Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

symptomatic but cause undetermined

1st line – dietary advice, bowel intervention, coping strategies

Back
INITIAL
|
symptomatic but cause undetermined
1st line – 

dietary advice, bowel intervention, coping strategies

In the primary care setting, treatment can be initiated without a definitive diagnosis. This may be sufficient for some patients to manage their condition. Diet is altered in order to promote an ideal stool consistency and predictable bowel emptying. A food diary is helpful in identifying foodstuffs that may be associated with loose stools.

Ispaghula supplements may help with stool consistency but should be introduced slowly so as to avoid bloating.

Advice regarding regular and effective bowel evacuation may reduce leakage.

Faecal incontinence can be a demoralising and socially debilitating disease. However, various mechanisms can allow even severely symptomatic people to lead normal lives. In addition to empathy, support, and understanding, advice on continence products may help avoid more invasive treatment. An anal plug is effective in controlling faecal incontinence in a small proportion of patients who can tolerate it.[47] Polyurethane plugs are considered to be better than polyvinyl-alcohol plugs.

Primary options

ispaghula: consult product literature for guidance on dose

symptomatic with contributing condition

1st line – condition-specific intervention

Back
INITIAL
|
symptomatic with contributing condition
1st line – 

condition-specific intervention

Condition-specific intervention is the treatment of, for example, rectal prolapse, third-degree haemorrhoids, or intervertebral disc compression (cauda equina syndrome), prior to determining if any further referral or investigation of faecal incontinence is required.

The National Institute for Health and Care Excellence (NICE) in the UK recommends addressing the following conditions before starting any specific management of faecal incontinence: faecal loading, potentially treatable diarrhoea (e.g., infective causes, inflammatory bowel disease), warning signs of lower gastrointestinal cancer, rectal prolapse or third-degree haemorrhoids, acute anal sphincter injury, and acute disc prolapse/cauda equina syndrome.[43]

ACUTE

constipation with overflow

1st line – dietary advice, bowel intervention, coping strategies

Back
ACUTE
|
constipation with overflow
1st line – 

dietary advice, bowel intervention, coping strategies

Diet is altered in order to promote an ideal stool consistency and predictable bowel emptying. A food diary is helpful in identifying foodstuffs that may be associated with loose stools.

Ispaghula supplements may help with stool consistency but should be introduced slowly so as to avoid bloating.

Advice regarding regular and effective bowel evacuation may reduce leakage.

Faecal incontinence can be a demoralising and socially debilitating disease. However, various mechanisms can allow even severely symptomatic people to lead normal lives. In addition to empathy, support, and understanding, advice on continence products may help avoid more invasive treatment. An anal plug is effective in controlling faecal incontinence in a small proportion of patients who can tolerate it.[47] Polyurethane plugs are considered to be better than polyvinyl-alcohol plugs.

Primary options

ispaghula: consult product literature for guidance on dose

2nd line – enema/suppositories

Back
ACUTE
|
constipation with overflow
2nd line – 

enema/suppositories

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. Such programmes are often used in spinal injury patients where the lack of sensation in the rectum results in impaction and overflow.

In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

3rd line – oral laxatives

Back
ACUTE
|
constipation with overflow
3rd line – 

oral laxatives

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.

Primary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

4th line – retrograde or antegrade irrigation

Back
ACUTE
|
constipation with overflow
4th line – 

retrograde or antegrade irrigation

Consider in selected people with constipation or colonic dysmotility associated with incontinence. Irrigation allows effective and efficient colonic cleansing and minimises post-defecation leak.

Retrograde irrigation is usually self-administered at a regular interval at the convenience of the patient but requires a reasonable level of manual dexterity and cognition. 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]

Retrograde irrigation is preferable to antegrade irrigation, which requires surgery, can be complex, and is not effective in all patients. In patients with an appendicostomy for antegrade irrigation, stoma-related complications occur in up to 36% of patients but are usually easy to treat. Stenosis is most common.[85]

spinal cord damage or neurogenic bowel disorder

1st line – dietary advice, bowel intervention, coping strategies, neurogenic bowel management programme

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
1st line – 

dietary advice, bowel intervention, coping strategies, neurogenic bowel management programme

Diet is altered in order to promote an ideal stool consistency and predictable bowel emptying. A food diary is helpful in identifying foodstuffs that may be associated with loose stools.

Ispaghula supplements may help with stool consistency but should be introduced slowly so as to avoid bloating.

Advice regarding regular and effective bowel evacuation may reduce leakage.

Faecal incontinence can be a demoralising and socially debilitating disease. However, various mechanisms can allow even severely symptomatic people to lead normal lives. In addition to empathy, support, and understanding, advice on continence products may help avoid more invasive treatment. An anal plug is effective in controlling faecal incontinence in a small proportion of patients who can tolerate it.[47] Polyurethane plugs are considered to be better than polyvinyl-alcohol plugs.

The aim of a neurogenic bowel management programme is to formulate a regular routine for bowel evacuation. This may include digital anorectal stimulation or manual evacuation.[8]

Primary options

ispaghula: consult product literature for guidance on dose

Consider – retrograde or antegrade irrigation

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
Consider – 

retrograde or antegrade irrigation

Additional treatment recommended for SOME patients in selected patient group

Consider in selected people with constipation or colonic dysmotility associated with incontinence. Irrigation allows effective and efficient colonic cleansing and minimises post-defecation leak.

Retrograde irrigation is usually self-administered at a regular interval at the convenience of the patient but requires a reasonable level of manual dexterity and cognition. 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]

Although it requires surgery, can be complex, and is not effective in all patients, antegrade irrigation improves faecal continence and quality of life in patients with spinal cord injury.[54] In patients with an appendicostomy for antegrade irrigation, stoma-related complications occur in up to 36% of patients but are usually easy to treat; stenosis is most common.[85]

Consider – antidiarrhoeal medication

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. Such programmes are often used in spinal injury patients where the lack of sensation in the rectum results in impaction and overflow. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

2nd line – sacral nerve stimulation

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
2nd line – 

sacral nerve stimulation

Sacral nerve stimulation involves implantation of a stimulator wire through the sacral foramen (usually S3) to stimulate the sacral nerve plexus directly using low-amplitude electrical impulses. The mechanism of action is unknown but appears to benefit those with an element of denervation. In addition, it is clear that the patient does not need to feel the stimulation; subsensory stimulation is as effective.[59] Appropriate patients can be tested with a temporary wire before permanent stimulation is given to those with a good response.

Complications are few and mainly mild. Data from one 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 device may require reprogramming, and a loss of efficacy with time can often be remedied by individualising the programme parameters.[58]

Consider – retrograde or antegrade irrigation

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
Consider – 

retrograde or antegrade irrigation

Additional treatment recommended for SOME patients in selected patient group

Consider in selected people with constipation or colonic dysmotility associated with incontinence. Irrigation allows effective and efficient colonic cleansing and minimises post-defecation leak.

Retrograde irrigation is usually self-administered at a regular interval at the convenience of the patient but requires a reasonable level of manual dexterity and cognition. 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]

Although it requires surgery, can be complex, and is not effective in all patients, antegrade irrigation improves faecal continence and quality of life in patients with spinal cord injury.[54] In patients with an appendicostomy for antegrade irrigation, stoma-related complications occur in up to 36% of patients but are usually easy to treat; stenosis is most common.[85]

Consider – antidiarrhoeal medication

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. Such programmes are often used in spinal injury patients where the lack of sensation in the rectum results in impaction and overflow. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

3rd line – neosphincter

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
3rd line – 

neosphincter

This treatment aims to reconstruct the sphincter either with an alternative sphincter muscle (usually gracilis) or with an artificial cuff device. The invasive nature of the surgery and significant complication rates mean that treatment should be reserved for highly symptomatic patients in 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).

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
spinal cord damage or neurogenic bowel disorder
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. Such programmes are often used in spinal injury patients where the lack of sensation in the rectum results in impaction and overflow. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

external sphincter deficiency

1st line – dietary advice, bowel intervention, coping strategies

Back
ACUTE
|
external sphincter deficiency
1st line – 

dietary advice, bowel intervention, coping strategies

Diet is altered in order to promote an ideal stool consistency and predictable bowel emptying. A food diary is helpful in identifying foodstuffs that may be associated with loose stools.

Ispaghula supplements may help with stool consistency but should be introduced slowly so as to avoid bloating.

Advice regarding regular and effective bowel evacuation may reduce leakage.

Faecal incontinence can be a demoralising and socially debilitating disease. However, various mechanisms can allow even severely symptomatic people to lead normal lives. In addition to empathy, support, and understanding, advice on continence products may help avoid more invasive treatment. An anal plug is effective in controlling faecal incontinence in a small proportion of patients who can tolerate it.[47] Polyurethane plugs are considered to be better than polyvinyl-alcohol plugs.

Primary options

ispaghula: consult product literature for guidance on dose

Consider – antidiarrhoeal medication

Back
ACUTE
|
external sphincter deficiency
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
external sphincter deficiency
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

2nd line – pelvic floor exercises, biofeedback, and electrical stimulation

Back
ACUTE
|
external sphincter deficiency
2nd line – 

pelvic floor exercises, biofeedback, and electrical stimulation

Pelvic floor muscle exercises, biofeedback, and electrical stimulation are aimed at improving sensation, coordination, and strength of the pelvic floor. Some aspects of treatment can be self-administered as taught by a nurse consultant; this may require specific equipment given over several dedicated sessions.

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. 

Consider – antidiarrhoeal medication

Back
ACUTE
|
external sphincter deficiency
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
external sphincter deficiency
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

3rd line – anterior sphincter repair

Back
ACUTE
|
external sphincter deficiency
3rd line – 

anterior sphincter repair

The aim of surgery is to restore the integrity of the external sphincter muscle. Treatment should be given only if conservative treatment options have been unsuccessful. Initial success rates of 70% to 80% are possible but there is often a rapid deterioration, with less than 45% remaining satisfied after 5 to 10 years.[68][69][70] Function may be sustained with adjunctive biofeedback.[67][68][71][74] If deterioration occurs due to surgical failure, repeat repair may be considered if indicated following endoanal ultrasound.[86]

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 to occur 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]

In some patients, sacral nerve stimulation (SNS) may be the treatment of choice over sphincter repair.[8] There is some evidence that, even with a large sphincter defect, patients may respond to SNS without sphincter repair.[8]

Consider – antidiarrhoeal medication

Back
ACUTE
|
external sphincter deficiency
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
external sphincter deficiency
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

4th line – sacral nerve stimulation

Back
ACUTE
|
external sphincter deficiency
4th line – 

sacral nerve stimulation

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. The mechanism of action is unknown but appears to benefit those with an element of denervation. In addition, it is clear that the patient does not need to feel the stimulation; subsensory stimulation is as effective.[59] Appropriate patients can be tested with a temporary wire before permanent stimulation is given to those with a good response.

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 device may require reprogramming, and a loss of efficacy with time can often be remedied by individualising the programme parameters.[58]

In some patients, SNS may be the treatment of choice over sphincter repair.[8] There is some evidence that even with a large sphincter defect, patients may respond to SNS without sphincter repair.[8]

Consider – antidiarrhoeal medication

Back
ACUTE
|
external sphincter deficiency
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
external sphincter deficiency
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

5th line – neosphincter

Back
ACUTE
|
external sphincter deficiency
5th line – 

neosphincter

This treatment aims to reconstruct the sphincter either with an alternative sphincter muscle (usually gracilis) or with an artificial cuff device. The invasive nature of the surgery and significant complication rates mean that treatment should 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).

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
external sphincter deficiency
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

internal sphincter dysfunction

1st line – dietary advice, bowel intervention, coping strategies

Back
ACUTE
|
internal sphincter dysfunction
1st line – 

dietary advice, bowel intervention, coping strategies

Diet is altered in order to promote an ideal stool consistency and predictable bowel emptying. A food diary is helpful in identifying foodstuffs that may be associated with loose stools.

Ispaghula supplements may help with stool consistency but should be introduced slowly so as to avoid bloating.

Advice regarding regular and effective bowel evacuation may reduce leakage.

Faecal incontinence can be a demoralising and socially debilitating disease. However, various mechanisms can allow even severely symptomatic people to lead normal lives. In addition to empathy, support, and understanding, advice on continence products may help avoid more invasive treatment. An anal plug is effective in controlling faecal incontinence in a small proportion of patients who can tolerate it.[47] Polyurethane plugs are considered to be better than polyvinyl-alcohol plugs.

Primary options

ispaghula: consult product literature for guidance on dose

Consider – antidiarrhoeal medication

Back
ACUTE
|
internal sphincter dysfunction
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
internal sphincter dysfunction
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

2nd line – pelvic floor exercises, biofeedback, and electrical stimulation

Back
ACUTE
|
internal sphincter dysfunction
2nd line – 

pelvic floor exercises, biofeedback, and electrical stimulation

Pelvic floor muscle exercises, biofeedback, and electrical stimulation are aimed at improving sensation, coordination, and strength of the pelvic floor. Some aspects of treatment can be self-administered as taught by a nurse consultant; this may require specific equipment given over several dedicated sessions.

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. 

Consider – antidiarrhoeal medication

Back
ACUTE
|
internal sphincter dysfunction
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine phosphate would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
internal sphincter dysfunction
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

3rd line – injection of bulking agent

Back
ACUTE
|
internal sphincter dysfunction
3rd line – 

injection of bulking agent

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] However, the evidence for efficacy is limited and most trials on this intervention have methodological weaknesses.[81][82]

Consider – antidiarrhoeal medication

Back
ACUTE
|
internal sphincter dysfunction
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
internal sphincter dysfunction
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

4th line – sacral nerve stimulation

Back
ACUTE
|
internal sphincter dysfunction
4th line – 

sacral nerve stimulation

Sacral nerve stimulation involves implantation of a stimulator wire through the sacral foramen (usually S3) to stimulate the sacral nerve plexus directly using low-amplitude electrical impulses. The mechanism of action is unknown but appears to benefit those with an element of denervation. In addition, it is clear that the patient does not need to feel the stimulation; subsensory stimulation is as effective.[59] Appropriate patients can be tested with a temporary wire before permanent stimulation is given to those with a good response.

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 device may require reprogramming, and a loss of efficacy with time can often be remedied by individualising the programme parameters.[58]

Consider – antidiarrhoeal medication

Back
ACUTE
|
internal sphincter dysfunction
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
internal sphincter dysfunction
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

intact sphincter complex

1st line – dietary advice, bowel intervention, coping strategies

Back
ACUTE
|
intact sphincter complex
1st line – 

dietary advice, bowel intervention, coping strategies

Diet is altered in order to promote an ideal stool consistency and predictable bowel emptying. A food diary is helpful in identifying foodstuffs that may be associated with loose stools.

Ispaghula supplements may help with stool consistency but should be introduced slowly so as to avoid bloating.

Advice regarding regular and effective bowel evacuation may reduce leakage.

Faecal incontinence can be a demoralising and socially debilitating disease. However, various mechanisms can allow even severely symptomatic people to lead normal lives. In addition to empathy, support, and understanding, advice on continence products may help avoid more invasive treatment. An anal plug is effective in controlling faecal incontinence in a small proportion of patients who can tolerate it.[47] Polyurethane plugs are considered to be better than polyvinyl-alcohol plugs.

Primary options

ispaghula: consult product literature for guidance on dose

Consider – antidiarrhoeal medication

Back
ACUTE
|
intact sphincter complex
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
intact sphincter complex
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

2nd line – pelvic floor exercises, biofeedback, and electrical stimulation

Back
ACUTE
|
intact sphincter complex
2nd line – 

pelvic floor exercises, biofeedback, and electrical stimulation

Pelvic floor muscle exercises, biofeedback, and electrical stimulation are aimed at improving sensation, coordination, and strength of the pelvic floor. Some aspects of treatment can be self-administered as taught by a nurse consultant; this may require specific equipment given over several dedicated sessions. The benefit is variable but the procedures are safe with no real side effects or potential complications. Requires a certain amount of dexterity and cognition and therefore not suitable for everyone.

Consider – antidiarrhoeal medication

Back
ACUTE
|
intact sphincter complex
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
intact sphincter complex
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

3rd line – sacral nerve stimulation

Back
ACUTE
|
intact sphincter complex
3rd line – 

sacral nerve stimulation

Sacral nerve stimulation involves implantation of a stimulator wire through the sacral foramen (usually S3) to stimulate the sacral nerve plexus directly using low-amplitude electrical impulses. The mechanism of action is unknown but appears to benefit those with an element of denervation. In addition, it is clear that the patient does not need to feel the stimulation; subsensory stimulation is as effective.[59] Appropriate patients can be tested with a temporary wire before permanent stimulation is given to those with a good response.

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 device may require reprogramming, and a loss of efficacy with time can often be remedied by individualising the programme parameters.[58]

Consider – antidiarrhoeal medication

Back
ACUTE
|
intact sphincter complex
Consider – 

antidiarrhoeal medication

Additional treatment recommended for SOME patients in selected patient group

If incontinence is associated with loose stools, antidiarrhoeal agents may be of benefit by reducing bowel secretions and motility. Loperamide also has a direct augmenting effect on the sphincter complex.[48] It has fewer adverse effects than the other drugs in this group. It is usually well tolerated but may cause abdominal pain, dry mouth, nausea, and dizziness. For those intolerant to loperamide, codeine would be the next choice. Other alternatives include diphenoxylate/atropine and amitriptyline, which may act to reduce rectal motor activity.[49]

For most agents, treatment duration may be indefinite, but appears to be safe long term at low dose. If diphenoxylate/atropine is used, again, treatment duration may be indefinite, but dosage should be reduced after initial disease control to reduce treatment side effects.

Primary options

loperamide: 4 mg orally as a single dose initially, followed by 2 mg after each loose stool, maximum 16 mg/day

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours, maximum 240 mg/day

OR

diphenoxylate/atropine: 2.5 to 5 mg orally four times daily, maximum 20 mg/day

More

OR

amitriptyline: 10-25 mg orally once daily at night

Consider – oral laxatives/enema/suppository

Back
ACUTE
|
intact sphincter complex
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

4th line – neosphincter

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ACUTE
|
intact sphincter complex
4th line – 

neosphincter

This treatment aims to reconstruct the sphincter either with an alternative sphincter muscle (usually gracilis) or with an artificial cuff device. The invasive nature of the surgery and significant complication rates mean that treatment should 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).

Consider – oral laxatives/enema/suppository

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ACUTE
|
intact sphincter complex
Consider – 

oral laxatives/enema/suppository

Additional treatment recommended for SOME patients in selected patient group

The use of an enema or suppository regimen may help to more effectively evacuate the rectum, removing any faecal bolus and reducing overflow incontinence. In addition, enemas and suppositories may regulate bowel function in non-constipated patients, allowing more effective evacuation at a socially convenient time and reducing post-defecatory seepage.

Suppositories may cause burning and irritation around the perianal region. Enemas can cause fluid and electrolyte disturbance if used chronically.

The US Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over the age of 55 years, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children aged 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[84]

Primary options

sodium phosphate: consult product literature for guidance on dose

OR

glycerol rectal: consult product literature for guidance on dose

Secondary options

lactulose: 15-30 mL orally once or twice daily, maximum of 60 mL/day

OR

senna: consult product literature for guidance on dose

ONGOING

severe incontinence refractory to other treatments

1st line – stoma

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ONGOING
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severe incontinence refractory to other treatments
1st line – 

stoma

A stoma is often very successful in controlling the symptoms of faecal incontinence but may have significant psychosocial issues and stoma-related complications. 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]

Complications commonly include skin complaints, stoma prolapse/retraction, and herniation.

Appropriate counselling and stoma siting before surgery and adequate support afterwards reduces many potential complications. Using prosthetic mesh to reinforce the stoma when it is initially formed may decrease the risk of parastomal hernia at 6 months to 24 months compared with no mesh reinforcement. [ Cochrane Clinical Answers logo ]

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