Management of faecal incontinence in adults

National Institute for Health and Care Excellence (NICE), 2007 Maeda, 2021

This topic describes the management of faecal incontinence. For general advice about managing functional gastrointestinal disorders, including patient support and psychiatric or psychological assessment, see Approach to managing functional gastrointestinal disorders.

In patients with faecal incontinence who have loose stools, correction of the stool consistency is beneficial. This can be achieved through dietary modification to restrict osmotically active carbohydrates (ie Low-FODMAP diet) or use of psyllium (eg Metamucil; see Overview of laxatives used in adults).

If dietary modification and psyllium are not effective, an antidiarrheal drug or a neuromodulatory drug (eg a tricyclic antidepressant) can be trialled.

For patients with faecal incontinence who have loose stools in whom dietary modification and psyllium are not effective, use:

loperamide 2 mg orally, 1 to 4 times daily if required. loperamide loperamide loperamide

If neuromodulation is preferred (eg after discussing the benefits and disadvantages of different treatment options with the patient), use:

1amitriptyline 5 to 10 mg orally, at night. Increase slowly as tolerated up to 30 to 50 mg at night amitriptyline amitriptyline amitriptyline

OR

1nortriptyline 5 to 10 mg orally, at night. Increase slowly as tolerated up to 30 to 50 mg at night. nortriptyline nortriptyline nortriptyline

Patients with faecal impaction associated with constipation should be treated with a laxative—see Faecal impaction in adults for more information.

If symptoms persist despite the above therapies, refer to a gastroenterologist for anorectal manometry and endoanal ultrasound (to investigate the pelvic floor and sphincter function and structure), and consideration of second-line therapies such as biofeedback, rectal irrigation, anal plugs and surgical intervention.