Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

with constipation and fecal impaction

1st line – oral laxative

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ACUTE
|
with constipation and fecal impaction
1st line – 

oral laxative

In functional or organic fecal incontinence presenting with fecal impaction and constipation, oral laxatives are the first-line option for disimpaction of fecal matter. In patients with organic fecal incontinence, any underlying cause (e.g., anatomical abnormality or medical condition) should also be addressed.

Both polyethylene glycol/electrolyte solution (PEG) and magnesium citrate are appropriate first-line oral laxatives in the outpatient setting. Although PEG is generally more tolerable as it is tasteless, PEG and magnesium citrate are equally effective given good patient compliance. PEG is usually given orally to outpatients, but may require inpatient treatment administered via nasogastric tube if the patient is unable to take it orally.

Mineral oil is not as well tolerated as PEG or magnesium citrate, but is still considered a first-line option by some providers. It should not be used in children <5 years of age or those with a history of neurological disease or gastroesophageal reflux.

Primary options

polyethylene glycol/electrolytes: consult product literature for guidance on dose

OR

magnesium citrate: consult product literature for guidance on dose

OR

mineral oil: children 5-11 years of age: 5-15 mL orally once daily when required; children >12 years of age: 15-45 mL orally once daily when required

2nd line – enema

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ACUTE
|
with constipation and fecal impaction
2nd line – 

enema

In functional or organic fecal incontinence presenting with fecal impaction and constipation, if the patient does not respond to oral laxatives, an enema is indicated as second-line treatment to soften the stool.

Mineral oil enema and hypertonic phosphate enema have similar efficacy.

With enema use, rectal manipulation may lead to rectal irritation and bleeding.

In patients with organic fecal incontinence, any underlying cause (e.g., anatomical abnormality or medical condition) should also be addressed.

The Food and Drug Administration (FDA) warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Patients who may be at higher risk include young children; adults over the age of 55 years; patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel; and patients who are using medications that affect renal function. Use caution in children ages 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[32]

Primary options

mineral oil: children 2-11 years of age: 30-60 mL rectally as a single dose; children >11 years of age: 120 mL rectally once daily

OR

sodium phosphate: consult product literature for guidance on dose

3rd line – oral laxative + enema

Back
ACUTE
|
with constipation and fecal impaction
3rd line – 

oral laxative + enema

In functional or organic fecal incontinence presenting with fecal impaction and constipation, if disimpaction is unsuccessful with a single treatment of laxative or enema, combination of both treatments may be necessary as a third-line option. In patients with organic fecal incontinence, any underlying cause (e.g., anatomical abnormality or medical condition) should also be addressed.

Both polyethylene glycol/electrolyte solution (PEG) and magnesium citrate are appropriate first-line oral laxatives in the outpatient setting. Although PEG is generally more tolerable as it is tasteless, PEG and magnesium citrate are equally effective given good patient compliance. PEG is usually given orally to outpatients, but may require inpatient treatment administered via nasogastric tube if the patient is noncompliant.

Mineral oil is not as well tolerated as PEG or magnesium citrate, but is still considered a first-line option by some providers. It should not be used in children <5 years of age or those with a history of neurological disease or gastroesophageal reflux.

Mineral oil enema and phosphate enema have similar efficacy. With enema use, rectal manipulation may lead to rectal irritation and bleeding.

The FDA warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Patients who may be at higher risk include young children; adults over the age of 55 years; patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel; and patients who are using medications that affect renal function. Use caution in children ages 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[32]

Primary options

polyethylene glycol/electrolytes: consult product literature for guidance on dose

or

magnesium citrate: consult product literature for guidance on dose

or

mineral oil: children 5-11 years of age: 5-15 mL orally once daily when required; children >12 years of age: 15-45 mL orally once daily when required

-- AND --

mineral oil: children 2-11 years of age: 30-60 mL rectally as a single dose; children >11 years of age: 120 mL rectally once daily

or

sodium phosphate: consult product literature for guidance on dose

4th line – surgery

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ACUTE
|
with constipation and fecal impaction
4th line – 

surgery

When aggressive medical treatment is unsuccessful in patients with organic fecal incontinence, surgical treatments may be used in rare instances to keep the bowel disimpacted.

Postsurgical functional outcomes for anorectal malformations vary greatly. Gastrointestinal experts decide on surgical interventions (e.g., appendicostomy, cecostomy, sphincter reconstruction, colostomy, artificial sphincters) case by case.[33][34][35]

Residual incontinence after surgery is treated with laxatives, dietary interventions, and establishing good bowel habits.

without constipation

1st line – bowel retraining program + increased fiber in diet

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ACUTE
|
without constipation
1st line – 

bowel retraining program + increased fiber in diet

In patients with functional or organic fecal incontinence presenting without constipation, interventions include bowel retraining program, increasing fiber in diet, biofeedback, and possible use of loperamide as a last resort if incontinence interferes with social activities.

Bowel retraining program is aimed at strengthening the internal muscles or internal sphincter and regaining rectal sensation. Usually the patient is asked to sit on the toilet and push for 5 to 10 minutes, 2 or 3 times daily.[16] While sitting on the toilet, knees should be bent and feet placed up on a step stool. The child should push out the feces, even without the sensation of defecation, so that the muscles are retrained. Positive reinforcement can be done with a reward system when the child experiences successful toileting and avoids soiling.

Dietary interventions involve increasing free daily water intake to at least 4 to 8 glasses per day, increasing daily intake of fiber (suggested number of grams of fiber per day equals patient age plus 5), and consuming 5 fruits or vegetables per day.[12] The use of soluble or insoluble fiber supplementation is decided on a case-by-case basis. Soluble fibers tend to bulk the stool, while insoluble fibers tend to make the stool looser. Soluble fibers (e.g., psyllium, pectin) are therefore preferred, though their reported effectiveness is inconsistent and one meta-analysis found that there is no evidence to support the prescription of fiber supplementation in the diet of constipated children.[29][30]

In patients with organic fecal incontinence, any underlying cause (e.g., anatomical abnormality or medical condition) should also be addressed.

Consider – behavioral medicine evaluation

Back
ACUTE
|
without constipation
Consider – 

behavioral medicine evaluation

Treatment recommended for SOME patients in selected patient group

In functional or organic fecal incontinence, the patient may benefit from behavioral medicine consultation from a mental health professional or psychologist if psychosocial factors are underlying etiology.

Consider – anorectal biofeedback

Back
ACUTE
|
without constipation
Consider – 

anorectal biofeedback

Treatment recommended for SOME patients in selected patient group

In functional or organic fecal incontinence, the usefulness of anorectal biofeedback remains unconfirmed.[31]

Consider – loperamide

Back
ACUTE
|
without constipation
Consider – 

loperamide

Treatment recommended for SOME patients in selected patient group

In functional or organic fecal incontinence, use of loperamide is a last resort if incontinence interferes with social activities. It is an opioid receptor agonist that can increase anal sphincter pressure.

There are limited studies concerning the efficacy of loperamide suppositories in adolescents with functional nonretentive fecal soiling (the suppositories are not available in the US).[36]

Primary options

loperamide: children 2-5 years of age: consult specialist for guidance on dose; children 6-8 years of age: 2 mg orally twice daily on day 1, followed by 0.1 mg/kg after each loose stool when required, maximum 4 mg/day; children 9-11 years of age: 2 mg orally three times daily on day 1, followed by 0.1 mg/kg after each loose stool when required, maximum 6 mg/day; children >11 years of age and adults: 4 mg orally initially, followed by 2 mg after each loose stool when required, maximum 16 mg/day

ONGOING

fecal impaction resolved

1st line – ongoing laxatives + diet + good bowel habits

Back
ONGOING
|
fecal impaction resolved
1st line – 

ongoing laxatives + diet + good bowel habits

In functional or organic fecal incontinence, once the fecal impaction has resolved, ongoing maintenance of the bowel should be instituted to avoid reaccumulation of retained fecal matter. In patients with organic fecal incontinence, any underlying cause (e.g., anatomical abnormality or medical condition) should also be addressed.

Treatment consists of laxative use, dietary interventions, and establishing good bowel habits. A systematic review found that behavioral interventions plus laxative treatment improves functional incontinence more than laxative therapy alone.[31]

Laxatives should be used daily and should be non-habit-forming (e.g., stool softeners). Options include polyethylene glycol/electrolyte solution or mineral oil. Dosing may vary but should be titrated so the patient produces 1 to 3 soft, well-formed stools per day without soiling. Mineral oil should not be used in patients who are <5 years of age or neurologically impaired.

Dietary interventions involve increasing free daily water intake to at least 4 to 8 glasses per day and increasing daily intake of fiber (suggested number of grams of fiber per day equals patient age plus 5) and consuming 5 fruits or vegetables per day.[12] The use of soluble or insoluble fiber supplementation is decided on a case-by-case basis. Soluble fibers tend to bulk the stool, while insoluble fibers tend to make the stool looser. Soluble fibers (e.g., psyllium, pectin) are therefore preferred, though their effectiveness is inconsistent and one meta-analysis found that there is no evidence to support the prescription of fiber supplementation in the diet of constipated children.[29][30]

Good toileting habits (bowel re-education exercises) involve the child sitting on the toilet for 5 to 10 minutes in the morning, after school, and after meals. While sitting on the toilet, knees should be bent and feet placed up on a step stool. The child should push out the feces, even without the sensation of defecation, so that the muscles are retrained.

Positive reinforcement can be done with a reward system when the child experiences successful toileting and avoids soiling.

Primary options

polyethylene glycol/electrolytes: consult product literature for guidance on dose

OR

mineral oil: children 5-11 years of age: 5-15 mL orally once daily when required; children >12 years of age: 15-45 mL orally once daily when required

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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