Dietary modification for treatment of fecal incontinence frequently involves avoidance of foods that precipitate loose stools and diarrhea. Common dietary irritants include spicy foods, coffee and other caffeinated beverages, beer and alcohol, and citrus fruits. Avoidance of dairy products or the addition of lactase dietary supplements is essential for those with lactose intolerance. The addition of fiber may improve fecal incontinence by functioning as a stool bulking agent to increase volume and density. The average individual in the United States consumes less than half the recommended daily fiber intake (25–35 g). Various fiber sources are listed in Table 28.9, with the highest content found in high-fiber cereals. It is difficult to consume the recommended daily amount from diet alone, and fiber supplements often are required. Although the increased stool volume and density helps many individuals maintain continence, excessive fiber with inadequate ﬂuid intake may predispose elderly patients to fecal impaction.
Constipating agents have the most value in patients with chronic loose stools or diarrhea.
They can also help improve symptoms in patients with fecal frequency and urgency. Loperamide (Imodium) and diphenoxylate hydrochloride with atropine (Lomotil) are the most commonly used agents. Loperamide has been shown to prolong transit time and stimulate anal sphincter function. With either of these agents, careful titration is recommended to prevent the primary side effect of constipation. It is generally preferable to begin using 2 to 4 mg of loperamide daily and then titrate up to 4 mg three to four times per day. A 4-mg dose before meals has been shown to increase anal tone and improve continence (93). Lomotil is started at a dose of one to two tablets every day or every other day and titrated up to one to two tablets three to four times a day as needed. Caution should be exercised for patients taking other anticholinergic medications. Anticholinergic side effects include dry mouth, drowsiness, lightheadedness, and tachycardia. Codeine can also be used as a constipating agent. It should be used judiciously in those with chronic disorders and in
Table 28.9 Fiber Sources
Modified from Ellerkmann MR, Kaufman H. Defecatory dysfunction. In: Bent AE, Ostergard DR, Cundiff GW, et al, eds. Ostergard’s urogynecology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002:362, with permission.
elderly patients because of side effects common to narcotics, including addiction with prolonged usage and central nervous system and respiratory depression. A study of 82 geriatric patients documented the efficacy of pharmacologic treatment for fecal incontinence (94). Patients were treated based on the underlying cause. Those with fecal impaction received lactulose and enemas, whereas those with neurogenic fecal incontinence received codeine phosphate as a constipating agent and enemas. The rate of cure for fecal incontinence was 60% in the treatment group versus 32% for controls (P <.001).