Treatment for Fecal Incontinence: Nonsurgical Approaches

Abstract

Fecal incontinence is defined as greater than 1 month of uncontrolled passage of fecal material or gas in a person age 4 years or older, who previously achieved control. Treatment of fecal incontinence can be challenging and should be individualized. This chapter discusses the general approaches to the management of fecal incontinence with a focus on nonoperative management. More invasive approaches such as replacement, repair, augmentation, stimulation, and fecal diversion are outlined.

Commentary by Tracy L. Hull, Cleveland Clinic, Department of Colon and Rectal Surgery, Cleveland, OH, USA

Commentary

• Tracy L. Hull 

Fecal incontinence (FI) as outlined in this chapter is not uncommon. The etiology is multifactorial, and treatment is individualized for each patient. Therefore, a comprehensive history is the first step in caring for this group of patients. Physical exam further refines treatment possibilities [63].

Some FI results from inflammatory conditions like ulcerative colitis. Treatment of the primary inflammatory process is the initial therapy. Otherwise, most treatment recommendations begin with a combination of nonsurgical approaches, which are discussed in detail in this chapter. The goal should aim toward total continence. Many studies determine successful results as 50% reduction in incontinent episodes. While a 50% reduction may be an improvement, any accidental episodes of FI can be humiliating and demoralizing.

Loose stools are a factor for many patients with FI, and strategies to minimize diarrhea are part of most recommendations. As mentioned, anal skin care with protective barrier creams is sometimes a forgotten component of treatment [64]. Physical therapy utilizing auditory and/or visual feedback emphasizes retraining for improved anal strength, pelvic coordination, and optimization of rectal sensitivity. This therapy can be operator dependent and time intensive to produce an acceptable outcome. Enemas or rectal washout is also a treatment strategy that may be successfully utilized for selected patients who are motivated to use this therapy [65, 66]. As outlined in the chapter, a combination of these treatments is part of the individual approach.

To further optimize quality of life, other nonsurgical approaches may be considered. While insertion of devices into the vagina in women or anal inserts seem like attractive options to prevent stool from being expelled at unwanted times, both success and tolerance have been suboptimal [66].

With the success of sacral nerve modulation, percutaneous tibial nerve stimulation seems like an attractive less invasive treatment that should stimulate similar nerve pathways. Results have not been straightforward, but as discussed in the chapter, selective patients may benefit [67].

Nonsurgical therapies are overall safe and do not burn bridges for other therapies. For patients who have failed all treatment options or are not candidates for other therapies, fecal diversion allows patients the ability to leave home, work, and attend social functions. A stoma should not be viewed as a failure, but instead as a means to improve quality of life in this group of patients [66].

As mentioned in this chapter, critical examination of studies regarding FI is essential when determining efficacy of therapy. As with many areas of pelvic floor research, patient selection for studies may not appropriately compare like patients, especially those with FI. FI is difficult to treat. Appraisal of the characteristics of patient included in studies and the primary aim should be scrutinized before fully dismissing a treatment with minimal risk to patients with FI.