Review: Fecal Incontinence in Older Adults

Fecal incontinence (FI) is a common, distressing problem, often associated with social isolation, job loss, depression, anxiety and poor quality of life. It's estimated to affect 14%–36% of the U.S. population. A variety of treatment options exist, and clinicians should remain alert to opportunities to manage this stigmatizing condition.

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In Clinics in Geriatrics, Trisha Pasricha, MD, resident fellow in Medicine at Massachusetts General Hospital, and Kyle Staller, MD, MPH, director of the Gastrointestinal Motility Laboratory in the Mass General Division of Gastroenterology, recently reviewed the epidemiology, risk factors, diagnosis and management of FI in older adults. This summary highlights information that is particularly important for primary care clinicians.

Classification

FI—unintentional passage of solid or liquid stool—can coexist with diarrhea and constipation, as well as with urinary incontinence. The American College of Gastroenterology recognizes three subtypes of FI:

1. Passive incontinence—Unintentional passage of stool or gas without awareness of its occurrence
2. Urge incontinence—Discharge of fecal matter despite attempts to retain it (patients may describe constantly being unable to reach the bathroom in time)
3. Fecal seepage—Unintentional passage of stool that can follow otherwise normal defecation, often presenting with fecal staining of undergarments (patients may demonstrate dyssynergia with impaired rectal sensation)

Risk Factors

There are a number of risk factors that drive FI:

• Aging itself results in several physiologic alterations that predispose to FI, including decreased anal resting and squeeze pressures, decreased rectal compliance and decreased rectal sensation
• Obstetric injury is no longer thought to be a major contributing risk factor for FI in older women, but it may work synergistically with the neuromuscular changes associated with aging
• Certain comorbidities, notably stroke, multiple sclerosis, diabetes mellitus, inflammatory bowel disease (IBD), irritable bowel syndrome and celiac disease, are commonly associated with FI
• Certain lifestyle factors, including obesity, smoking and anal intercourse (both men and women) are risk factors for FI; higher levels of physical activity and guideline-recommended levels of fiber intake (25 g/day) are protective
• Conditions that interfere with regular toileting, such as dementia, compromised ability to communicate and poor mobility, should not be overlooked
• Bowel disturbances, which are thought to be one of the most common risk factors for FI

Screening

Primary care clinicians should periodically ask all older patients about FI, and more frequent screening is warranted for those with risk factors. In one study, 88% of patients who discussed FI with a physician initiated the conversation themselves (published in Clinical Gastroenterology and Hepatology). Beyond being embarrassed, patients may not know it is a condition others experience, may consider it an inevitable part of aging or may not know treatment is available.

Many patients have never heard the term "fecal incontinence." "Accidental bowel leakage" is a good example of an alternative term to use for screening. A patient who reports "diarrhea" should be questioned more closely, because they may be intentionally using the wrong term due to embarrassment.

For cases in which FI is suspected, the review discusses the workup in detail.

Management

Referral to a gastroenterologist or colorectal surgeon is sometimes essential for optimal treatment. However, conservative treatment of FI should begin immediately at the primary care level, as it can yield symptom improvement or continence. In general, correcting bowel disturbance is much easier, less invasive, and in many cases, more effective than treatments targeting the anal sphincter.

An algorithmic approach is appropriate:

Suspected bowel disturbance

• For chronic diarrhea, lactose intolerance, celiac disease, small-bowel bacterial overgrowth or constipation with overflow incontinence, provide targeted workup and treatment
• For IBD and, usually, microscopic colitis, refer to a gastroenterologist

If no bowel disturbance, perform a rectal exam

• If normal:
  • Review medications (e.g., metformin; new medications, especially antibiotics; herbal supplements; changes in dosing) and diet (e.g., fiber, gluten, lactose, fructose, artificial sweeteners); if necessary, consider a trial of loperamide ± cholestyramine; as a final step, refer to a gastroenterologist
• If abnormal:
  • Dyssynergia—Refer for anorectal manometry or pelvic floor physical therapy
  • Decreased rectal tone—Workup for neurological causes or consider surgical referral
  • Rectal prolapse—Refer for magnetic resonance defecography or consider surgical referral

The anorectum-specific treatments with the best evidence are sacral nerve stimulation, a type of neuromodulation involving outpatient surgical implantation of electrodes adjacent to the sacral nerves, and biofeedback, which aims to retrain the patient's neuromuscular coordination and improve rectal sensation. These modalities typically require subspecialist guidance.

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