An 82-year-old woman is brought to the office due to new-onset fecal incontinence. The patient has a history of Alzheimer disease and lives with her daughter but is able to perform most of the activities of daily living independently. Her daughter states that the patient has had several incidents of involuntary stool leakage over the past week. She also has had mild abdominal discomfort but no fever, nausea, vomiting, or blood in stools. Other medical issues include hypertension and osteoarthritis. The patient has delivered 4 children vaginally. She does not use tobacco or alcohol. Temperature is 37 C (98.6 F), blood pressure is 140/80 mm Hg, and pulse is 78/min. The abdomen is nondistended and soft with mild generalized tenderness. There is no guarding or rebound tenderness. Bowel sounds are active. Rectal examination shows mildly decreased anal sphincter tone and a copious amount of hard stool. Perineal sensation is normal. Stool testing for occult blood is negative. Abdominal imaging shows no air-fluid levels or free intraperitoneal air. Which of the following is the most appropriate next step in management of this patient?

Question

An 82-year-old woman is brought to the office due to new-onset fecal incontinence.  The patient has a history of Alzheimer disease and lives with her daughter but is able to perform most of the activities of daily living independently.  Her daughter states that the patient has had several incidents of involuntary stool leakage over the past week.  She also has had mild abdominal discomfort but no fever, nausea, vomiting, or blood in stools.  Other medical issues include hypertension and osteoarthritis.  The patient has delivered 4 children vaginally.  She does not use tobacco or alcohol.  Temperature is 37 C (98.6 F), blood pressure is 140/80 mm Hg, and pulse is 78/min.  The abdomen is nondistended and soft with mild generalized tenderness.  There is no guarding or rebound tenderness.  Bowel sounds are active.  Rectal examination shows mildly decreased anal sphincter tone and a copious amount of hard stool.  Perineal sensation is normal.  Stool testing for occult blood is negative.  Abdominal imaging shows no air-fluid levels or free intraperitoneal air.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This elderly woman with fecal incontinence, hard stool within the rectum, and decreased anal sphincter tone likely has fecal impaction and overflow incontinence. Fecal impaction, often diagnosed by digital rectal examination, is the presence of large amounts of stool within the rectum that the patient is unable to pass. It is frequently associated with constipation and age-related changes, including slowing of fecal transit, decreased sensation of stool in the vault, and a reduction in anal sphincter tone (as seen in this patient). In elderly patients, fecal impaction is the most common cause of fecal incontinence due to liquid stool overflowing around impacted stool within the rectum. Abdominal imaging is helpful but not required for diagnosis and typically shows a normal bowel gas pattern with excessive stool present. Patients may have rectal bleeding due to ulcerations caused by stool in the rectum. In the setting of stool impaction, the most appropriate initial treatment is to perform manual disimpaction, followed by enema or suppository to empty the colon. The patient should then be treated with an aggressive oral bowel regimen to prevent recurrence. (Choice A) Antimotility drugs and bulk-forming agents would be helpful in the setting of chronic diarrhea after infection has been ruled out, but they would worsen fecal impaction caused by constipation. (Choice B) Increasing dietary fiber and using stool softeners should be recommended to this patient with constipation, but these methods alone may be insufficient for removing the obstruction caused by impacted stool. Both should be initiated after successful manual disimpaction. (Choice D) A rectal tube is used in patients who have acute pseudoobstruction of the colon, which would result in a dilated colon and abdominal distension. (Choice E) Anal sphincterotomy is the treatment for recurrent or nonhealing anal fissures. Patients with anal fissures often become constipated due to intense pain with passage of stool. This patient did not have anal pain and is more likely to have constipation from other causes. Educational objective: Fecal impaction is a common condition in elderly patients and is often associated with overflow stool incontinence. It is managed with manual rectal disimpaction followed by enemas to clear the bowels. Once complete emptying has been achieved, the patient should increase fiber and fluid intake as well as start an aggressive bowel regimen to prevent recurrence.

An 82-Year-Old Woman Is Brought to the Office Due to New-Onset