What is the management and treatment approach for a patient with fecal incontinence?

Management of Fecal Incontinence

All patients with fecal incontinence must begin with rigorously implemented conservative therapies before considering surgical interventions, progressing through a stepwise algorithm from dietary modification and antidiarrheal medications to biofeedback therapy, then minimally invasive procedures, and finally surgery for refractory cases. 1, 2

Initial Assessment: Key Clinical Details

Characterize the exact pattern of incontinence to identify treatable causes and guide therapy 2, 3:

• Relationship to diarrhea: Bowel disturbances, particularly diarrhea and rectal urgency, are the most important independent risk factors (OR=53 for diarrhea) 1, 2
• Type of incontinence: Urge (aware of need but cannot reach toilet), passive (unaware of leakage), or combined 3
• Timing: Relationship to meals, activity level, and circumstances of episodes 2, 4
• Mobility status: Needing help getting to the toilet is a strong independent risk factor 1, 2

Identify contributing factors 1, 2:

• Dietary triggers: poorly absorbed sugars (sorbitol, fructose), caffeine, lactose 2, 4
• Medications: opioids, anticholinergics, cyclizine worsen bowel dysfunction 2
• Associated conditions: diabetes, stroke, inflammatory bowel disease, prior obstetric/surgical trauma 1, 3

Stepwise Treatment Algorithm

Step 1: Conservative Management (First-Line for All Patients)

Dietary and bowel habit modifications 1, 2:

• Eliminate poorly absorbed sugars and caffeine through targeted elimination trials 2
• Add fiber supplementation to improve stool consistency 2, 5
• Implement scheduled toileting every 2 hours while awake, every 4 hours at night 1, 2
• Establish bowel training program utilizing gastrocolic reflex after meals 2, 4

Pharmacologic management for diarrhea-associated incontinence 2, 5:

• Loperamide 2 mg taken 30 minutes before breakfast, titrated up to 16 mg daily as needed 2
• Loperamide increases anal sphincter tone, reduces urgency and incontinence, and prolongs intestinal transit time 5
• Tolerance to antidiarrheal effect has not been observed 5

Step 2: Biofeedback Therapy (After Basic Conservative Measures Fail)

Pelvic floor retraining with biofeedback is the next step, using electronic and mechanical devices to improve pelvic floor strength, sensation, contraction, and rectal tolerance 1, 2:

• Can improve symptoms in more than 70% of cases 2, 4
• Many patients considered "refractory" have not received optimal conservative therapy including meticulous characterization of bowel habits and appropriate medication titration 2

Step 3: Diagnostic Testing (When Conservative Therapy and Biofeedback Fail)

Anorectal manometry identifies anal weakness, altered rectal sensation, and impaired rectal balloon expulsion 2, 6

Imaging studies (endoanal ultrasound or MRI) visualize internal and external sphincter defects when considering surgery or devices 2, 3

Step 4: Minimally Invasive Interventions

Perianal bulking agents 1, 2:

• Dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) is FDA-approved 2
• 52% of patients achieve ≥50% improvement in incontinence episodes at 6 months 2

Barrier devices should be offered to patients who failed conservative/surgical therapy or who don't want more invasive interventions 1, 2

Sacral nerve stimulation should be considered for medically-refractory severe fecal incontinence after failure of conservative therapy, biofeedback, and perianal bulking 1, 2

Avoid percutaneous tibial nerve stimulation - should not be used in clinical practice until further evidence is available 1

Step 5: Surgical Options

Sphincteroplasty may be considered in 1, 2:

• Postpartum women with fecal incontinence and recent sphincter injuries
• Patients presenting later with symptoms unresponsive to conservative and biofeedback therapy with evidence of sphincter damage, when perianal bulking and sacral nerve stimulation have failed

Major anatomic defects (rectovaginal fistula, full thickness rectal prolapse, fistula in ano, cloacalike deformity) should be rectified surgically 1, 2

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 interventions, and sphincteroplasty 1, 2

Last-resort options for medically-refractory severe fecal incontinence 1:

• Artificial anal sphincter or dynamic graciloplasty may be considered when all other options have failed
• Magnetic anal sphincter device may be considered, but data are limited and 40% of patients had moderate or severe complications 1

Critical Clinical Caveats

A 50% reduction in incontinence episodes or days with incontinence is considered clinically significant improvement 1, 2

Many patients do not volunteer this symptom due to embarrassment - fecal incontinence causes devastating impact on quality of life including loss of confidence, self-respect, and social isolation 1, 3

In stroke patients, fecal incontinence prevalence is 30-40% in hospital, 18% at discharge, and 7-9% at 6 months, with most cases improving over time 1, 2

Avoid these interventions based on limited evidence 1:

• Sacral nerve stimulation for defecatory disorders (not fecal incontinence)
• Anterograde colonic enemas for long-term management
• STARR and related procedures for structural abnormalities in defecatory disorders