Winter 2025

Winter 2025 Issue

Identifying and Managing Fecal Incontinence
By Mark D. Coggins, PharmD, BCGP, FASCP
Today’s Geriatric Medicine
Vol. 18 No. 1 P. 22

Offer Sympathetic Support and Improve Individual Experience to Patients With Bowel Incontinence

Fecal incontinence, also known as accidental bowel leakage or bowel incontinence, is a complex and often misunderstood condition that requires greater attention from health care providers. Fecal incontinence is characterized by the involuntary loss of bowel control, which can vary from occasional accidents to frequent and debilitating episodes that significantly affect a patient’s daily life. The impact of this condition extends beyond physical discomfort; it can severely affect a patient’s emotional and social well-being.

Increasing education for both patients and health care providers about fecal incontinence is essential, as it can improve diagnosis, treatment, and the overall quality of life for individuals suffering from this often-stigmatized condition. Many patients are reluctant to discuss their symptoms due to embarrassment, which can lead to delayed care and unresolved issues. Additionally, some health care providers may lack adequate knowledge about effective management strategies, limiting treatment options.

This article aims to enhance health care professionals’ awareness and understanding of fecal incontinence, helping to improve patient outcomes and provide compassionate support to those facing its challenges.

Prevalence of Fecal Incontinence
Fecal incontinence is common, impacting millions. In the general adult population, 7% to 15% of adults contend with this condition.1 The prevalence increases dramatically for those hospitalized, affecting 18% to 33% of patients.2 Among the vulnerable population residing in nursing homes, the statistics are even more striking, as fecal incontinence impacts between 50% and 70% of residents.3 Despite these staggering figures, the true prevalence of fecal incontinence is likely underestimated due to the embarrassing nature of its symptoms and patients’ reluctance to discuss them. Also, although fecal incontinence is more common among older adults, it’s not an inevitable part of aging and often can be managed effectively with appropriate treatment.

Consequences of Fecal Incontinence
Fecal incontinence can significantly impact various aspects of a person’s life, leading to a diminished sense of well-being and quality of life. The effects of fecal incontinence are multifaceted and include the following4:

• Psychological Effects: Individuals with fecal incontinence often experience psychological stress that can lead to anxiety, depression, and feelings of anger, sadness, hopelessness, shame, and embarrassment.4,5

• Social Withdrawal: The emotional burden and fear of incontinent episodes can prevent patients from engaging in activities they once enjoyed. Those with fecal incontinence may avoid gatherings, travel, or even outings with friends and family, leading to feelings of isolation and loneliness.

• Impact on Relationships: Embarrassment and anxiety can strain relationships. Patients with fecal incontinence often find it hard to discuss their condition, leading to misunderstandings and a lack of support from loved ones.

• Daily Activity Limitations: The fear of accidents can disrupt daily routines, as individuals may need to plan their activities around bathroom access. This can result in a loss of spontaneity in their lives.

• Dependence on Others: Severe cases of fecal incontinence can lead to dependence on caregivers or family members with daily tasks and hygiene, negatively impacting self-esteem and autonomy. Additionally, this dependence may play a significant factor in the need to seek nursing home placement.

• Physical Health: In addition to emotional and social effects, fecal incontinence can result in physical complications such as urinary tract infections, skin irritations, and nutritional deficiencies, which further exacerbate distress and discomfort.

• Health Care Access: The stigma surrounding fecal incontinence may hinder individuals from seeking medical help, which can delay diagnosis and treatment, ultimately affecting their overall health outcomes.

Types of Fecal Incontinence
Fecal incontinence can be categorized into two main types: urge fecal incontinence and passive fecal incontinence. Patients experiencing urge fecal incontinence have a sudden, intense urge to defecate, which can make it difficult to reach a restroom in time. In contrast, individuals with passive fecal incontinence may inadvertently pass stool or mucus without any awareness or sensation of needing to go.

Symptoms
Symptoms of fecal incontinence can be diverse and distressing and may include the following:

• a sudden and intense urge to have a bowel movement;
• unintentional leakage of stool;
• an inability to control the passage of gas;
• frequent accidents where bowel movements occur without any warning;
• staining of undergarments; and
• discomfort or cramping in the abdomen associated with bowel movements.

Causes of Fecal Incontinence
The causes of fecal incontinence are complex and multifactorial, including physical, neurological, and psychological issues. These include the following:

• Chronic Diarrhea: Conditions such as irritable bowel syndrome, inflammatory bowel disease, or infections can cause chronic diarrhea, overwhelming the body’s ability to control bowel movements. Additionally, chronic diarrhea can weaken the muscles of the anal sphincter, leading to a loss of control.

• Constipation: Prolonged constipation can weaken the anal sphincter muscles and lead to fecal impaction. This may result in the overflow of liquid stool, causing accidental leakage. Excessive straining during bowel movements can also damage the nerves that control the anal sphincter muscles, further compromising bowel control.

• Neurological Disorders: Conditions like multiple sclerosis, Parkinson’s disease, and spinal cord injuries can disrupt the nerve signals that control bowel movements, leading to incontinence. Childbirth, surgical procedures, or trauma may also damage the anal sphincter muscles, reducing control.

• Psychological Factors: Stress, depression, and anxiety can influence bowel habits and contribute to incontinence. Psychological conditions may alter an individual’s perception of bodily urges and control.

• Rectal Sensation Issues: If the rectum fails to accurately sense the presence of stool, it may not provide adequate warnings for the need to defecate, resulting in incontinence.

• Surgical Complications: Surgeries involving the abdominal or pelvic area, particularly those related to the rectum or colon, can sometimes lead to fecal incontinence.

• Medications: Certain medications, especially those affecting bowel motility or causing diarrhea, can increase the risk of fecal incontinence.

Polypharmacy and Fecal Incontinence
Polypharmacy is a major concern for older adults, as it can heighten the risk of medication-related side effects, including constipation, diarrhea, and cognitive decline. These conditions can, in turn, exacerbate fecal incontinence. As such, deprescribing medications to reduce polypharmacy should be a focus. It is advisable to conduct a comprehensive medication review for those with incontinence to identify any medications that might contribute to or worsen the problem. Some medications that may affect bowel control include the following:

• Laxatives: Overuse, particularly of stimulant laxatives, can lead to diarrhea and increased bowel urgency.

• Antibiotics: These can disrupt the normal gut flora, leading to diarrhea and other gastrointestinal issues.

• Diuretics: These medications may cause dehydration or increase bowel movements, which can impact bowel control.

• Antidepressants: Certain antidepressants, such as selective serotonin reuptake inhibitors like sertraline, may cause gastrointestinal side effects, including diarrhea. Conversely, antidepressants with anticholinergic effects, such as amitriptyline, can lead to constipation and cognitive dysfunction.

• Proton Pump Inhibitors: Often overused, these acid-reducing medications can cause gastrointestinal dysbiosis, potentially leading to diarrhea.

• Magnesium-Containing Antacids: These can result in loose stools and diarrhea.

• Certain Antipsychotics: Some of these medications may cause constipation or other gastrointestinal issues, leading to unpredictable bowel movements.

• Narcotics/Opioids: While these pain medications typically cause constipation, discontinuation can lead to rebound diarrhea.

• Metformin: This commonly used antidiabetic medication can cause gastrointestinal upset, including diarrhea.

• Chemotherapy Agents: Many of these can cause diarrhea as a side effect.

Bowel and Symptom Journal
Individuals with fecal incontinence should be encouraged to keep a bowel and symptom journal, commonly referred to as a stool diary. This journal should include the following information:

• date and time of each bowel movement;
• consistency of the stool (eg, hard, soft, watery);
• amount of stool passed;
• any symptoms experienced;
• instances of leakage (if applicable);
• dietary intake, including types and quantities of food;
• fluid intake;
• level of physical activity;
• sleep patterns; and
• changes in stress and emotional state.

Keeping track of this information can help identify patterns and triggers related to bowel health. For example, it may reveal connections between certain foods and drinks and issues like fecal incontinence. Additionally, maintaining a journal can enhance communication between health care providers and their patients.

Management of Fecal Incontinence
The management of fecal incontinence involves a combination of strategies tailored to the underlying causes, the severity of the condition, and the specific goals of each individual. Conservative treatments such as altering one’s diet, taking medication, participating in bowel retraining, and engaging in pelvic floor muscle strengthening exercises have been shown to alleviate symptoms by approximately 60%.1 These approaches have a success rate of preventing fecal incontinence in one out of every five individuals.1 Surgical interventions such as sacral nerve stimulation and anal sphincter augmentation may be required for some individuals with more severe fecal incontinence.

Absorbent Pads
Absorbent pads specifically designed for incontinence are the most common treatment option for individuals managing fecal incontinence.6 These pads can be comfortably worn in underwear, offering a discreet and effective solution for managing leakage. By providing greater confidence and security, absorbent pads enable individuals to participate fully in daily activities and social interactions without the fear of embarrassment.

Dietary Changes
Patients experiencing fecal incontinence should avoid foods that may worsen their symptoms. Common foods known to aggravate diarrhea associated with fecal incontinence include the following:

• alcoholic beverages;
• caffeinated foods and drinks;
• dairy products;
• beans and vegetables from the cabbage family;
• fatty and greasy foods;
• spicy foods and cured meats;
• foods and drinks containing fructose, such as apples, peaches, and pears; and
• artificial sweeteners like sorbitol, mannitol, and xylitol.

Individuals experiencing fecal incontinence should also be advised to consume smaller, more frequent meals. For some people, eating a large meal can trigger the urge to have a bowel movement and may lead to diarrhea. By opting for smaller and more frequent meals, the frequency of bowel movements can be reduced.

Increased Fiber Intake
Fiber plays an essential role in the management of fecal incontinence, particularly in regulating bowel movements and improving stool consistency. Individuals experiencing fecal incontinence due to constipation or hemorrhoids may benefit from eating fiber-rich foods, staying hydrated, and engaging in physical exercise.

Bowel Training
Bowel training is a therapeutic method that helps individuals regain control over bowel movements, particularly for those facing fecal incontinence or irregular habits. Bowel training involves creating a consistent daily bathroom schedule, usually aimed for after meals when the urge to defecate is strongest. And, though it requires patience and consistency, many individuals experience significant improvements over time.

Kegel Exercises
These exercises strengthen the pelvic muscles that support the organs involved in bowel and bladder control, such as the rectum and bladder. When doing Kegel exercises, you alternate between squeezing and relaxing these muscles. To experience significant benefits, it’s important to perform them daily.

Biofeedback
Biofeedback is a therapy for fecal incontinence that helps individuals gain control over their pelvic floor muscles. Using electrodes, a therapist monitors muscle activity, providing real-time feedback. This allows patients to identify and strengthen the muscles needed for bowel control, improving their ability to prevent leakage and enhance bowel function.

Surgical Interventions
Surgery is a viable option for patients when other interventions fail to achieve the desired results and may include the following:

• Sphincteroplasty: This is a form of surgery to correct defects in the anal sphincter and may be necessary for individuals who have experienced trauma, injury, or specific medical conditions that weakened the sphincter.

• Sacral Nerve Stimulation: A minimally invasive surgical procedure that implants a device near the tailbone to send electrical impulses to the sacral nerves. These nerves control the pelvic floor and muscles related to bowel function.

• Artificial Anal Sphincter: This small implant mimics the natural anal sphincter muscle and is controlled by a discreet bulb pump placed within the body.

• Colostomy: A surgical procedure that creates an opening in the abdominal wall for the colon, with a bag attached to collect stool.

A Call to Health Care Providers
Fecal incontinence is treatable, but individuals experiencing symptoms must feel comfortable discussing their concerns with a health care provider to receive appropriate treatment. There is a clear opportunity for health care providers to improve discussions with patients about fecal incontinence symptoms. One analysis revealed that two-thirds of women with fecal incontinence do not seek care for their symptoms, despite 40% experiencing symptoms severe enough to affect their quality of life.7 Contributing to the issue is that providers routinely fail to inquire about fecal incontinence during outpatient visits. This failure is, in part, because health care professionals are often reluctant to inquire about fecal incontinence due to the complexity of evaluation and due to a lack of clinical experience and knowledge of current management approaches.8

The stigma surrounding the condition makes it difficult for both patients and health care providers to discuss the topic of fecal incontinence openly.4 Conversations about fecal matter are considered taboo in many societies and can be viewed as inappropriate or offensive. Despite its importance to human health, the deep sense of embarrassment associated with excreting waste can delay medical intervention and even discourage individuals from seeking help. Studies have found that patients with fecal incontinence want health care providers to take a more proactive approach in initiating discussions about the condition.4 Not only do providers have a responsibility to start these conversations, but doing so can also help reduce the stigma and encourage patients to seek appropriate care.

Providers may also need to adjust the terminology used during discussions; for instance, terms like “anal” and “fecal” can be more embarrassing for patients, who have been found to prefer phrases such as “accidental bowel leakage” and “leakage” instead of “incontinence.”4

Furthermore, patients with fecal incontinence have voiced concerns about a lack of sensitivity from health care providers. While some patients with fecal incontinence report positive interactions with health care providers, studies indicate that many patients frequently report feeling dismissed. A recurring theme from one study was the need for motivational messaging from providers. 9 Individuals with fecal incontinence frequently express a desire for treatment guidance, encouragement to continue living their lives, and counseling to support the personal effort required to manage their condition.

Final Thoughts
Fecal incontinence is a significant yet often overlooked condition that affects countless individuals, impacting their physical, emotional, and social wellbeing. By fostering an environment of open communication and understanding around this topic, patients and health care providers can work together to address the challenges associated with fecal incontinence. Increased awareness, education, and sensitivity are crucial in breaking down the barriers of stigma, ensuring that those affected receive the timely and compassionate care they deserve. With appropriate management strategies and support, individuals living with fecal incontinence can reclaim their quality of life and engage fully in their daily activities.

— Mark D. Coggins, PharmD, BCGP, FASCP, is a long term care expert and corporate pharmacy consultant for Touchstone-Communities, a leading provider of senior care that includes skilled nursing care, memory care, and rehabilitation for older adults throughout Texas. He’s a past director of the American Society of Consultant Pharmacists and was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the Excellence in Geriatric Pharmacy Practice Award.

References
1. Whitehead WE, Palsson OS, Simren M. Treating fecal incontinence: an unmet need in primary care medicine. N C Med J. 2016;77(3):211-215.

2. Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol. 2015;110(1):127-136.

3. Rao SS, Bharucha AE, Chiarioni G, et al. Anorectal disorders. Gastroenterol. 2016;150(6):1430-1442.

4. Authors; Majid U, Spry C. Patient and care provider perspectives on the management of fecal incontinence: a qualitative rapid review: CADTH Health Technology Review [Internet]. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; November 2023.

5. Olsson F, Bertero C. Living with faecal incontinence: trying to control the daily life that is out of control. J Clin Nurs. 2015;24(1-2):141-150.

6. Treatment of fecal incontinence. National Institute of Diabetes and Digestive and Kidney Diseases website. https://www.niddk.nih.gov/health-information/digestive-diseases/bowel-control-problems-fecal-incontinence/treatment. Updated July 2017.

7. Brown HW, Wexner SD, Segall MM, Brezoczky KL, Lukacz ES. Accidental bowel leakage in the mature women’s health study: prevalence and predictors. Int J Clin Pract. 2012;66(11):1101-1108.

8. Meyer I, Richter HE. Impact of fecal incontinence and its treatment on quality of life in women. Womens Health (Lond). 2015;11(2):225-238.

9. Cichowski SB, Dunivan GC, Rogers RG, Komesu YM. Patients' experience compared with physicians' recommendations for treating fecal incontinence: a qualitative approach. Int Urogynecol J. 2014;25(7):935-940.