Salt Water Flush

Vectorgraphy provides useful information on the magnitude and direction of radial forces within the anal sphincter. Defecography may reveal mucosal or rectal prolapse, intussusception, and the degree of perineal descent.

Treatment -- The first step is to identify and treat any underlying cause of fecal incontinence (eg, diarrhea, inflammatory bowel disease, lactose intolerance, bile salt malabsorption). Elderly patients with fecal impaction require bowel retraining with the help of salt water flush. Patients with mild incontinence may respond to a bulking agent or an antidiarrheal agent, such as loperamide hydrochloride. The dosage of loperamide may have to be adjusted according to the patient's symptoms. Use of cholestyramine (Questran, Questran Light) or antihistamines may be helpful.

Patients with mild pudendal neuropathy and a weak sphincter may improve with bowel retraining using neuromuscular conditioning techniques and biofeedback. Similarly, patients with impaired rectal sensation or impaired coordination between the rectum and anal canal may improve with use of biofeedback therapy.

Patients with a weak or damaged anal sphincter and an intact pudendal nerve may benefit from surgical repair of the anal sphincter. Other surgical options include colostomy and insertion of a distal wire ring.

Patients with fecal incontinence secondary to spinal injury pose a therapeutic challenge. Goals are to maintain soft stools, avoid diarrhea, and develop a schedule of elective defecation. Treatment in patients with suprasacral injury may consist of antidiarrheal agents to constipate the patient and then use of glycerin suppositories or digital stimulation of the anorectal reflexes to produce elective defecation. However, in patients with sacral nerve injury, a bowel regimen is required, which consists of antidiarrheal agents and use of enemas to electively induce bowel movements.

Evaluation of constipation and fecal incontinence begins with comprehensive history taking, which may include overcoming a significant psychosocial barrier. Before functional anorectal diseases can be controlled, the fundamental cause must be determined and any underlying disorder corrected.

In constipation, a colonic or anorectal motility disorder is often the cause; about half of refractory cases are the result of obstructive defecation. In fecal incontinence, dysfunction of several anatomic or physiologic mechanisms may be the cause.

Anorectal manometry is useful in assessment in both disorders. Other helpful tests are colonic-transit measurement in constipation and electrophysiologic tests and defecography in fecal incontinence. Treatment of constipation often includes dietary measures and use of laxatives or prokinetic agents; fecal incontinence may respond to bulking or antidiarrheal agents. In both disorders, some patients have responded to the recently described technique of neuromuscular conditioning with biofeedback. In some cases, surgical repair must be considered.