Introduction
At any age, fecal incontinence is one of the most dev- astating of all nonfatal illnesses, resulting in consid- erable embarrassment, anxiety, and social isolation to those who suffer from it. So embarrassing is it that individuals with incontinence frequently do not vol- unteer this complaint to their physicians and must be asked directly about fecal incontinence [1]. The physician should also be aware that patients might complain of “diarrhea,” which may be a euphemism for fecal incontinence.
Background and Prevalence
The presence of fecal incontinence is especially prob- lematic for the elderly and institutionalized individu- als, in whom the prevalence of incontinence is high- er than that of the general adult population and which is equally prevalent in both men and women (Table 1). Among ambulatory persons >65 years, the frequency of incontinence has ranged from 3.7 to 27% [2–5] depending upon whether defining criteria encompass mild and infrequent soiling or just the most frequent and severe (Table 1). Incontinence is most often associated with chronic diarrhea, multiple health problems, and poor self-perceived health [6].
In hospitalized elderly, the prevalence of inconti- nence ranges from 10 to 25% [7]. More than half of all
elderly patients in long-term care facilities suffer from fecal incontinence, in part related to the high prevalence of dementia and delirium in such settings [8–10]. Incontinence in residents in long-term facili- ties and those who are institutionalized for cognitive or psychiatric reasons is associated with poor overall health, increased mortality, and significantly increased expenditures for health care [11, 12].
“Double incontinence” (both urinary and fecal) is a major cause of institutionalization in the elderly [9, 10, 13].
Risk Factors and Causes of Fecal Incontinence
As with persons of all ages, fecal incontinence in eld- erly individuals has multiple etiologies and requires careful assessment of each patient. Following is a partial list of causes of fecal incontinence in the eld- erly:
•
Decreased rectal sensation – Fecal impactions – Megarectum – Diabetes mellitus•
Decreased reservoir capacity – Radiation– Surgical resection – Ischemia
– Inflammation
•
Impaired anal sphincter/puborectalis function – Spinal cord lesions– Pudendal neuropathy – Trauma, surgery
•
Functional impairment– Dementia, delirium, confusion – Weakness, immobility, instability – Depression, psychosis
•
Other – Diarrhea– Inadequate toilet arrangements
In ambulatory intact elderly patients, causation is similar to that in the general adult population and requires an assessment similar to that of younger
Fecal Incontinence in Elderly and Institutionalized Patients
Arnold Wald
33
Table 1. Prevalence of fecal incontinence in elderly po- pulationsa
Population Prevalence
Ageⱖ65 years (community) 3.7–27%
Hospitalized patients 10–25%
Nursing home >50%
Hospitalization with dementia >80%
aSee text for references
adults [7]. It should be the philosophy of all health care workers that fecal incontinence is not a normal consequence of the aging process but often occurs as a result of structural or functional impairment of continence mechanisms and/or alteration of stool consistency and delivery. It is also useful to recall that fecal continence requires the ability to sense rec- tal filling and impending defecation, appropriate responses of the anal sphincters and puborectalis muscle to prevent unwanted defecations, the ability of the distal colon and rectum to store fecal material for variable periods of time, and motivation by the individual to remain continent [14]. Abnormalities of any one or several of these must be considered as potential causes of incontinence in a patient of any age.
In contrast to ambulatory elderly individuals, fac- tors other than impaired continence mechanisms become more important in the institutionalized or hospitalized patient. These factors include lack of motivation associated with cognitive dysfunction or behavioral maladaptation. The possibility of acute or chronic obstipation with fecal impaction leading to overflow incontinence must always be considered in the appropriate clinical setting [12]. Immobility, inadequate toileting arrangements, use of constipat- ing medications, and diarrhea due to infections, medications, or inflammation must also be carefully assessed for. For example, the use of patient trunk restraints was found to be the most important cause for the development of incontinence in nursing homes, even after adjusting for the major reasons why restraints were implemented [15]. Clearly, restraints prevent access to toilet facilities and repre- sent a remedial cause of incontinence in this popula- tion.
A frequent cause of fecal incontinence in the insti- tutionalized or otherwise functionally impaired patient is fecal impaction, either with or without megarectum. In these patients, anal sphincter pres- sures are generally normal and are no different before and after disimpaction [16]. Two critical abnormalities are frequently encountered. First, there is impaired rectal sensation so that the rectums of recently disimpacted patients require distension with much higher volumes before patients perceive fullness or desire to defecate [17]. Second, patients are unable to perceive rectal volumes that are suffi- ciently large to inhibit the resting tone of the internal anal sphincter. Thus, liquid stool is able to seep around the impaction and pass through the decreased sphincter pressures of the anal canal, resulting in spurious diarrhea. Failure to identify an impaction may lead to the inappropriate prescription of antidiarrheal agents, which will exacerbate the problem.
Evaluation and Management
A wide array of diagnostic tests is available to assess anorectal structure and function in selected patients with fecal incontinence [14]. Diagnostic tests often illuminate underlying pathophysiology and provide a greater understanding of causation. It has been argued that such information should lead to more rational decision making when choosing among treatment options. It is therefore appropri- ate to ask whether in an elderly patient with fecal incontinence the standard of care should include validated and often informative manometric and imaging studies of the anorectum. In most elderly and institutionalized patients, such tests are often not necessary [18]. In my opinion, the vast majority of these patients can be managed satisfactorily with a careful history and a directed physical examina- tion that includes digital rectal examination and a focused exam involving the perineum, lower extremities, and back. This is certainly so in patients with overflow incontinence, those with decreased colorectal storage capacity, and those with minor soiling associated with internal anal sphincter weakness. In some of the remaining patients in whom the cause of fecal incontinence is not apparent or in whom surgery may provide remediation, studies of anorectal structure and function may provide useful information about appropriate management. This should not include most elderly patients, including those who are func- tionally intact and living at home.
Overflow Incontinence
Fecal impaction with overflow incontinence may occur in patients of all ages but is disproportionate- ly seen in those with dementia, psychosis, and the elderly, especially those who are institutionalized.
This diagnosis should always be considered in a clin- ical setting in which there is frequent or constant seepage of liquid stools. Diagnosis is confirmed by a digital rectal examination (if the impaction is in the low rectum) or by an abdominal X-ray that demon- strates fecal loading in a patient who is incontinent of diarrheal stools (Fig. 1). Treatment consists of disimpaction, thorough colon cleansing, and a bowel-retraining regimen, together with periodic bowel emptying depending upon clinical circum- stances (see below). The latter is critically important because of the high recurrence rate in patients with- out appropriate follow-up measures [19]. There is no indication for diagnostic anorectal studies in such patients.
Reservoir Incontinence
Impaired rectal and/or colonic storage capacity is another cause of chronic fecal incontinence. This entity is frequently suggested by the patient’s history and may in some patients require confirmation by an endoscopic evaluation. Some of the more frequently encountered causes in elderly patients are inflamma- tory bowel diseases involving the colon and rectum, proctectomy, and radiation proctopathy leading to fibrosis. Treatment consists of anti-inflammatory drugs for inflammatory bowel diseases in an effort to reverse inflammation; in the absence of a reversible condition, dietary fiber restriction with antidiarrheal agents helps minimize stool volume and regulate delivery (see below). Anorectal physiological tests are generally unnecessary in this clinical situation.
Minor Soiling with Normal Bowel Habits
Another important group of patients is frequently composed of healthy older men and women who
present with minor soiling or seepage in the pres- ence of normal bowel habits. This does not involve incontinence of solid stool but, rather, “spotting” of underclothes by persistent soiling of the perianal area. Digital anorectal examination often suggests decreased anal canal tone at rest, strong voluntary contraction of the external anal sphincter and pub- orectalis muscle, and absence of fecal impaction, mucosal, or hemorrhoidal prolapse and other peri- anal conditions that can produce minor soiling.
This clinical scenario is consistent with isolated weakness or dysfunction of the internal anal sphincter. A history of lateral internal sphincteroto- my, i.e., for anal fissure, should alert the physician to this diagnosis, but in most patients, internal anal sphincter dysfunction is idiopathic and appears to be associated with aging- related fibrosis [20]. The use of a simple anal cotton plug as an absorbent barrier can often alleviate this embarrassing prob- lem (see below). Formal physiological testing is rarely necessary.
Fig. 1.Large rectum and left colon filled with impacted stool in a patient who is incontinent of liquid stool (“spurious diar- rhea”)
Incontinence with Anorectal Sphincteric Abnormalities
The remaining ambulatory elderly patients with fecal incontinence will exhibit one or a combination of abnormalities of continence mechanisms. Most can be ascertained when a directed physical examination is performed by a skilled and experienced examiner [14, 18]. For example, the tone of the internal anal sphincter and the contractile strength of the external anal sphincter can be assessed by digital examination of the anal canal at rest (largely reflecting internal anal sphincter function) and when the patient tight- ens the anal canal (external anal sphincter function).
Deeper insertion of the finger allows assessment of puborectalis muscle contraction strength. Having the patient bear down, especially in a squatting or dorsal lithotomy position, allows optimal assessment for rectal prolapse or excessive descent of the perineum, suggesting weakness of the pelvic floor muscles. Only impaired rectal sensation cannot be assessed by con- ventional physical examination; however, this rarely occurs in the absence of other evidence of a neuro- logic disorder involving the spinal cord or central nervous system. In general, sacral denervation is sug- gested by a patulous (“gaping”) anal sphincter observed when the examining finger is removed, perianal anesthesia or hypoesthesia, and absence of anal sphincter contractions (“anal wink”) with mild stroking of the perianal skin.
Management Principles
Management of fecal incontinence at any age and in all population groups is based upon identifying and correcting the underlying cause(s) identified at the initial assessment. The general scenarios associated with incontinence in the elderly or institutionalized persons may be divided broadly on the basis of clini- cal presentations (Table 2).
Overflow Incontinence
Identification of fecal impaction with or without megarectum is of great importance, because remedi- ation is available and highly effective [7, 19]. Disim- paction is the first step and often includes digital fracturing of the bolus. If the impaction is very hard, a 500– to 750–ml water enema with 1–2 tablespoons of mineral oil added can serve to soften the bolus to facilitate fragmentation and passage of the fecal bolus. Once the obstructive mass is removed, larger- volume warm-water enemas may be administered to cleanse the colon. If the patient is unable to do so independently, visiting nurses may be employed to provide enemas daily until colon cleansing is com- plete. Alternatively, a larger volume of polyethylene glycol (PEG) electrolyte solution may be given orally as 240 ml every 30 min until the rectal contents are
Table 2.Management of fecal incontinence in elderly or institutionalized persons
Causes Management
Overflow Disimpaction
Colon evacuation
Periodic defecation with laxatives/enemas if necessary
Reservoir Low-fiber diet
Loperamide
Periodic defecation with or without laxatives Isolated internal anal sphincter weakness Loperamide as needed
Anal cotton plug
Anal sphincter impairment Loperamide
Surgery?
Sacral nerve stimulation?
Behavioral/dementia Prompted defecation or loperamide with regular laxatives, suppositories, or enemas three times a week
General measures Skin care
Pads Odor control Caregiver support
free of stool. On occasion, gastrografin enemas are useful for this purpose and also serve to exclude obstructive colon disease. If the colon in such patients is not effectively emptied, impaction recur- rence is quite high.
As mentioned earlier, such patients are prone to reimpaction because of underlying rectal sensation impairment, megarectum, or predisposing causes of constipation. Thus, habit training with laxatives should be started to ensure periodic defecation. This involves regularly scheduled attempts to defecate with the assistance of small amounts of osmotic lax- atives, such as PEG-containing solutions. Oral or rec- tal stimulant laxatives are given if there is no defeca- tion for 3 days. Fiber supplements are not helpful and only add to the fecal load. With appropriate attention to detail, recurrent impactions should be effectively prevented.
Reservoir Incontinence
This clinical situation is generally identified by clini- cal history and examination. If a treatable cause of reduced colorectal storage capacity such as ulcerative colitis is not present, treatment strategies should incorporate reduction of stool volume by decreasing dietary fiber and alteration of stool delivery with antidiarrheal agents such as loperamide and diphe- noxylate with atropine [21]. Evacuation of the colon once or twice per week with oral laxatives prevents stool buildup in these patients.
Internal Anal Sphincter Weakness (Minor Soiling)
If patients report normal bowel habits with minor seepage, the best approach is to employ an anal cot- ton pledget to occlude the anal canal. This is held in place by the gluteal muscles and tissues and serves as a physical and absorbent barrier to anal seepage, somewhat analogous to a vaginal tampon. The use of a narrow panty liner serves as a contingency mecha- nism and prevents underwear staining. This is par- ticularly useful for ambulatory persons and has the added advantage of being inexpensive and readily available. This device is often effective for patients with minor seepage due to anal cushion defects, i.e., after hemorrhoidectomy or fistula in ano.
Diarrhea/Loose Stools
On occasion, diarrhea may overwhelm normal conti- nence mechanisms, but in the elderly, altered stool delivery and increased stool liquidity may also
breach mild sphincter dysfunctions that are subclin- ical because of underlying constipation or simply normal firm stool. Identification and treatment of acute diarrhea in the elderly who are especially prone to Clostridium difficile infections or who are more susceptible to bacterial diarrheas because of gastric achlorhydria caused by disease or use of medications such as proton pump inhibitors is too extensive to review comprehensively here [13]. Additional causes of loose stools in the elderly include microscopic colitis (diagnosed only by colonic biopsies), bile-salt- induced diarrheas occurring after cholecystectomy, bacterial overgrowth syndromes [22], and diar- rheagenic medications. Normalizing stool delivery by treating specific disorders with the use of antidiar- rheal agents such as loperamide often ameliorates fecal incontinence [21]. Adequate doses and timing are important, i.e., 2–4 mg 30 min before meals or prior to social occasions to avoid accidents outside the home. The coexistence of diarrhea predominant or mixed irritable bowel syndrome (IBS) may be especially troublesome in the elderly; in patients with these forms of IBS, the cautious use of tricyclic agents with reduced receptor affinity for receptors produc- ing unwanted side effects such as nortriptyline, imipramine, and desipramine may be helpful [23, 24].
Incontinence in Persons with Dementia or Psychiatric Illness
Incontinence may occur in patients with dementia or psychiatric illness for three main reasons:
1. Patients with advanced dementia may lose neuro- logical control of bowel and bladder functions.
2. Behavioral disturbances impair the social impetus to reach a toilet in an appropriate and timely way.
These may involve impaired memory, expressive or receptive aphasia, or complete apathy.
3. Comorbid conditions that remain unrecognized in a psychotic or demented individual.
Management of such patients requires careful analysis of possible causative or contributing factors and attempts to correct them. These include simpli- fying access to toilets, using clothing that is easily undone, creating a secure and familiar environment, preventing constipation, and avoiding medications that can cause diarrhea [15, 25, 26].
Incontinence in the Independently Functioning Elderly
Fecal incontinence in independently functioning adults of all ages may be associated with one or a combination of rectal sensory and continence muscle abnormalities. In addition to conservative measures
focused on changes in stool consistency and delivery, other therapies have been recommended [27]. These therapies include surgical repair of disrupted anal sphincter muscles, and pelvic floor training and biofeedback for compliant and cognitively intact patients who are not candidates for surgery. Sacral nerve stimulation is a new and hopeful approach for selected patients who fail other forms of therapy.
Pelvic Floor Training and Biofeedback
Both pelvic floor training and biofeedback have been reported to be effective in many patients with fecal incontinence associated with impaired functioning of the puborectalis muscle and/or the external anal sphincter. In contrast to pelvic floor retraining, which is directed exclusively at reeducating weak- ened or impaired muscles, biofeedback often employs techniques to alter rectal sensation and sphincter muscle responsiveness to intrarectal stim- uli such as balloon distension. However, the biofeed- back literature does not reflect a unified mechanistic approach. There appears to be a general consensus that improvement of thresholds of perception of rec- tal sensation and the synchronization of external anal sphincter contractions to rectal distension are important factors associated with improvement [28].
In contrast, increased striated muscle strength and endurance after biofeedback training have not been shown consistently.
There is widespread agreement that biofeedback is effective in many patients who fulfill entry criteria, and it has no adverse consequences. However, the biofeedback literature has been plagued by method- ological inadequacies, few long-term follow-up stud- ies, and absence of consistent and validated out- comes. There is no consensus concerning which components of biofeedback are important, including the critical role of the patient–therapist relationship [28]. To address these issues, a recent study exam- ined critical components of the biofeedback process by randomizing 171 patients with fecal incontinence into four therapeutic groups [29]. Slightly more than 50% of patients reported clinical improvement on an intention-to-treat analysis. However, there were no differences between patients who received only advice from nurse therapists about strategies to reduce incontinence, those who received both advice and verbal instructions about sphincter exercises, those who received advice together with a hospital- based biofeedback program, and those who received both hospital and home biofeedback. At present, the evidence for using instrument-based training is insufficient, but the value of dedicated and trained individuals to work with patients cannot be overstat- ed [29].
Surgery
Anal sphincteroplasty has been performed for many years and is based on the straightforward premise of repairing an anatomically disrupted anal sphincter complex. The use of anal sonography to demonstrate anal sphincter disruptions has largely replaced the more invasive and painful electromyographic (EMG) mapping of the external sphincter. Although studies have reported short-term improvement of fecal conti- nence in up to 85% of patients following surgery, long-term follow-ups have been disappointing [30].
In three recent representative series, full continence after sphincteroplasty was maintained in only 28% of patients after a mean follow-up of 40 months and in only 11–14% of patients followed for over 69 months.
Suggested predictive factors for treatment failure include the presence of an internal anal sphincter defect, prolongation of pudendal nerve terminal motor latencies (PNTML), external anal sphincter atrophy as demonstrated by pelvic magnetic reso- nance imaging (MRI), and the presence of IBS with diarrhea predominance. In the absence of demonstra- ble anal sphincter defects, the efficacy of surgery to correct abnormalities of the pelvic floor, such as ante- rior levatorplasty, postanal repair, and total pelvic floor repair, is unproven. A Cochrane Review conclud- ed that there was insufficient evidence to determine whether clinically important differences between var- ious alternative procedures existed to guide clinical practice [31]. These procedures cannot be recom- mended for patients of any age with neurogenic incontinence or in the absence of structural defects.
Sacral Nerve Stimulation
Sacral spinal nerve stimulation is a new therapeutic approach for patients with fecal incontinence that is associated with structurally intact anal sphincters.
This technique is an extension of the successful use of this modality for urinary voiding and continence dis- orders, with the realization that stimulating elec- trodes implanted into pelvic floor muscles are prone to infection, migration, and fibrous tissue reactions.
The procedure involves the following three phases:
1. Location of sacral spinal nerves by percutaneous probing with a needle electrode to identify the nerve root that maximally stimulates anal sphinc- ter contraction.
2. Temporary placement of an electrode to chroni- cally stimulate the nerve root identified as the most efficient during acute testing.
3. Permanent implantation of a neurostimulator for chronic therapeutic stimulation.
In patients who successfully complete the first two phases, clinical improvement of fecal incontinence
has been confirmed in both short- and long-term studies [32]. Clinical parameters include substantial decrease in episodes of stool incontinence and signif- icant improvement of quality-of-life parameters, as assessed by validated quality-of-life questionnaires, for periods ranging from 6 months to more than 5 years. Objective physiologic changes include increas- es in both resting and squeeze pressures, increased squeeze durations, decreased thresholds of rectal sensation, and increased time of retention of a saline load. A multicenter study in the United States is cur- rently in progress.
Conclusions
Fecal incontinence in the elderly is a socially devas- tating disorder with numerous potential etiologies.
Appropriate management begins with a detailed his- tory and physical examination that either reveal the probable cause or determine that additional diagnos- tic studies to elucidate pathophysiology may be required. A large array of therapeutic options is available, many with little evidence to support effica- cy, but together, they allow most incontinent patients to be managed effectively.
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