Faecal incontinence in the elderly : epidemiology and management

Faecal incontinence occurs in up to 10% of community dwelling persons > or = 65 years of age and approximately 50% of nursing home residents. It is a vastly under-reported problem that has a devastating effect on those who experience it as well as their spouses and caregivers. There are three broad categories of faecal incontinence among the elderly: (i) overflow incontinence; (ii) reservoir incontinence; and (iii) rectosphincteric incontinence. The first two can be diagnosed based upon the patient's history and physical examination and the response to dietary and pharmacological interventions. The third is assessed by careful physical examination supplemented by diagnostic tests directed towards evaluation of anorectal continence mechanisms. The most important of these is anorectal manometry, which can be supplemented by studies of structure (anal ultrasonography or pelvic floor magnetic resonance imaging) and neuromuscular function (electromyogram). A variety of therapeutic interventions are employed in patients with rectosphincteric incontinence; these include dietary, behavioural, pharmacological and surgical modalities chosen on the basis of the results of diagnostic testing. For isolated internal anal sphincter weakness, a cotton barrier in the anal canal is often effective. Acute sphincter injury is best treated with sphincteroplasty but, otherwise, surgical procedures are of uncertain benefit. Peripheral neurogenic incontinence may be treated with antidiarrhoeal agents, biofeedback techniques and dietary manipulations. Sacral spinal nerve stimulation is a promising new technique for selected patients with neurogenic faecal incontinence and is currently undergoing testing in the US and Europe. Significant improvement in quality of life can be achieved in most elderly persons with faecal incontinence.