Management of Fecal Incontinence in Elderly Males

Initial Assessment and Reversible Causes

In men, assessing prostate size during digital rectal examination is crucial, as benign prostatic hyperplasia affects 60% of men by age 60 and 80% by age 80, contributing to constipation and subsequent overflow incontinence, according to the American Urological Association 1
Diabetes mellitus should be checked for diabetic autonomic neuropathy causing neurogenic bladder and bowel dysfunction, plus polyuria from glycosuria that may contribute to fecal urgency, as recommended by the American Diabetes Association 2, 1
Neurological disorders, such as dementia, stroke, and spinal cord disease, directly impair continence mechanisms and should be identified, as stated by the American Academy of Neurology 2, 3

Diarrhea is the single most important independent risk factor (OR=53) for fecal incontinence, and its management is crucial, according to the American Gastroenterological Association 2, 4
Loperamide 2 mg, one tablet 30 minutes before breakfast, should be started and titrated up to 16 mg daily as needed to manage diarrhea-predominant incontinence, as recommended by the American Gastroenterological Association 4
Fiber supplementation should be added to improve stool consistency and reduce diarrhea-associated incontinence, as stated by the American Gastroenterological Association 4

Optimize diabetic control aggressively to reduce autonomic neuropathy progression, as recommended by the American Diabetes Association 5
Address peripheral neuropathy contributing to reduced anorectal sensation, as stated by the American Academy of Neurology 2
Screen for and treat candida infections, which are more common in diabetic patients, according to the Infectious Diseases Society of America 1

Never assume infection based solely on bowel symptoms in elderly patients, as atypical presentations are common and asymptomatic colonization is prevalent, as stated by the European Urology Association 8
Do not attribute incontinence solely to age or pre-existing conditions without systematic evaluation for reversible causes, as recommended by the American Geriatrics Society 3
Avoid placing indwelling catheters for incontinence management without proper indications, as this dramatically increases infection risk, according to the American Urological Association 3