Other Issues

Emotional distress   Skin conditions   Poor nutrition

The emotional distress caused by fecal incontinence can cause social isolation and insecurity in being in public. Losing control over bowel function can cause a patient to withdraw from being in public. Patients may try to hide the problem and avoid social situations that may be embarrassing with an incontinence accident.

The skin around the anus tends to be very delicate and sensitive. Chronic contact with stool can cause irritation, pain, and itching as well as lead to ulcerations. We will talk more about skin care for patients with fecal incontinence in the coming slides.

Fecal incontinence can include losses of nutrients in stool that the body doesn’t get the chance to adequately absorb. The poor nutrition that results can complicate the ability to maintain normal body functions, including skin healing and care. If this condition is likely, nutrient supplements to help improve absorption or to provide additional nutrients in the face of poor absorption may be recommended.

 

Fecal Incontinence: Treatment Options

We will discuss some self-care and behavioral modification strategies that are important features of treatment throughout the range of conservative to pharmacologic and surgical treatments. Options around patient counseling and education regarding self-care and behavior modification treatment options will be covered in upcoming slides.

 

Self-care and behavioral modification Over-the-counter and prescription   medications Biofeedback Sacral nerve stimulation Bulking agents Surgery

If diarrhea is common, over-the-counter antidiarrheal medications, such as loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol, Kaopectate) may be used with some effectiveness limited to about 15% to 20% of patients. In cases of constipation, laxatives, stool softeners, and fiber supplementation may be recommended.

Beyond over-the-counter medications, prescription medications may be used to treat causes of fecal incontinence. These conditions may include irritable bowel syndrome, Crohn’s disease, and ulcerative colitis.

Biofeedback has been used to correct muscle weakness and has been documented to provide some improvement in 50% to 70% of patients. Biofeedback can help patients to learn how to sense when stool is filling the rectum in cases of passive incontinence and control urgency symptoms in cases of urge incontinence. While the biofeedback method has typically been medical office based, it can be used with home biofeedback devices. Recent research suggests that combinations of biofeedback and other treatments may be most effective.

Sacral nerves control the function of anal sphincters, the colon, and the rectum. When nerves are not working properly, painless electrical stimulation of sacral nerves can be delivered with a battery-operated device through thin wires placed under the skin near the sacral nerves located above the tailbone. Stimulation appears to help the nerves to work properly.

Surgical options include:

Surgeries to treat causes of fecal incontinence, such as removal of hemorrhoids and repair for rectal prolapse and rectocele.

Sphincteroplasty to reconnect separated ends of the anal sphincter that are torn by childbirth or other injuries, which is the most common surgical treatment for fecal incontinence

Artificial anal sphincter which is a cuff around the anus with a small pump under the skin that allows inflation or deflation of the cuff to control stool passage. This surgery is not common due to the potential downsides.

Colostomy brings the colon through an abdominal wall opening for stools to be collected in a bag outside of the abdomen for disposal. This procedure may be considered a last resort effort because of the potential effect on quality of life.

 

Patient/Caregiver Strategies and Tips

Skin care   Dietary modification   Tips for coping in social situations and outings

Self-care strategies can be helpful in less-severe cases, but can also be used in combination with more aggressive treatments. Treatment options start with educating the patient and/or their caregiver about fecal incontinence. Behavioral changes may include avoiding precipitating factors, such as activities that stimulate motility shortly after a meal. For instance, having a cup of coffee (a colonic stimulant) and a brisk walk (a motility stimulant) may result in urge incontinence.

Skin care will be important to prevent complications of fecal incontinence, such as discomfort, odor, and skin sores due to chronic moisture contact. The anal area can be gently washed with water after each bowel movement. Showering or soaking in a bath can be beneficial. Note that rubbing with dry toilet paper and using soap can dry and irritate the skin. Pre-moistened, alcohol-free, perfume-free towelettes or wipes can be used instead. Skin should be thoroughly dry, preferably air dried after a bowel movement and cleaning. If time is short, then gently patting the area dry with toilet paper or a clean washcloth can be used. Moisture barrier creams may help to reduce the contact with fecal matter in the anal area. The area should be clean and dry before applying cream. Anal discomfort may also be relieved by using a non-medicated talcum powder or cornstarch. Soiled underwear should be changed quickly. Tight clothing can restrict airflow and make skin problems worse, so wearing cotton underwear and loose-fitting clothes can reduce those risks. Absorbent pads and disposable underwear with wicking layers can help to keep moisture from irritating skin. 

Patients may be advised to look for a connection between certain types of food and fecal incontinence. Dietary adjustments to include high-fiber and more fluid, preferably water, consumption can help to prevent constipation. Common foods that may lead to diarrhea include spicy, fatty, and greasy foods. Avoiding foods that may have a laxative effect may be appropriate in cases of diarrhea. These may include some sugar alcohols, such as xylitol used to sweeten gum, prunes that irritate the gut, caffeine-containing foods and beverages, and lactose in cases of lactose intolerance.

Straining during defecation can lead to weakened pelvic muscles. Patients with constipation issues can be advised to avoid straining during defecation and using a sitting or squatting position to avoid straining.

Tips for coping may include some strategies to increase confidence in venturing out and social situations. A checklist may include using the toilet just before leaving home, wearing a pad or disposable garment, carrying supplies for cleaning up, carrying a change of clothing, mapping out where toilets are located before needing them, and the use of fecal deodorants – non-prescription pills to reduce the smell of stool and gas.