Fecal Incontinence

Occurs in up to 10% of the elderly

Minor incontinence

• Slight soilage of undergarments that tends to occur after bowel movements or with straining or coughing

• Causes

  • Local anal problems, such as prolapsed hemorrhoids or isolated weakness of the internal anal sphincter

  • Ulcerative proctitis

  • Chronic diarrheal conditions

  • Irritable bowel syndrome

Major incontinence

• Complete uncontrolled loss of stool

• Causes

  • Significant sphincteric or neurologic damage resulting from obstetric trauma (especially forceps delivery, episiotomy, or pudendal nerve damage)

  • Rectal prolapse

  • Prior anal surgery

  • Physical trauma

  • Aging

  • Diabetes mellitus

  • Dementia

  • Cerebrovascular accident

  • Multiple sclerosis

  • Spinal cord injury

  • Cauda equina syndrome

Incontinence of stool, minor or major

Confirm an intact anocutaneous reflex by stimulation of perianal skin

Digital examination during relaxation and squeezing to assess resting tone and external sphincter function and to exclude fecal impaction

Anoscopy to assess for hemorrhoids, fissures, and fistulas

Proctosigmoidoscopy to exclude rectal carcinoma or proctitis

Anal ultrasonography or pelvic MRI to assess integrity of sphincters

Anal manometry and surface electromyography to assess rectal sensation, resting and voluntary squeeze pressures, and innervation

Minor incontinence

• Fiber supplements

• Bulking agents

• Loose application of a cotton ball near the anal opening

• Kegel perineal strengthening exercises

Major incontinence

• Antidiarrheal drugs (eg, loperamide, 2 mg before meals and prophylactically before social engagements, shopping trips, etc)

• Scheduled toilet use after glycerin suppositories or tap water enemas

Provide elderly more time and assistance to reach toilet

Prevent stool impaction and "overflow" incontinence

Biofeedback training with pelvic floor strengthening (Kegel) exercises (alternating 5-second squeeze and 10-second rest for 10 minutes twice daily) may be helpful

Injection of sterile gel containing dextranomer and sodium hyaluronate submucosally into the proximal anal canal

• Indicated for patients who have not responded to conservative therapies, such as fiber supplements and antidiarrheal agents

• Reduces incontinence episodes by bulking up of the anal wall and consequent narrowing of the anal canal

• In clinical trials, more than one-half of treated patients reported a > 50% reduction in the number of fecal incontinence episodes

Sacral nerve stimulation device

• In uncontrolled trials, improvement was seen in 83% of selected patients

• Inserts also are available that can be placed in the anus or vagina to enhance continence

Surgical intervention in patients who have not responded to medical therapy, especially patients with traumatic disruption of sphincters