From the Guidelines
Fecal burden should be managed with a combination of lifestyle modifications and medications, starting with osmotic laxatives like polyethylene glycol (MiraLAX) 17 grams mixed in 8 ounces of water daily for 3-7 days, as recommended by the most recent guidelines 1. To address fecal burden, it is essential to increase dietary fiber intake to 25-30 grams daily, drink at least 2 liters of water per day, and engage in regular physical activity.
Medication Management
For medication management, the following options can be considered:
- Osmotic laxatives like polyethylene glycol (MiraLAX) 17 grams mixed in 8 ounces of water daily for 3-7 days
- Stimulant laxatives such as bisacodyl (Dulcolax) 5-10 mg orally or as a 10 mg suppository, if significant impaction is present
- Enemas, such as Fleet enemas or mineral oil retention enemas, for severe cases
Enema Use
Enemas can be effective in managing fecal burden, but their use should be guided by the presence of a full rectum or fecal impaction, as identified by digital rectal examination (DRE) 1. The choice of enema type depends on the individual patient's needs and medical history, with options including:
- Normal saline enemas to distend the rectum and moisten stools
- Osmotic micro-enemas, which contain a combination of agents to soften the stool and stimulate bowel contractions
- Hypertonic sodium phosphate enemas, which distend and stimulate rectal motility
- Docusate sodium enemas, which soften stool by aiding water penetration of the fecal mass
Maintenance Therapy
After the initial cleanout, maintenance therapy with daily fiber supplements and regular osmotic laxatives may be needed to prevent recurrence of fecal burden 1. Regular bowel habits, proper hydration, and adequate fiber intake help maintain normal stool consistency and prevent the reaccumulation of fecal matter in the colon. It is crucial to note that fecal burden occurs when colonic motility is decreased or when there is inadequate fluid in the stool, making it difficult to pass. Therefore, a comprehensive approach that addresses these underlying factors is essential for effective management.
From the Research
Fecal Burden Management
- Fecal incontinence is a multifactorial disorder that imposes considerable social and economic burdens 2
- Successful management of fecal incontinence depends on identifying and treating underlying cause(s), such as infection, dietary factors, medication, or immobility-induced incontinence, constipation, or fecal impaction 3
- Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits 2, 4, 5
Treatment Options
- Medications such as loperamide or diphenoxylate/atropine are useful for diarrhea with incontinence 3
- Laxatives (eg, polyethylene glycol, lactulose), secretagogues (eg, lubiprostone), enemas, suppositories, and timed toileting assistance may be effective for constipation 3
- Sacral nerve stimulation has shown reasonable short-term effectiveness and some complications 2, 5, 6
- Injecting an inert bulking agent around the anal canal led to ≥50% reductions of FI in up to 53% of patients 5
Nursing Care
- Nursing care includes use of absorbent pads, special undergarments, anal hygiene, and skin care 3
- Biofeedback therapy is modestly effective in treating fecal incontinence 2, 5
- Patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients 5