Medical management of fecal incontinence.

Diarrhea and constipation are known risk factors for fecal incontinence. This report reviews how to diagnose and medically treat patients with chronic diarrhea, chronic constipation with overflow incontinence, and incontinence resulting from rectal mucosal prolapse secondary to hemorrhoids. Antidiarrheal agents (including loperamide, diphenoxylate, and difenoxin) and the tricyclic antidepressant amitriptyline improve continence in patients with diarrhea-associated incontinence. Other antidiarrheal agents are under investigation. The mechanism is believed to be decreased intestinal motility and stool frequency resulting in more formed stools. Increases in anal canal resting pressure may also contribute to improvement in continence. Adverse effects are constipation from excessive use. In addition to antidiarrheal drugs, fiber supplements may improve incontinence associated with diarrhea. Transient, benign cases of constipation usually respond to increasing fluid intake and dietary fiber, improving mobility, or eliminating the concurrent use of constipating drugs. For mild to moderate constipation, bulking agents, laxatives, and stool softeners are used cautiously so as not to excessively loosen stools and exacerbate anal incontinence. Laxatives have been shown to improve continence, possibly through the mechanism of eliminating fecal impaction. Prolapsing hemorrhoids may partially obstruct defecation and cause soilage from the passage of fecal material, mucus, or blood. With endoscopic banding, a ligator is attached to an endoscope and a tight band is placed around the enlarged vein, causing the hemorrhoid to thrombose.