve pelvic floor strength, sensation, and coordination 1

• Biofeedback improves symptoms in more than 70% of patients with defecatory disorders 1
• The motivation of patient and therapist, frequency and intensity of retraining, and involvement of behavioral psychologists contribute to success 1

Diagnostic Testing for Refractory Cases

Anorectal testing should be performed only after failure of conservative therapies and biofeedback 1, 2

Essential Tests

• Anorectal manometry to identify anal weakness, altered rectal sensation, or impaired rectal balloon expulsion 2
• Endoanal ultrasound or MRI to identify sphincter defects, atrophy, and patulous anal canal 2

Minimally Invasive Interventions

Perianal Bulking Agents

• Consider dextranomer microspheres when conservative measures and biofeedback fail—52% of patients show ≥50% improvement in incontinence episodes at 6 months 2
• This is less invasive than sacral nerve stimulation and should be considered before more aggressive interventions 1

Sacral Nerve Stimulation (SNS)

• SNS is the preferred surgical option for moderate to severe fecal incontinence after failed conservative and biofeedback therapy 1, 2
• At 12 months, 71% of patients receiving permanent SNS achieved ≥50% reduction in FI frequency 1
• SNS is safe and effective with lower complication rates than other surgical procedures 1

Barrier Devices

• Offer barrier devices to patients who have failed conservative or surgical therapy, or those who refuse more invasive interventions 1

Percutaneous Tibial Nerve Stimulation (PTNS)

• PTNS should NOT be used for managing fecal incontinence in clinical practice due to insufficient evidence—one RCT showed no significant difference between PTNS (38%) and sham stimulation (31%) for ≥50% reduction in FI frequency 1

Surgical Options

Sphincteroplasty

• Anal sphincter repair should be considered in:
  • Postpartum women with FI 1, 2
  • Patients with recent sphincter injuries 1, 2
  • Patients presenting later with sphincter damage unresponsive to conservative and biofeedback therapy when perianal bulking and SNS are unavailable or unsuccessful 1

Advanced Surgical Options (Reserved for Severe, Refractory Cases)

• Artificial anal sphincter or dynamic graciloplasty for severe, medically-refractory FI who have failed barrier devices, SNS, perianal bulking, sphincteroplasty, and are not candidates for colostomy 1, 2

Magnetic Anal Sphincter Device

• May be considered only after failure of all other options, but data regarding efficacy are limited and 40% of patients experience moderate or severe complications 1

Anatomic Defects

• Major anatomic defects must be surgically corrected—including rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloacal deformity 1

Colostomy

• A colostomy should be considered in patients with severe FI who have failed conservative treatment and all other interventions 1
• In tertiary centers, surgery is necessary in less than 5% of patients with fecal incontinence 1

Critical Pitfalls to Avoid

• Inadequate trial of conservative therapy is the most common error—many patients undergo surgical therapy without rigorous implementation of dietary modification, antidiarrheal medications, scheduled toileting, and biofeedback therapy 1, 2
• Failure to identify evacuation disorders with overflow incontinence—retained stool can masquerade as true fecal incontinence and requires different management 2
• Premature progression to invasive treatments without proper characterization of bowel habits and circumstances surrounding incontinence episodes 2