Treatment of Fecal Incontinence in the Elderly

Initial Assessment and Conservative Management

The American Gastroenterological Association recommends that all elderly patients with fecal incontinence should begin with a rigorous trial of conservative therapies, including dietary modification, antidiarrheal medications, fiber supplementation, scheduled toileting, and pelvic floor exercises, before considering any surgical or device-based interventions 1, 2
Diarrhea is the single most important risk factor for fecal incontinence in older women, with an odds ratio of 53, according to the American Gastroenterological Association 1
Loperamide 2 mg, one tablet 30 minutes before breakfast, titrating up to 16 mg daily as needed, is recommended for patients with diarrhea-predominant fecal incontinence, as suggested by the American Gastroenterological Association 1, 2
Trial dietary elimination of poorly absorbed sugars and caffeine benefits approximately 25% of patients, as recommended by the American Gastroenterological Association 1, 2
Fiber supplementation improves stool consistency and reduces diarrhea-associated incontinence, according to the American Gastroenterological Association 1, 2
Scheduled toileting and bowel training programs establish regular habits, as suggested by the American Gastroenterological Association 2
Pelvic floor exercises strengthen musculature, even in elderly patients, according to the American Gastroenterological Association 2

Anorectal manometry identifies anal weakness, altered rectal sensation, or impaired rectal balloon expulsion, as recommended by the American Gastroenterological Association 2
Anal imaging identifies sphincter defects, atrophy, and patulous anal canal, according to the American Gastroenterological Association 2

Sacral nerve stimulation is the preferred surgical option, with 71% of patients achieving ≥50% reduction in incontinence episodes at 12 months, as recommended by the American Gastroenterological Association 3, 2
Perianal bulking agents may be considered, with 52% showing ≥50% improvement at 6 months, according to the American Gastroenterological Association 2

Ensure toilet access, especially with decreased mobility, as a critical prevention measure, as recommended by the American Society of Clinical Oncology 4
Optimize toileting by educating patients to attempt defecation twice daily, 30 minutes after meals, straining no more than 5 minutes, according to the American Society of Clinical Oncology 4
Use polyethylene glycol 17 g/day for elderly patients requiring laxatives, as it offers efficacy with a good safety profile, as recommended by the American Society of Clinical Oncology 4
Avoid liquid paraffin in bed-bound patients or those with swallowing disorders due to aspiration pneumonia risk, according to the American Society of Clinical Oncology 4
Use isotonic saline enemas rather than sodium phosphate enemas in older adults to avoid adverse effects, as recommended by the American Society of Clinical Oncology 4
Monitor for dehydration and electrolyte imbalances when using laxatives in patients on diuretics or cardiac glycosides, according to the American Society of Clinical Oncology 4

Do not proceed to invasive therapies without a rigorous trial of conservative management, as many patients considered "refractory" have not received optimal conservative therapy, as recommended by the American Gastroenterological Association 1, 2
Do not use bulk laxatives in non-ambulatory patients with low fluid intake, as it risks mechanical obstruction, according to the American Society of Clinical Oncology 4