Initial Management of Fecal Incontinence

Rationale for Biofeedback as First-Line Treatment

The American Gastroenterological Association recommends a stepwise approach to fecal incontinence management, with pelvic floor retraining with biofeedback therapy recommended for patients with fecal incontinence who do not respond to conservative measures, such as diet, fluids, and bowel training 1
Conservative measures alone, such as diet, fluids, and bowel training, benefit only approximately 25% of patients with fecal incontinence 1
Biofeedback therapy is specifically effective for patients with sphincter weakness and can improve both squeeze pressures and continence outcomes, particularly in those with partial external sphincter failure 1

Cholestyramine is indicated for bile-salt malabsorption causing diarrhea, not for sphincter dysfunction, according to the American Gastroenterological Association 2
Diphenoxylate-atropine is appropriate for diarrhea-associated incontinence, but not for sphincter weakness, as recommended by the American Gastroenterological Association 2

Sphincteroplasty should be considered in postpartum women with fecal incontinence and recent sphincter injuries, but only after conservative and biofeedback therapy have been tried, as stated by the American Gastroenterological Association 3
The American Gastroenterological Association's Best Practice Advice 7 states that sphincteroplasty may be considered in patients who present later with symptoms of fecal incontinence unresponsive to conservative and biofeedback therapy and evidence of sphincter damage 3

The biofeedback program should include electronic and mechanical devices to improve pelvic floor strength, sensation, and contraction, as well as toilet training and scheduled defecation programs, according to the American Gastroenterological Association 2
Treatment duration of at least 3 months is recommended before considering failure, as stated by the American Gastroenterological Association 1, 5

If symptoms persist after 3+ months of biofeedback therapy, perianal bulking agents, such as dextranomer injection, may be considered, as recommended by the American Gastroenterological Association 1, 3
Sacral nerve stimulation may be considered for moderate-to-severe fecal incontinence, according to the American Gastroenterological Association 1, 6
Sphincteroplasty may be considered when bulking and sacral nerve stimulation are unavailable or unsuccessful, as stated by the American Gastroenterological Association 3, 4