What are the treatment options for rectal incontinence?

Treatment of Rectal Incontinence

All patients with rectal incontinence must undergo rigorous conservative therapy before considering surgical interventions, with sacral nerve stimulation being the preferred surgical option for those who fail conservative management. 1

Initial Conservative Management (First-Line for All Patients)

Conservative therapy must be rigorously implemented and includes the following specific measures 1:

Bowel Habit Modification

• Meticulous characterization of bowel patterns, timing of incontinence episodes (relationship to meals/activity), and prior treatments 1
• Dietary elimination of poorly absorbed sugars (sorbitol, fructose) and caffeine after careful dietary history 1
• Scheduled toileting and bowel training programs to establish predictable evacuation patterns 1

Pharmacologic Management Based on Stool Consistency

For diarrhea-predominant incontinence:

• Loperamide starting at 2 mg taken 30 minutes before breakfast, titrated up to 16 mg daily as needed 1, 2
• Loperamide increases anal sphincter tone, reduces urgency, prolongs intestinal transit time, and increases stool viscosity 2
• Fiber supplementation to improve stool consistency and reduce diarrhea-associated incontinence 1
• Bile acid sequestrants (cholestyramine or colesevelam) for idiopathic diarrhea, as bile-salt malabsorption is common 1
• Alternative options include anticholinergic agents and clonidine 1

For constipation with overflow incontinence:

• Laxatives to address fecal impaction 1
• Small enemas or tap water rectal cleansing to reduce likelihood of stool leakage 1
• Anorectal testing to identify evacuation disorders 1

Pelvic Floor Biofeedback Therapy

• Indicated after initial medical management for patients with persistent symptoms 1
• Uses electronic and mechanical devices to improve pelvic floor strength, sensation, contraction coordination, and rectal tolerance 1
• Particularly effective for evacuation disorders with overflow incontinence 1

Surgical and Device-Aided Therapy (Second-Line)

Critical caveat: Many patients undergo surgery without adequate conservative therapy trials, but surgery is necessary in less than 5% of patients 1

Sacral Nerve Stimulation (SNS) - Preferred Surgical Option

• SNS is the safe and effective surgical option with the strongest evidence for fecal incontinence 1
• Achieves ≥50% reduction in incontinence frequency in 71% of patients at 12 months, significantly superior to medical treatment alone (MD −6.30,95% CI −10.34 to −2.26) 1
• Consider SNS when conservative therapy fails and symptoms persist 1

Perianal Bulking Agents

• Dextranomer injection achieves ≥50% reduction in incontinence frequency in 52% of patients versus 31% with sham at 6 months 1
• Consider as alternative to SNS or when SNS is not feasible 1

Posterior Tibial Nerve Stimulation (PTNS)

• Evidence is mixed: one trial showed 82% response rate at 6 weeks maintained over 6 months 1
• However, a larger multicenter trial showed no significant difference from sham (38% vs 31%) 1
• Less reliable than SNS based on conflicting evidence 1

Other Surgical Procedures

• Limited evidence supports routine use of other surgical procedures except colonic stoma for refractory cases 1
• Magnetic anal sphincter shows modest efficacy but potential for severe side effects 1

Special Consideration: Rectal Prolapse with Incontinence

For patients with full-thickness rectal prolapse causing incontinence:

• Abdominal rectopexy preferred for younger, healthier patients (recurrence 0-8%) 3, 4
• Add sigmoid resection if chronic constipation is present 4, 5
• Perineal procedures (Altemeier, recurrence 5-21%) reserved only for elderly or high-risk patients 3
• Incontinence often improves after prolapse correction, but may require additional treatment 3

Common Pitfalls to Avoid

• Do not proceed to surgery without documented trials of loperamide titration, dietary modification, and biofeedback therapy 1
• Do not overlook bile acid malabsorption as a treatable cause of diarrhea-associated incontinence 1
• Do not miss fecal impaction with overflow incontinence, which requires laxatives rather than antidiarrheals 1
• Do not use bowel resection in patients with pre-existing diarrhea or severe incontinence, as symptoms may worsen 5