Fecal incontinence is a symptom of many disorders that can affect the nerves and muscles controlling defecation; it is not just due to exceptionally voluminous diarrhea. Underlying problems should be identified and treated, because that may improve incontinence. If treatment of the underlying problem does not correct incontinence, several approaches can be employed successfully. General approaches include stimulation of defecation at intervals to empty the rectum under supervised conditions; treatment of diarrhea, if present; addressing coexisting psychologic problems, such as depression; use of continence aids, such as adult diapers; and perineal skin care to prevent skin breakdown. Drug therapy includes use of constipating drugs, such as loperamide or diphenoxylate, that can impede the gastrocolic reflex, thereby limiting rectal filling and the likelihood of incontinence. Biofeedback training is useful in patients with some ability to sense rectal distention and to contract the external anal sphincter; instrumental learning using manometric or electromyographic biofeedback can be used to reinforce the rectoanal contractile response to rectal distention. Improvement in continence has been noted in up to 70% of suitable candidates with a single biofeedback training session. Patients with external anal sphincter disruption due to childbirth injury or other trauma may benefit from direct external anal sphincter repair (sphincteroplasty). In others, tightening up the anal canal by encirclement with nonabsorbable mesh (Thiersch procedure), perianal injection of fat, collagen, or synthetic gel, or radiofrequency electrical energy (Stretta procedure) may provide some palliation. Creation of a new sphincter mechanism by muscle transposition and encirclement of the anal canal is another approach that has been improved by use of electrical stimulators to keep the neosphincter contracted. Artificial anal sphincters patterned after artificial urinary sphincters have met with some success, but local infection remains problematic. When all else fails, fecal diversion (ileostomy, colostomy) can be effective in rehabilitating patients.
