Abstract
Constipation and fecal incontinence (FI) are common complaints predominantly affecting the elderly and women. They are associated with significant morbidity and high healthcare costs. The causes are often multi-factorial and overlapping. With the advent of new technologies, we have a better understanding of their underlying pathophysiology which may involve disruption at any levels along the gut–brain–microbiota axis. Initial approach to management should always be the exclusion of secondary causes. Mild symptoms can be approached with conservative measures that may include dietary modifications, exercise, and medications. New prokinetics (e.g., prucalopride) and secretagogues (e.g., lubiprostone and linaclotide) are effective and safe in constipation. Biofeedback is the treatment of choice for dyssynergic defecation. Refractory constipation may respond to neuromodulation therapy with colectomy as the last resort especially for slow-transit constipation of neuropathic origin. Likewise, in refractory FI, less invasive approach can be tried first before progressing to more invasive surgical approach. Injectable bulking agents, sacral nerve stimulation, and SECCA procedure have modest efficacy but safe and less invasive. Surgery has equivocal efficacy but there are promising new techniques including dynamic graciloplasty, artificial bowel sphincter, and magnetic anal sphincter. Despite being challenging, there are no short of alternatives in our toolbox for the management of constipation and FI.
Highlights
Both constipation and fecal incontinence (FI) are common symptoms facing primary care physicians and gastroenterologists alike
Constipation can be broadly classified as functional constipation (FC), dyssynergic defecation (DD), and constipation-predominant irritable bowel syndrome (IBS-C)
The current review aims to provide an update on the pathophysiology and current management options of these two common conditions
Summary
Both constipation and fecal incontinence (FI) are common symptoms facing primary care physicians and gastroenterologists alike. Constipation can be broadly classified as functional constipation (FC), dyssynergic defecation (DD), and constipation-predominant irritable bowel syndrome (IBS-C). These sub-categories are defined according to the Rome III criteria [5, 6]. FI affects approximately 8.3% of non-institutionalized adults [11] and at least 30% of residents in nursing homes [12] These figures are likely to be underestimated because of several barriers, including misconceptions, embarrassment, and social stigma. The functions are coordinated through neurotransmitters (acetylcholine, nitric oxide, serotonin, calcitonin gene-related peptide), colonic reflexes, learned behaviors, and gut microbiota. Methanogenic flora has been found to be significantly associated with constipation [16, 17] and its elimination with antibiotics has been shown to improve symptoms [18]
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