Approach

Faecal incontinence is often multifactorial, and reversible causes should be addressed first. Initial management can be carried out in a primary care setting, but if unsuccessful and the patient wishes to pursue active management, referral to a specialised service for further assessment and treatment is recommended. An optimal treatment regimen may be a complex combination of various surgical and non-surgical therapies.

Treatment of contributing conditions may help alleviate symptoms and should be considered prior to further specialist treatments. These include intervertebral disc compression (cauda equina syndrome); treatable causes of diarrhoea (e.g., infection, inflammatory bowel disease); and anorectal problems, such as rectal prolapse and third-degree haemorrhoids.[42][43]

Primary care treatment: diet, bowel habit intervention, coping strategies

The aim of dietary intervention is to promote an ideal stool consistency and predictable bowel emptying. When considering dietary changes it is essential to ensure that overall nutrient intake is balanced, particularly in older people. A food diary is useful, with modification of one food at a time in an attempt to identify potential symptom contributors. Specific foods that may contribute include prunes, rhubarb, fruit juices, licorice, and figs. Artificial sweeteners (e.g., sorbitol) also have laxative properties.[26]​ Alcohol, caffeine, and some vegetables (beans, broccoli, cauliflower, and cabbage) are often associated with loose stools. An increase in soluble dietary fibre (e.g., ispaghula supplements) may improve stool consistency by absorbing intraluminal water.[44][45] Gradual increase of fibre intake over a period of a few days will result in less bloating and discomfort. Although there is no evidence as to effectiveness, expert opinion would suggest the following bowel habit interventions:

  • Encourage bowel movement after a meal (using the gastrocolic reflex).

  • Ensure private, comfortable, easily accessible toilet facilities.

  • Encourage a sitting or squatting position to optimise evacuation and avoid straining.

During initial assessment and management of faecal incontinence, patients should be offered advice on coping mechanisms. This includes emotional and psychological support for what is a demoralising and socially detrimental condition. In addition, information should be given on the use of continence products such as:

  • Disposable pads: no advantage has been shown to any particular design of disposable pads for faecal incontinence.[46]

  • Anal plugs: if tolerated, they can be helpful in preventing incontinence.[47]

  • Skin care advice.

  • Odour-control products and laundry needs.

  • Disposable gloves.

Provide patients with contact details for relevant support groups. These groups can advise on continence products and strategies for coping.

Incontinence associated with loose stool

If dietary factors, laxative use, and infection have been addressed, antidiarrhoeal agents may be offered. Antidiarrhoeal agents are best prescribed regularly. Commonly used drugs include loperamide and codeine. They act to decrease intestinal motility and secretions. In addition, loperamide has been shown to have a direct effect on augmenting the anal sphincter.[48] Codeine is usually prescribed if loperamide is not tolerated. Amitriptyline is a tricyclic antidepressant that in low dose has been shown to improve faecal continence in one open-label study.[49] It may act to reduce rectal motor activity. Treatment duration may be indefinite, but appears to be safe long term at low dose.[50] Diphenoxylate/atropine is another alternative if preferred drugs are not effective. Again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Constipation and overflow

If constipation and faecal impaction is thought to play a role, enemas and suppositories may help to promote more complete bowel emptying and minimise post-defecation leakage.[51] Such a programme may particularly benefit those with severe constipation and overflow incontinence.[52] Rectal preparations are recommended initially and patients may require regular treatments over several days to achieve clearance. Oral laxatives are reserved for those in whom rectal preparations are not successful.

Retrograde (via the rectum) or antegrade irrigation (usually via an appendicostomy) may be considered in selected people with constipation or colonic dysmotility associated with incontinence. Antegrade irrigation requires the surgical formation of an appendicostomy allowing direct irrigation of the bowel lumen via a stoma. Irrigation allows effective and efficient colonic cleansing and minimises post-defecation leak. Antegrade irrigation can be complex and not effective in all patients.[53]

Modern equipment allows rapid and easy retrograde irrigation, although the procedure does require a certain amount of dexterity if used unaided. The National Institute for Health and Care Excellence (NICE) in the UK recommends retrograde irrigation if bowel continence cannot be achieved by medication, or changes to diet and physiotherapy.[43]

Spinal cord damage or neurogenic bowel disorder

Referral to a neurological bowel management programme is recommended if initial conservative measures are insufficient. The aim of this is to establish a predictable routine of bowel motion avoiding both incontinence and constipation. This may involve consideration of digital anorectal stimulation or manual evacuation. Antegrade irrigation improves faecal continence and quality of life in patients with spinal cord injury.[54]

Sacral nerve stimulation (SNS) involves implantation of a stimulator wire through the sacral foramen (usually S3) to stimulate the sacral nerve plexus directly using low-amplitude electrical impulses.[55][56][57] It is not clear how the stimulation works but it is not necessarily a motor response and more likely to be a sensory and/or central effect. The device may require reprogramming, and a loss of efficacy with time can often be remedied by individualising the programme parameters.[58] The patient does not need to feel the stimulation; subsensory stimulation is as effective.[59] Complications are few and mainly mild. Data from a systematic review suggest an adverse event frequency of 13%.[60]​ The most important complication is infection (2%), which may require removal of the device.

The procedure can be considered for patients with faecal incontinence with an intact sphincter complex (incontinence due to either denervation or atrophy). The procedure may also be indicated in those with a small defect in whom sphincter surgery is deemed inappropriate.[61] Although SNS has shown promising early results with minimal associated morbidity, long-term clinical outcomes are not available.[61] A temporary system is usually trialled for a couple of weeks and if successful and acceptable to the patient, a permanent system can be put into place.

If sacral nerve stimulation is unsuccessful, a neosphincter may be considered. There are two options: the stimulated graciloplasty neosphincter (a surgically constructed, functioning sphincter, using transported gracilis muscle) or an artificial cuff device.[62] Both may improve continence but are associated with a significant incidence of adverse effects and a high removal rate.[62][63][64][65]

They should therefore be reserved for highly symptomatic patients for whom less invasive options have been unsuccessful or for those who are inappropriate for surgical intervention (due to major sphincter disruption, severe neural damage, or congenital disorders such as anal atresia).[65] With the gracilis transposition technique approximately one third of patients develop a major wound problem involving the perineum, the stimulator, and/or the leg wound. Technical failure (lead/battery displacement, lead fracture) is also common.​[62]

Infection is frequent with the artificial bowel sphincter; usually the result of erosion of the device into the rectum or perianal skin. Removal occurs in about one third of all patients.[63]​ Even if the device can be salvaged, revision is often required for device malfunction (cuff rupture, balloon and pump leaks, and migration).

External sphincter deficiency

If dietary advice, bowel habit intervention, and coping strategies do not significantly improve symptoms or if the patient requests further investigation, referral to a specialist is warranted. Management may include strategies such as pelvic floor exercises, biofeedback, and electrical stimulation.[66] The American College of Obstetricians and Gynecologists recommends pelvic floor exercises with or without biofeedback for strengthening anal sphincter and levator ani muscles.[27]​​ The aim is to improve sensation, coordination, and strength of the pelvic floor. Exercises may be self-directed, taught via verbal or written instruction, or taught using vaginal or anal equipment allowing feedback to the patient through the device. Electrical stimulation is carried out using a specific anal probe.

The beneficial effect of biofeedback can be variable. Although many studies have suggested improvement in up to 90% of patients, several randomised controlled trials have shown such interventions to be no better than standard care.[8][67] Nevertheless, treatment does no harm and consensus opinion is that one of these interventions should be considered for people who continue to have episodes of faecal incontinence after initial management. 

Anterior sphincter repair is appropriate for those with an external sphincter defect and symptoms unresponsive to non-surgical therapy. Internal sphincter defects, pudendal nerve neuropathy, multiple defects, and loose stools can decrease the success of an anterior sphincter repair. The external anal sphincter is repaired or tightened through a small anterior incision. Initial success rates of 70% to 80% are possible, but there is often a rapid deterioration, with less than 45% of patients remaining satisfied after 5 to 10 years.[68][69][70] As few as 10% will be fully continent after as short a time as 5 years post operation.[71] Despite poor long-term results, surgery has few serious complications. Wound infection occurs in approximately one quarter but is often mild with no serious sequelae.[72] Wound disruption has been reported in up to 41% of patients. The presence of complex injuries such as cloacal defect or recto-vaginal fistula were found to increase the incidence of wound breakdown.[73] Adjunctive biofeedback may help sustain improvement over time.[67][68][71][74]

If there is a contraindication to surgery, SNS is a further option. There is some evidence that, even with a large sphincter defect, patients may respond to SNS without sphincter repair.[8] If there is severe sphincter disruption and repair is not possible, a neosphincter may be considered, although the invasive nature of the surgery and significant complication rates mean that treatment should be reserved for the highly symptomatic patient where less invasive options are unsuitable or have been unsuccessful.

Internal sphincter dysfunction

If initial management is unsuccessful, specialist conservative management can be tried including pelvic floor exercises, biofeedback, and electrical stimulation.[66] In patients with passive leakage due to isolated internal sphincter defects or sphincter dysfunction, bulking the sphincter may augment the seal created by the sphincter and improve continence. A biomaterial is injected into the intersphincteric space.[75] Various materials have been used, including autologous fat, collagen compounds, silicone, teflon, dextranomers, and self-expandable prostheses.[76][77][78] It is a safe procedure with side effects limited to infection, erosion, and pain (often related to a too-superficial injection site).[79][80] This bulking of the internal sphincter can provide a more effective seal and may be particularly useful in those patients complaining of passive leakage (often due to internal sphincter dysfunction). However, the evidence for efficacy is limited and most trials on this intervention have methodological weaknesses.[81][82]

Intact sphincter complex

Initial management for those patients with an intact sphincter complex or only a minor tear is the same. Dietary advice, bowel habit intervention, and coping strategies are employed. If unsuccessful, biofeedback and pelvic floor exercises may help. Sacral nerve stimulation may be beneficial if all other conservative options have failed. The neosphincter has a role in the treatment of severe faecal incontinence if sphincter dysfunction is significant and other therapies have failed. The tricyclic antidepressant amitriptyline has also been shown to improve incontinence.[49]

Severe incontinence refractory to other treatments

A stoma (colostomy or ileostomy) is suitable for end-stage incontinence if all other therapies have failed or are inappropriate, or when preferred by the patient.[26]​ It is often successful in relieving symptoms but may have significant psychological impact regarding body image. It is often reserved for those where other options have failed, but may be considered early in the treatment regimen if the patient prefers, as it allows resumption of a normal life.[83] The patient should have appropriate counselling and stoma siting before surgery and adequate support afterwards. Complications commonly include skin complaints, stoma prolapse/retraction, and herniation.

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