Management of Bowel Incontinence

Initial Assessment and Evaluation

The American Gastroenterological Association recommends obtaining a detailed bowel diary documenting frequency, consistency, volume, and circumstances of incontinence episodes, as well as checking for fecal impaction via digital rectal examination, and identifying underlying bowel disturbances, particularly diarrhea, which is the single most important modifiable risk factor 1
The American Gastroenterological Association suggests screening for contributing medical conditions, such as diabetes, dementia, stroke, inflammatory bowel disease, and prior anal sphincter injury from obstetric trauma or surgery, as well as assessing for concurrent urinary incontinence, obesity, and history of cholecystectomy 1

The American Gastroenterological Association recommends identifying and eliminating poorly absorbed sugars and caffeine from the diet, and implementing scheduled toileting, attempting defecation twice daily, 30 minutes after meals when gastrocolic reflex is strongest, straining no more than 5 minutes 1
Ensure adequate toilet access, especially critical for patients with decreased mobility, and increase fluid intake to at least 1.5 liters daily, and encourage physical activity within patient's limitations 3, 4

For patients with diarrhea-predominant incontinence, the American Gastroenterological Association suggests using anti-diarrheal medications to reduce stool frequency and urgency, and adding fiber supplements to bulk and firm stool consistency 1
For patients with constipation or overflow incontinence, polyethylene glycol (PEG) 17 g/day is first-line pharmacological treatment due to efficacy and excellent safety profile in elderly patients 3, 4

If conservative measures fail after adequate trial, the American Gastroenterological Association recommends proceeding to pelvic floor retraining with biofeedback therapy, which uses electronic and mechanical devices to improve pelvic floor muscle strength, sensation and contraction, and rectal sensation and tolerance 1

Many patients labeled "refractory" have not received optimal conservative therapy, including meticulous dietary history, elimination trials, and proper bowel training, and do not proceed to invasive testing or surgery without first implementing comprehensive conservative management 1
In elderly patients with renal impairment, use magnesium-containing laxatives cautiously due to hypermagnesemia risk, and avoid liquid paraffin in bed-bound patients due to aspiration lipoid pneumonia risk 3

A 50% reduction in frequency of incontinence episodes is considered clinically significant improvement when monitoring treatment response 1