What is the best treatment approach for fecal incontinence in the elderly?

Treatment of Fecal Incontinence in the Elderly

All elderly patients with fecal incontinence should begin with a rigorous trial of conservative therapies—including dietary modification, antidiarrheal medications (particularly loperamide), fiber supplementation, scheduled toileting, and pelvic floor exercises—before considering any surgical or device-based interventions. 1, 2

Initial Assessment and Conservative Management

Step 1: Identify and Address Underlying Causes

• Perform digital rectal examination immediately to rule out fecal impaction, which causes overflow incontinence and is extremely common in elderly hospitalized patients 3
• Characterize bowel disturbances meticulously: diarrhea is the single most important risk factor (OR=53) for fecal incontinence in older women, far exceeding obstetric history 1
• Review medications: many elderly patients are on drugs that either promote diarrhea or constipation, contributing to incontinence 3, 4
• Assess mobility and cognitive status: dementia, physical disability, and immobility are major contributors in the elderly population 3, 5

Step 2: Implement Conservative Therapies Rigorously

For patients with diarrhea-predominant fecal incontinence:

• Start loperamide 2 mg, one tablet 30 minutes before breakfast, titrating up to 16 mg daily as needed 1, 2
• Trial dietary elimination of poorly absorbed sugars (sorbitol, fructose) and caffeine, which benefits approximately 25% of patients 1, 2
• Consider bile acid sequestrants (cholestyramine or colesevelam) since bile-salt malabsorption is common in idiopathic diarrhea 1
• Alternative agents include anticholinergics and clonidine for refractory diarrhea 1

For all patients:

• Fiber supplementation improves stool consistency and reduces diarrhea-associated incontinence 1, 2
• Scheduled toileting and bowel training programs establish regular habits 2
• Pelvic floor exercises strengthen musculature, even in elderly patients 2

Step 3: Biofeedback Therapy

• Pelvic floor retraining with biofeedback should be offered to patients who fail initial conservative measures, using electronic and mechanical devices to improve pelvic floor strength, sensation, and rectal tolerance 1
• Biofeedback is feasible in many elderly patients, even those with age-related physiological changes 5

Advanced Diagnostic Testing (When Conservative Therapy Fails)

Only proceed to testing after an adequate trial of conservative therapy:

• Anorectal manometry identifies anal weakness, altered rectal sensation, or impaired rectal balloon expulsion 2
• Anal imaging (ultrasound or MRI) identifies sphincter defects, atrophy, and patulous anal canal 2

Minimally Invasive Interventions

For moderate to severe fecal incontinence refractory to conservative and biofeedback therapy:

• Sacral nerve stimulation (SNS) is the preferred surgical option, with 71% of patients achieving ≥50% reduction in incontinence episodes at 12 months 1, 2
• Perianal bulking agents (dextranomer microspheres) may be considered, with 52% showing ≥50% improvement at 6 months 2

Surgical Options (Rarely Needed)

• Surgery is necessary in fewer than 5% of patients with defecatory disorders, typically those with considerable pelvic organ or rectal prolapse 1
• Anal sphincter repair (sphincteroplasty) is reserved for postpartum women, recent sphincter injuries, or documented sphincter damage unresponsive to all other therapies 2
• Artificial anal sphincter or dynamic graciloplasty for severe, medically-refractory cases who have exhausted all other options 2

Special Considerations for the Elderly

Elderly-Specific Management Principles:

• Ensure toilet access, especially with decreased mobility—this is a critical prevention measure 1
• Optimize toileting: educate patients to attempt defecation twice daily, 30 minutes after meals, straining no more than 5 minutes 1
• Use polyethylene glycol (PEG) 17 g/day for elderly patients requiring laxatives—it offers efficacy with a good safety profile 1
• Avoid liquid paraffin in bed-bound patients or those with swallowing disorders due to aspiration pneumonia risk 1
• Use isotonic saline enemas rather than sodium phosphate enemas in older adults to avoid adverse effects 1
• Monitor for dehydration and electrolyte imbalances when using laxatives in patients on diuretics or cardiac glycosides 1

For Patients with Advanced Dementia or Severe Disability:

• Bowel habit training programs are more appropriate than biofeedback in patients with advanced dementia 5
• Nursing care measures include absorbent pads, special undergarments, anal hygiene, and meticulous skin care 3
• Accept that some patients will remain incontinent despite appropriate management due to irreversible dementia, immobility, or comorbidities 3

Critical Pitfalls to Avoid

• Do not proceed to invasive therapies without a rigorous trial of conservative management: many patients considered "refractory" have not received optimal conservative therapy 1, 2
• Do not use stool softeners or laxatives in patients with weak anal sphincter and diarrhea—these worsen incontinence 3
• Do not overlook fecal impaction with overflow: this is the most common reversible cause in hospitalized elderly patients 3
• Do not use bulk laxatives (psyllium) in non-ambulatory patients with low fluid intake—risk of mechanical obstruction 1
• Do not ignore underlying infections: check for C. difficile, E. coli O157, ova and parasites in patients with acute diarrhea and incontinence 3