What is the best approach for treating fecal incontinence in an elderly patient?

Treatment of Fecal Incontinence in the Elderly

All elderly patients with fecal incontinence must begin with a rigorous trial of conservative therapies before considering any surgical or device-based interventions, as many patients labeled "refractory" have simply not received optimal conservative management. 1

Step 1: Address Diarrhea First—The Single Most Important Risk Factor

Diarrhea is the dominant risk factor for fecal incontinence in older adults, with an odds ratio of 53 compared to other causes. 1 This makes controlling stool consistency your primary therapeutic target.

Pharmacologic management:

• Start loperamide 2 mg, one tablet 30 minutes before breakfast, titrating up to 16 mg daily as needed for diarrhea-predominant fecal incontinence. 1
• This antidiarrheal approach is more effective than attempting to strengthen a weakened sphincter when liquid stool is the problem. 2

Dietary interventions:

• Trial elimination of poorly absorbed sugars (sorbitol, fructose) and caffeine—this benefits approximately 25% of patients. 1
• Add fiber supplementation to improve stool consistency and reduce diarrhea-associated incontinence. 1

Step 2: Rule Out Fecal Impaction with Overflow Incontinence

Perform a digital rectal examination on every hospitalized or institutionalized elderly patient with new-onset fecal incontinence to exclude fecal impaction. 2 Paradoxical diarrhea from overflow around impacted stool is common and easily missed.

If impaction is present:

• Discontinue all stool softeners and laxatives immediately, as these worsen incontinence. 2
• Perform manual disimpaction followed by enemas or suppositories. 3
• Establish maintenance therapy with polyethylene glycol 17 g/day to prevent recurrence. 3

Step 3: Optimize Toileting Access and Behavioral Measures

Critical environmental modifications:

• Ensure toilet access, especially for patients with decreased mobility—this is a prevention measure as important as any medication. 1
• Educate patients to attempt defecation twice daily, 30 minutes after meals when the gastrocolic reflex is strongest, straining no more than 5 minutes. 1
• Use scheduled toileting programs to establish regular bowel habits. 1

Pelvic floor exercises strengthen musculature even in elderly patients and should be prescribed. 1

Step 4: Advanced Interventions Only After Conservative Failure

If conservative measures fail after an adequate trial (typically 8-12 weeks), proceed with diagnostic testing:

Diagnostic workup:

• Anorectal manometry identifies anal weakness, altered rectal sensation, or impaired rectal balloon expulsion. 1
• Anal imaging (endoanal ultrasound) identifies sphincter defects, atrophy, and patulous anal canal. 1

Minimally invasive interventions in order of preference:

• Sacral nerve stimulation is the preferred surgical option, with 71% of patients achieving ≥50% reduction in incontinence episodes at 12 months. 1
• Perianal bulking agents may be considered next, with 52% showing ≥50% improvement at 6 months. 1
• Sphincteroplasty may be considered when perianal bulking and sacral nerve stimulation have failed or are unavailable, particularly in patients with sphincter damage unresponsive to conservative therapy. 4

Major surgical interventions reserved for severe refractory cases:

• Artificial anal sphincter or dynamic graciloplasty for patients who have failed all other treatments. 4
• Colostomy should be considered in patients with severe fecal incontinence who have failed conservative treatment and are not candidates for minimally invasive interventions. 4
• Major anatomic defects (rectovaginal fistula, full thickness rectal prolapse, fistula in ano) should be surgically corrected. 4

Special Geriatric Considerations

Medication safety:

• Use polyethylene glycol 17 g/day for elderly patients requiring laxatives—it offers efficacy with good safety profile and doesn't require high fluid intake like bulk-forming agents. 1, 3
• 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 electrolyte disturbances. 1
• Monitor for dehydration and electrolyte imbalances when using laxatives in patients on diuretics or cardiac glycosides. 1

For patients with dementia or severe physical disability:

• Bowel habit training programs are more realistic than biofeedback in advanced dementia. 5
• Consider rectal measures (enemas and suppositories) for patients with swallowing difficulties or repeated fecal impaction. 3

Critical Pitfalls to Avoid

Do not proceed to invasive therapies without exhausting conservative management—this is the most common error in practice. 1 Many patients considered "refractory" have not received optimal conservative therapy, particularly adequate trials of antidiarrheal medications and dietary modification.

Do not use bulk laxatives in non-ambulatory patients with low fluid intake—this risks mechanical obstruction. 1, 6

Do not rely on docusate alone—it is ineffective for both prevention and treatment of bowel disorders in the elderly. 3

If a patient has weak anal sphincter tone on examination, immediately discontinue all stool softeners and laxatives, as these cause diarrhea and worsen incontinence. 2