Fecal incontinence is a challenging clinical condition particularly in elderly diabetics. It has been estimated that upto one-fifth of patients with diabetes have fecal incontinence, although prevalences depend on criteria of incontinence applied. The incidence of fecal incontinence in diabetics appears to correlate with duration of the disease (90). Incontinence is probably multifactorial and involves age-related changes, diabetic neuropathy, multimorbidity, and polymedication (91). However, instability of the internal sphincter probably plays a major role in incontinent diabetics (92). Another important cause is fecal impaction (93).
The vast majority of patients with diabetes with fecal incontinence have normal or only moderately increased daily stool volumes, but also exhibit multiple abnormalities of anorectal sensory and motor functions (94). Fecal incontinence might be associated with severe diabetic diarrhea or constitute an apparently independent disorder. Diarrhea might, of course, produce stress on the continence mechanisms that are already impaired.
In evaluating fecal incontinence in patients with diabetes it is important to take an accurate history and to assess stool weight. Incontinent diabetics may complain of "diarrhea," eventhough their 24-hour stool weights are within normal limits (Table 3).
Anorectal function can be evaluated by anorectal manometry and tests of continence for solids and liquids. Anorectal manometry gives information about the maximum basal sphincter pressure, the maximum "squeeze" sphincter pressure, and the rectoanal inhibitory reflex (inflation of a balloon in the rectum causes a reflex relaxation of the internal anal sphincter). Continence for solids and liquids can be directly assessed simulating the stress of stools with a solid sphere or with rectally infused saline. Unfortunately, these tests do not appear to be very helpful in making therapeutic decisions. Appropriate treatment of incontinence in diabetics includes optimizing blood sugar control and biofeedback therapy. Surgical intervention should be reserved for cases refractory to medical treatment or for those patients with rectocele or obstetrical injury (95). The clinical outcome of surgical treatment of incontinence is far from uniform and caution is advisable before recommending it.
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