Surgery - Fecal incontinence in the elderly Surgical therapy is usually indicated for anatomic defects in the pelvic floor musculature and anal sphincters. Sphincteroplasty with overlapping anterior sphincter repair is the primary surgical procedure in patients with EAS defects commonly seen as a result of obstetric trauma. If an IAS defect is identified, then IAS imbrication (ie, overlapping of tissue layers) is performed. During dynamic graciloplasty, the fast twitch fatigable skeletal muscle is transformed into a slow twitch fatigable muscle that can provide sustained sphincterlike muscle response by an implanted pacemaker. In a 2002 systematic review of patients who had undergone dynamic graciloplasty, clinical improvements ranged between 38% and 90%. An alternative to stimulated gracilis muscle transposition is the artificial bowel sphincter (ABS), which like dynamic graciloplasty is placed around the native sphincter via perineal tunnels. Revision of both procedures approaches 50%. Currently, there is insufficient evidence on safety and effectiveness of ABS for FI, and it should be considered experimental. Experience with antegrade continence enema through a cecostomy button or appendicostomy is limited, but short-term results show a benefit of 40% to 60% in some series.

Summary

The management of FI in the elderly should employ an individualized and minimally invasive approach that is both practical and convenient. Attention to good nursing care with the application of a skin protectant to prevent ulcers, institution of motivational techniques, and assistance in keeping the elderly mobile is very important. Ritualized bowel evacuation/emptying regimens will prevent fecal impaction and overflow diarrhea. Fortunately, there are several medical as well surgical options for patients with FI. The ultimate goal is to improve quality of life and reduce morbidity and mortality in patients suffering with this potentially psychosocially and physically debilitating disorder.

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Dr Roach is a medical resident, Department of Medicine, Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY.

Dr Christie is Assistant Professor of Medicine, Emory University School Medicine, Atlanta, Ga. Dr Christie discloses that she is on the speaker’s bureau for Takeda Pharmaceuticals.

Source: Geriatrics