What is the best approach to manage a patient with stool incontinence?

Management of Stool Incontinence

Begin with conservative measures including dietary modification, fiber supplementation, scheduled toileting, and loperamide for diarrhea-associated incontinence, progressing to biofeedback therapy before considering surgical interventions. 1

Initial Assessment and Conservative Management

Identify Contributing Factors

• Determine premorbid bowel patterns and characterize the circumstances surrounding incontinence episodes, including relationship to meals, activity, and prior treatments 1
• Evaluate for diarrhea as the primary driver, as bowel disturbances (particularly diarrhea) and rectal urgency are the most important independent risk factors for fecal incontinence, far more than obstetric history 1, 2
• Review all medications, especially opioids, anticholinergics, and cyclizine, which can worsen bowel dysfunction 1
• Assess mobility status, as needing help getting to the toilet is the strongest independent risk factor for fecal incontinence at 3 months 1

First-Line Conservative Therapies

Dietary and Stool Consistency Management:

• For diarrhea-associated incontinence, obtain a careful dietary history to identify poorly absorbed sugars (sorbitol, fructose) and caffeine, followed by elimination trials 1
• Start loperamide 2 mg, taken 30 minutes before breakfast and titrated up to 16 mg daily as needed 1, 3
• Loperamide increases anal sphincter tone, reduces urgency, prolongs intestinal transit time, and increases stool viscosity 3
• Add fiber supplementation to improve stool consistency and reduce diarrhea-associated incontinence 1
• Consider bile-salt malabsorption treatment with cholestyramine or colesevelam, as this is common in idiopathic diarrhea 1

Behavioral Interventions:

• Implement scheduled toileting: offer commode/toilet every 2 hours while awake and every 4 hours at night 1
• Establish a bowel training program with consistent timing after meals to utilize the gastrocolic reflex 1
• For fecal seepage from overflow, use rectal cleansing with small enemas or tap water to reduce likelihood of stool leakage 1

When Conservative Measures Fail

Anorectal Testing

Perform anorectal manometry first to identify anal weakness, altered rectal sensation, and impaired rectal balloon expulsion 1

Add imaging when considering surgery or devices:

• Endoanal ultrasound is superior for visualizing internal sphincter tears 1
• MRI is superior for external sphincter defects, atrophy, and patulous anal canal 1

Biofeedback Therapy

Biofeedback is the next step after basic conservative measures fail, using electronic and mechanical devices to improve pelvic floor strength, sensation, and rectal tolerance 1, 4

• Effective in the majority of patients and particularly attractive because it is safe and well tolerated 4
• Improves symptoms in more than 70% of cases of defecatory disorders 5

Minimally Invasive Interventions

Perianal Bulking Injection

Dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) is FDA-approved for fecal incontinence 1

• In randomized controlled trials, 52% of active treatment patients vs. 31% of sham patients achieved ≥50% improvement in incontinence episodes at 6 months (OR: 2.36; P = 0.0089) 1
• Consider when biofeedback fails and before more invasive procedures 1

Sacral Nerve Stimulation

Sacral nerve stimulation should be considered for patients who fail conservative therapy, biofeedback, and perianal bulking 1

• Reserved for medically-refractory severe fecal incontinence 1

Surgical Options

Sphincteroplasty

Consider sphincteroplasty for women with fecal incontinence and recent sphincter injuries, or those presenting later with symptoms unresponsive to conservative and biofeedback therapy when perianal bulking and sacral nerve stimulation are unavailable or unsuccessful 1

Major Anatomic Defects

Rectify major anatomic defects surgically, including rectovaginal fistula, full thickness rectal prolapse, fistula in ano, or cloacalike deformity 1

Last Resort Options

Colostomy should be considered in patients with severe fecal incontinence who have failed conservative treatment and are not candidates for or have failed barrier devices, minimally invasive surgical interventions, and sphincteroplasty 1

Important Clinical Caveats

• Many patients considered "refractory" have not received optimal conservative therapy, including meticulous characterization of bowel habits, dietary elimination trials, and appropriate titration of antidiarrheal medications 1
• A 50% reduction in incontinence episodes or days with incontinence is considered clinically significant improvement in clinical trials 1
• Fecal incontinence has devastating impact on quality of life, causing loss of confidence, self-respect, and social isolation, yet many patients do not volunteer this symptom due to embarrassment 1, 2
• In stroke patients, fecal incontinence prevalence ranges from 30-40% in hospital, 18% at discharge, and 7-9% at 6 months, with most cases improving over time 1