Management of Fecal Incontinence in Diabetic Patients

Pathophysiology and Prevalence

Fecal incontinence in diabetic patients is primarily related to reduced and unstable internal anal sphincter tone, impaired rectal compliance, and diminished rectal sensation due to autonomic neuropathy 3, 4
Nocturnal incontinence is particularly prevalent in diabetic patients due to these specific anorectal dysfunctions 4
Diabetic patients often have disordered small and large intestinal motility that can contribute to diarrhea and subsequent incontinence 4
Poor glycemic control can exacerbate gastrointestinal symptoms and sensations, worsening incontinence 4, 5

Optimize glycemic control to minimize autonomic neuropathic effects on anorectal function, as recommended by the American Diabetes Association 6
Implement dietary modifications, including increasing dietary fiber to improve stool consistency, as suggested by the American Gastroenterological Association 2
Establish a bowel training program with scheduled toileting to improve predictability, as recommended by the American College of Gastroenterology 1, 2
For diarrhea-associated incontinence, prescribe loperamide (2 mg) starting 30 minutes before breakfast and titrate as needed up to 16 mg daily, according to the American Gastroenterological Association 2
Consider cholestyramine or colesevelam for bile salt-induced diarrhea, which is common in diabetic patients, as recommended by the American College of Gastroenterology 2

Assess for and treat concurrent gastroparesis, which often coexists with anorectal dysfunction, as recommended by the American Diabetes Association 7
Monitor for urinary incontinence, which frequently co-occurs with fecal incontinence in diabetic patients, according to the American Urological Association 8
Evaluate for peripheral neuropathy, which strongly correlates with diabetic cystopathy and fecal incontinence, as suggested by the American Diabetes Association 8
Be aware that fecal incontinence in diabetics may be exacerbated during periods of hyperglycemia, as noted by the American Diabetes Association 5

Don't attribute all bowel symptoms to diabetic neuropathy without ruling out fecal impaction, which can cause overflow incontinence, as warned by the American College of Gastroenterology 2
Don't overlook the importance of glycemic control as part of the comprehensive management plan, as emphasized by the American Diabetes Association 6
Remember that percutaneous tibial nerve stimulation is not currently recommended for routine clinical practice in managing fecal incontinence, according to the American College of Gastroenterology 1