Introduction
Management of fecal incontinence (FI) should be based on a meticulous assessment of pathophysiolo- gy through both clinical and physiological diagnostic workup. There are cases with prevalently altered diet and hygiene. Very frequently, diarrhea and constipa- tion can be found involved in the development and maintenance of FI [1–3], both in the presence or absence of other traumatic or nontraumatic causes.
Consequently, in those cases, treatment must be directed toward cure of these dysfunctions, either as single-line or combined treatment. Little evidence exists in the available literature about medical thera- py for FI; recently, a Cochrane Database Review high- lighted that “there is little evidence with which to assess the use of drug therapies for the management of fecal incontinence” [4]. Therefore, medical treat- ment in FI is debatable and often pragmatic.
Diet and Patient Education
Patients should be educated to avoid excessive straining at defecation to reduce the risk of pudendal nerve damage. Perianal hygiene must be addressed, including delicate soaps specifically for use in the perianal area, to avoid perianal irritation and pruri- tus. Only in selected cases should absorbents, dia- pers, and tampons be recommended. Patients must be educated to reduce or avoid foods that induce loose stools, excessive gastrointestinal transit, or increased intestinal gas production (i.e., milk and derivates, excessive legumes and vegetables, choco- late, tomatoes, caffeine, prunes, grapes, figs).
Chronic Diarrhea
Up to 50% of patients with chronic diarrhea can pres- ent FI [5]. The most common cause of chronic diar- rhea associated with FI is irritable bowel syndrome (IBS) [6]. In these patients, abdominal pain or dis-
comfort, altered stool frequency, altered stool form, and/or relief of discomfort after a bowel movement may coexist [7–9]. FI can also be associated with other causes of chronic diarrhea:
– Lactose intolerance
– Excess of medications (laxatives, antacids, prostaglandins, nonsteroidal anti-inflammatory drugs)
– Hyperthyroidism – Diabetes
– Nonabsorbable sugars – Crohn’s disease – Ulcerative colitis
– Benign or malignant rectal tumors – Small-bowel bacterial overgrowth – Bile acid malabsorption
– Celiac sprue – Microscopic colitis – Chronic pancreatitis
Usually, these causes create excessive water and electrolyte passage into the small/large bowel, loss of protein and fluid, alteration of intestinal peristalsis, and stool transit time.
For FI associated with mild chronic diarrhea or mild chronic constipation, bulking agents of either natural (psyllium, gum arabic, methyl cellulose) or synthetic (calcium polycarbophil) fibers should be considered as first-line treatment. Moreover, a daily fiber supplementation for 1 month has been demon- strated to significantly reduce FI [10].
Persistence of diarrhea should be treated with spe- cific antidiarrheal agents. Patients should always be warned about the possible constipating effect of these agents. Loperamide is a synthetic opioid with both calcium-receptor-antagonist- and calcium-channel- blocking actions. Then, due to this action, augment- ed water and electrolyte absorption is obtained by reduction of intestinal peristalsis and prolonged gas- trointestinal transit time. Moreover, it increases internal anal sphincter tone and reduces urge sensa- tion and bowel-movement frequency by reducing sensitivity to the rectoanal inhibitory reflex (RAIR).
Compared with diphenoxylate, loperamide is more
Medical Treatment of Fecal Incontinence
Carlo Ratto, Angelo Parello, Lorenza Donisi, Francesco Litta, Giovanni B. Doglietto
14
effective in reducing urgency, stool frequency, and central nervous system (CNS) adverse events (it does not cross the blood-brain barrier) [11–13]. However, caution must be used in dosage to avoid undesirable constipation. Only a few studies have been directed toward evaluating the benefits of loperamide in FI patients [14–16]. Diphenoxylate and difenoxin are opioids with antiperistaltic action, but they cross the blood-brain barrier, causing mild euphoria if taken in excess, requiring atropine. No effects on anal pres- sures have been demonstrated. An overdosage could cause toxic megacolon in an inflamed colon. Clinical studies have tested the effectiveness of phenylephrine gel in patients with FI. This is a selective alpha 1 adrenergic agonist, increasing internal anal sphincter tone and resting anal pressure [17, 18]. Amitriptyline, a tricyclic antidepressant with anticholinergic, sero- tonergic, and antimuscarinic actions, has been demonstrated to reduce amplitude and frequency of rectal motor complexes, increase colonic transit time, and improve symptoms in patients with FI or IBS [19–21].
Chronic Constipation
FI can occur in patients affected by chronic constipa- tion as a consequence of stool retention in the rec- tum, resulting in overflow incontinence. Chronic fecal retention determines a significantly decreased anorectal sensation. On the other hand, constipation can be caused by excessive consumption of drugs, including antidiarrheals, narcotics, calcium-channel blockers, antidepressants, and other psychotropic agents. Finally, particularly in the older subjects, dehydration and insufficient fiber and fluid intake cause chronic constipation. Overflow FI is particular- ly frequent in institutionalized patients. It can require manual disimpaction, stool softeners, laxa- tives, enemas, or suppositories [22].
Accurate diagnosis of constipation-FI sequence is determinant to avoid planning incorrect or excessive treatment. Physical examination, anorectal manome- try and electrophysiology, endoanal ultrasound, con- trast defecography, and radiologic transit time evalu- ation can contribute to the identification of patho- physiological processes and exclude other causes of both constipation and FI.
The above-mentioned bulking agents as well as laxatives and stool softeners can be used, provided that caution is used to avoid excessively loose feces, thus worsening FI. Dietary manipulation, by improv- ing fiber intake (including wheat bran, psyllium husk, methylcellulose, polycarbophils), can be effec- tive because stool weight is increased and consisten- cy is decreased.
Both lactulose and sorbitol stimulate intestinal peristalsis by a water-transport mechanism into the bowel. Undesirable side effects are abdominal bloat- ing and flatulence, with subsequent patient discom- fort. Glycerin, given as an enema, can obtain rectal emptying. Saline laxatives interfere with bowel osmosis and peristalsis, improving intestinal motili- ty. However, administration to patients with cardiac or renal failure or electrolyte anomalies needs special caution.
Some 5-HT mediators display a different mecha- nism of action. Tegaserod is a 5-HT4 agonist that improves intestinal peristalsis and increases transit time of both the small intestine and the colon; also, it may ameliorate abdominal pain and distention [23, 24].
References
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Chapter 14 Medical Treatment of Fecal Incontinence
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