Evaluation and Management of Fecal Incontinence in an 85-Year-Old Woman
Beyond infectious stool testing, you should perform a detailed digital rectal examination to assess sphincter tone and pelvic floor function, initiate bowel modifiers (fiber supplements or anti-diarrheal agents depending on stool consistency), and consider anorectal manometry if simple measures fail after 4–6 weeks.
Initial Clinical Assessment
History Taking—Key Elements to Elicit
Characterize the type of incontinence: Ask specifically whether she experiences urge incontinence (awareness of impending bowel movement but inability to reach toilet), passive incontinence (leakage without awareness), or both, as this guides subsequent management 1, 2.
Quantify severity: Document the frequency of episodes, volume of leakage, stool consistency (liquid vs. solid), and whether episodes occur day and night 1.
Identify precipitating factors: Bowel disturbances—particularly diarrhea—are the most common modifiable risk factor for fecal incontinence 1. Ask about chronic diarrhea, constipation with overflow, dietary triggers, and medication side effects 3.
Screen for major risk factors in elderly patients: Urinary incontinence is the single greatest risk factor for developing fecal incontinence; immobility, dementia, diabetes, stroke, and Parkinson's disease are also strongly associated 4.
Obstetric and surgical history: Although less relevant at age 85, prior vaginal deliveries (especially forceps-assisted), anal surgery (sphincterotomy, fistulotomy), or pelvic surgery increase risk 5, 3.
Physical Examination—Essential Maneuvers
Digital rectal examination (DRE) is mandatory and should include 6:
- Inspection of the perianal area for fissures, scars, or anatomical abnormalities
- Resting anal sphincter tone assessment (hypotonic suggests sphincter weakness or neurogenic cause; hypertonic may indicate functional withholding or spasm)
- Squeeze maneuver: Ask the patient to contract the sphincter around your finger to evaluate voluntary sphincter function and puborectalis contraction
- Simulated evacuation: Instruct the patient to "bear down as if having a bowel movement" to assess for pelvic floor dyssynergia or paradoxical contraction
- Palpation for fecal impaction in the rectal vault (a common cause of overflow incontinence in elderly patients)
A normal digital rectal examination does not exclude pelvic floor dysfunction or defecatory disorders, so proceed with empiric treatment even if the exam is unremarkable 6.
Diagnostic Testing Beyond Stool Studies
Baseline Laboratory Work
Complete blood count (CBC) is the only routine test recommended in the absence of alarm symptoms 6.
Metabolic panels (thyroid-stimulating hormone, glucose, calcium) have low diagnostic yield and are not routinely recommended unless other clinical features suggest a specific endocrine or metabolic disorder 6.
When to Pursue Anorectal Testing
Anorectal manometry should be performed if symptoms persist despite 4–6 weeks of optimized bowel modifiers and behavioral measures 6, 1.
Manometry evaluates resting and squeeze sphincter pressures, rectal sensation, and coordination of pelvic floor muscles during defecation 1.
Endoanal ultrasound or MRI may be added if manometry suggests sphincter defects, particularly in patients with prior obstetric or surgical trauma 1.
Defecography (fluoroscopic or MRI) is reserved for cases where structural abnormalities (rectocele, rectal prolapse, intussusception) are suspected 1.
Stepwise Management Algorithm
Step 1: Bowel Modification (First-Line Therapy)
For liquid or loose stools (most common in elderly patients):
For constipation with overflow incontinence:
Establish a regular toileting schedule: Encourage attempts to defecate 30 minutes after meals (when the gastrocolic reflex is strongest) and limit straining to ≤5 minutes 6.
Step 2: Behavioral and Supportive Measures
Ensure toilet accessibility, especially if mobility is impaired 6.
Pelvic floor muscle exercises (Kegel exercises) may improve voluntary sphincter control, though evidence is limited in elderly patients 3.
Biofeedback therapy is effective for patients with dyssynergic defecation identified on manometry, but requires cognitive ability and motivation 1, 2.
Step 3: Advanced Therapies (If Conservative Measures Fail)
Perianal bulking agents (injectable dextranomer/hyaluronic acid) may augment sphincter function in select cases 1.
Sacral neuromodulation (sacral nerve stimulation) is an option for refractory cases, particularly when sphincter defects are absent or minor 1, 2.
Surgical sphincter repair is rarely indicated in elderly patients but may be considered if a discrete sphincter defect is identified and the patient is a surgical candidate 1.
Common Pitfalls to Avoid
Assuming incontinence is "just age-related" without a thorough evaluation misses treatable causes such as fecal impaction, medication side effects, or diarrheal disorders 1, 4.
Failing to perform a digital rectal examination is a critical omission; this simple bedside test provides essential diagnostic information 6.
Overlooking urinary incontinence: The coexistence of urinary and fecal incontinence is extremely common in elderly patients and should prompt evaluation of both 4.
Prescribing fiber supplements to immobile patients with low fluid intake increases the risk of bowel obstruction 6.
Using sodium phosphate enemas in elderly patients carries a risk of electrolyte disturbances; isotonic saline enemas are safer 6.
Practical Summary
Start with a focused DRE to assess sphincter tone, pelvic floor function, and rule out impaction. Initiate bowel modifiers based on stool consistency (anti-diarrheals for loose stools, osmotic laxatives for constipation). Establish a toileting routine and ensure accessibility. If symptoms persist after 4–6 weeks, refer for anorectal manometry to guide further therapy 6, 1, 2.