About 25% of patients with fecal incontinence benefit from conservative treatments, which merit a “rigorous trial” before considering surgery, experts write in a Clinical Practice Update in the December issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.08.023).
“A stepwise approach should be followed for management of fecal incontinence. In our experience, many incontinent patients who are considered refractory to conservative therapy have not received an optimal trial of conservative therapy,” states Adil E. Bharucha, MBBS, MD, of the Mayo Clinic and the Mayo Foundation in Rochester, Minn., and his associates.
Fecal incontinence affects 7%-15% of individuals and has potentially “devastating” implications for quality of life, the experts note. They recommend starting treatment by meticulously documenting bowel habits, triggers of incontinence, and treatment history. For fecal incontinence with diarrhea, they suggest eliminating caffeine and poorly absorbed dietary sugars, such as sorbitol and fructose, and adding loperamide, starting with one 2-mg tablet taken 30 minutes before breakfast and titrating up to a maximum of 16 mg per day. Other conservative therapeutic options for diarrhea include fiber supplementation, scheduled toileting, a bowel retraining program, anticholinergic agents, clonidine, and cholestyramine or colesevelam to correct bile salt malabsorption. Patients whose fecal incontinence involves constipation should start with laxatives and anorectal testing for evacuation disorders. Rectal cleansing with a small enema or tap water can help prevent stool leakage, the experts write.
If these conservative measures fail to improve fecal incontinence, they recommend anorectal manometry to test for anal weakness, reduced or increased rectal sensation, and impaired rectal balloon expulsion, all of which can improve with biofeedback therapy to retrain the pelvic floor. If biofeedback fails, consider perianal bulking agents, such as intra-anal injection of dextranomer, the experts suggest. Sacral nerve stimulation might be indicated if moderate or severe fecal incontinence does not respond to at least 3 months of conservative treatment. However, the experts do not recommend percutaneous tibial nerve stimulation, which failed to outperform sham stimulation in a 12-week, double-blind, multicenter trial (Lancet. 2015;386:1640-8). Surgery is indicated for fecal incontinence associated with major anatomic defects, such as rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity. Additionally, sphincteroplasty is an option for postpartum women with fecal incontinence, patients with recent sphincter injuries, and patients with sphincter damage and fecal incontinence fecal incontinence that fails to improve with conservative and biofeedback therapy, perianal bulking injection, and sacral nerve stimulation, according to the clinical practice update.
Barrier devices should be offered if fecal incontinence fails conservative treatments and surgery, or if surgery is not an option. Most anal plugs are “poorly tolerated,” with two exceptions – a Food and Drug Administration–approved device from Renew Medical and a vaginal insert and pressure-regulated pump from Pelvalon. Colostomy might be indicated if patients with severe fecal incontinence fail conservative treatment and or are not candidates for barrier devices, minimally invasive surgeries, and sphincteroplasty.
If severe fecal incontinence that is refractory to or contraindicated for all these interventions, the experts suggest considering artificial anal sphincter repair by dynamic graciloplasty. Surgery also is indicated to repair major anatomic defects such as rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity, they noted. A magnetic anal sphincter device is a possibility for patients with medically refractory severe fecal incontinence who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. However, the study that led to FDA approval of a magnetic anal sphincter device included only 35 patients, and 7 (20%) had the device removed because of infection, erosion, or inefficacy. Another patient required a stoma in order to be able to defecate, and a total of 40% had moderate or severe complications when pain and bleeding were also considered, the experts noted.
Biofeedback is the preferred treatment for defecatory disorders – that is, chronic constipation or constipation-predominant irritable bowel syndrome with impaired rectal evacuation, according to the clinical practice update. The experts recommend against sacral nerve stimulation, anteretrograde colonic enemas, and stapled transanal rectal resection for patients with defecatory disorders. Surgical treatment typically is reserved for the small minority of patients with considerable pelvic organ or rectal prolapse, they note.
The National Institutes of Health Sciences provided funding. The authors reported having no conflicts of interest.