From the Guidelines
Fecal incontinence in adults should be managed with a stepwise approach, starting with conservative therapies such as dietary changes, bowel training programs, and management of diarrhea and constipation, as these measures can benefit approximately 25% of patients. This approach is recommended as the first line of treatment, as it is non-invasive and can be effective in managing symptoms 1. The stepwise approach includes:
- Dietary changes to increase fiber intake to 20-30 grams daily
- Bowel training programs to improve evacuation
- Management of diarrhea and constipation with diet and medications if necessary
- Avoiding foods that trigger symptoms, such as caffeine, alcohol, dairy, and spicy foods
For patients who do not respond to conservative measures, pelvic floor retraining with biofeedback therapy is recommended 1. This therapy can help improve pelvic floor strength, sensation, and contraction, and can be effective in managing fecal incontinence. Additionally, perianal bulking agents such as intraanal injection of dextranomer may be considered for patients who do not respond to biofeedback therapy 1.
In cases where conservative measures and biofeedback therapy fail, sacral nerve stimulation should be considered for patients with moderate or severe fecal incontinence 1. This treatment option can be effective in managing symptoms and improving quality of life. It is also important to note that loperamide (2 mg) can be used to manage diarrhea-associated fecal incontinence, starting with 1 tablet taken 30 minutes before breakfast and titrated as necessary up to 16 mg daily 1. Fiber supplementation can also be used to improve stool consistency and reduce diarrhea-associated fecal incontinence 1.
From the Research
Definition and Prevalence of Fecal Incontinence
- Fecal incontinence is defined as the unintentional loss of solid or liquid stool, with a worldwide prevalence of ≤7% in community-dwelling adults 2.
- It is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence 3.
Risk Factors and Classification
- The main risk factors for fecal incontinence include bowel disturbances, anal sphincter trauma, rectal urgency, and chronic illness 2.
- Fecal incontinence can be classified by its type (urge, passive, or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity 2.
Diagnosis and Treatment
- The initial clinical evaluation of fecal incontinence requires a focused history and physical examination, with diagnostic tests and therapies implemented stepwise 2, 3.
- Non-surgical options, such as diet and lifestyle modification, behavioral measures, and pharmacotherapy, are often effective, especially in patients with mild fecal incontinence 2, 3.
- Biofeedback therapy, pelvic floor muscle strengthening, and devices placed anally or vaginally may also be used to treat fecal incontinence 3, 4, 5.
- Surgery, including sacral neuromodulation and anal sphincteroplasty, may be considered in severe cases 2, 3.
Treatment Outcomes and Combination Therapy
- Combination therapy with biofeedback, loperamide, and stool-bulking agents has been shown to be effective in treating fecal incontinence in women 5.
- A randomized controlled trial found that combination therapy was superior to single treatments in terms of symptoms and functions, with significant improvements in leakage episodes, urgency, and rectal sensory thresholds 5.
- Another study found that loperamide and biofeedback were equivalent to placebo and education, and that combination therapy may result in only negligible improvement over individual therapies 4.