Fecal (Bowel) Incontinence

What is fecal (bowel) incontinence?

Fecal incontinence — also called bowel incontinence — is when you can’t manage or control your bowel movements (pooping). Liquid or solid stool (poop) leaks out when you don’t want it to. Fecal incontinence may be as mild as having a little leakage when you pass gas or as severe as unintentionally passing solid stools.

Several factors affect your ability to regulate bowel movements. The muscles in your pelvic floor, rectum and anus must be working correctly to hold poop and (when the time’s right) release it. Nerves have to work with these muscles so your body knows when it’s time to poop. Finally, you have to be physically able to reach the toilet in time.

If any of these things go awry, you may have issues with fecal incontinence.

Types of fecal incontinence

There are two types of fecal incontinence:

• Urge incontinence: You feel the urge to poop but can’t make it to the toilet fast enough to prevent soiling yourself (having an accident). This is the most common type. It usually involves issues with the muscles that control your bowel movements.
• Passive incontinence: Your rectum (which holds your poop) has stretched as much as it can to contain your poop, but your body isn’t registering that you need to go. In this situation, you’ll pass the movement (poop) without realizing it. This type usually involves issues with how your nerves communicate with your muscles.

How common is fecal incontinence?

It’s very common. Researchers estimate that it affects 1 in 3 people — or even more. Bathroom visits are a private matter; many people have likely experienced fecal incontinence at some point or another but just don’t talk about it.

What are the signs and symptoms of fecal incontinence?

Some people only have issues with leakage when they have diarrhea (runny stools). For others, fecal incontinence is an ongoing experience. Signs and symptoms include:

• Poop leaking when you pass gas.
• Poop leaking when you’re physically active.
• Feeling like you have to poop but being unable to make it to the toilet in time.
• Finding poop in your underwear after a regular bowel movement.
• Losing the ability to control your bowel movements entirely.

What causes fecal incontinence?

The most common causes of fecal incontinence include constipation, diarrhea and conditions that damage the muscles or nerves that help you poop. Prior surgeries and procedures can also play a role.

• Diarrhea: Loose, watery stools are much more challenging for your muscles to hold in than firm ones. Over time, frequent diarrhea can cause the muscles in your rectum and anus to weaken.
• Constipation: Frequent bouts of constipation can also weaken your rectal and anal muscles. Straining to poop can cause nerve damage. With chronic constipation, the liquid parts of a stool can seep out around the firm stool that’s stuck, leading to incontinence.
• Muscle damage: Muscle damage can occur during a difficult vaginal delivery, when doctors have to use forceps or make a small cut (an episiotomy) to make a larger opening for your baby to come out. Surgery on your anal or rectal area (like surgery to remove hemorrhoids or to treat an abscess or fistula) can also cause muscle damage, leading to incontinence.
• Nerve damage: Many of the same things that can damage your muscles, like surgery and a difficult vaginal delivery, can also damage the nerves that control their movement. This includes nerves that control “rectal sensation,” the signal that tells you it’s time to poop. Several chronic conditions affecting your nerves increase your risk of fecal incontinence. Overusing laxatives can also damage these nerves.
• Inability of your rectum to stretch: The muscles of your rectum should be stretchy to help you hold poop. If they’re not elastic enough, poop can seep out. Conditions and procedures that cause scarring can prevent your rectum from stretching. Scar tissue isn’t as stretchy as healthy tissue. For example, Crohn's disease can lead to scarring that prevents stretching, and so can radiation therapy.
• Pelvic organ prolapse (POP): POP is when weakened pelvic muscles can’t fully support your pelvic organs. These organs include your rectum, vagina, uterus and bladder. As a result, the organs slip or sag. A rectal prolapse occurs when your rectum falls into your anus. A rectocele occurs when your rectum slips onto your vagina’s back wall. Both forms of prolapse can lead to fecal incontinence.

Risk factors

Anyone can experience fecal incontinence, but your risk is greater depending on your:

• Age: Fecal incontinence is more common if you’re over 65. Muscles naturally weaken with age. Still, although the risk is greater, fecal incontinence isn’t a “natural” part of aging. See a healthcare provider if you’re having issues.
• Sex: Women and people assigned female at birth (AFAB) are at greater risk. Experiences unique to women and people AFAB are also associated with greater risk, including vaginal childbirth and receiving hormone therapy for menopause.

Conditions that cause muscle or nerve damage or tissue scarring can increase your risk of fecal incontinence, including:

• Alzheimer’s disease
• Dementia
• Parkinson’s disease
• Type 2 diabetes
• Multiple sclerosis
• Proctitis
• Inflammatory bowel disease (IBD)
• Irritable bowel syndrome (IBS)
• Stroke

What are the complications of fecal incontinence?

The leakage can take a toll on your skin around your butthole (anus), causing it to feel irritated. This can include the feeling of burning, itching, and throbbing pain. Eventually, you may develop sores (ulcers). You can take steps to care for your skin to prevent this from happening.

But not all complications are physical. A greater concern for most people with fecal incontinence is the toll it can take on your mental and emotional well-being. It’s common to feel embarrassed, anxious or stressed over the leakage. It can prevent you from being as social as you’d like. It’s essential to seek care and support so the condition doesn’t cause you to isolate or compromise your mental health.

How is fecal incontinence diagnosed?

You’ll see a gastroenterologist or a colorectal surgeon, specialists trained to help you. Your healthcare provider will ask you questions about your symptoms and do a physical exam and a rectal exam. Don’t be embarrassed to talk freely about the issues you’re having.

Tests

You may need the following tests to find what’s causing the leakage:

• Anorectal manometry: This test studies the strength of your anal sphincter muscles, including how effectively they coordinate with your rectum to control bowel movements.
• Balloon expulsion test: You may take this test alongside anorectal manometry, especially if your provider suspects chronic constipation may be causing your incontinence. It also tests how well your anal sphincter muscles and rectum are working to pass stool.
• Endorectal ultrasound or MRI: These tests help your provider check the structure of your anal sphincter muscles and surrounding tissue. They can show tissue damage or abnormalities related to incontinence.
• Pudendal nerve terminal motor latency test: This test measures how well your pudendal nerve (the nerve that controls your anal sphincter) is working.
• Anal sphincter electromyography (EMG): This test determines if nerve damage is why your anal sphincter muscles aren’t working properly. It also examines the coordination between your rectum and anal muscles.
• Defecography: This test takes X-ray or MRI images to see how your organs and muscles work when you’re holding and releasing stool.
• Endoscopy: This test uses a scope with a camera to check for abnormalities in your lower digestive system (inflammation, a tumor or scar tissue) that may cause fecal incontinence. A flexible sigmoidoscopy and colonoscopy check your colon (large intestine). A proctoscopy checks your rectum and anus. And an anoscopy checks your anus.

You may need a blood test or stool test to check for causes of frequent diarrhea, like infection-causing microbes (bacteria, viruses and parasites).

How is fecal incontinence treated or managed?

Depending on what’s causing your fecal incontinence and how severe it is, you may need surgery, therapy or medications. In some instances, you can manage fecal incontinence with lifestyle changes.

Dietary changes

You can change what you eat and drink to manage incontinence related to diarrhea or constipation. It’s a good idea to track what you consume daily, noting what foods or drinks make you less likely to have healthy bowel movements. Then, do everything you can to avoid them.

For diarrhea, avoid foods that can loosen your stools or make you have to go, including:

• Caffeine, alcohol, some fruit juices and prunes
• Beans and cabbage family vegetables
• Spicy foods and cured or smoked meats
• Artificial sweeteners
• Dairy products

For constipation, change your eating and drinking habits to prevent chronic constipation. This includes:

• Eating fiber-rich foods (whole grains, fruits, vegetables, beans and nuts)
• Drinking more water (at least eight to 10 glasses a day)

Exercises and training

Exercises and training condition your body to maintain better control over your bowel movements. Some types you can do at home. Others you do in a provider’s office or under the guidance of a trained therapist.

• Bowel training: You’ll work with a provider to teach your body when to poop so you can better manage your bowel movements. For example, you may go first thing after having your morning coffee. If your body won’t cooperate at first, you may need to take a daily enema to help you control when you poop. Don’t use an enema without checking with your doctor first.
• Kegel exercises: These exercises strengthen the pelvic muscles that support organs that help you poop and pee, like your rectum and bladder. During a set of Kegel’s, you alternate between squeezing and relaxing these muscles. You’ll need to do them daily to experience benefits.
• Biofeedback: You’ll work with a trained therapist to strengthen the muscles surrounding your anus. Electrodes connected to your body will register muscle movement onto a computer. The technology allows you to locate the muscles you need to poop and exercise them so they work better to prevent leakage.

Medications

Medications include anti-diarrheal drugs and medicines that treat constipation, like bulk laxatives, suppositories or enemas. Don’t use over-the-counter (OTC) medications without checking with your healthcare provider first. If an OTC medicine isn’t doing the trick, you may need a prescription medicine to manage the leakage.

Medicines for diarrhea include:

• Loperamide (Imodium A-D®)
• Diphenoxylate (Lomotil®)

Medicines for constipation (and occasionally diarrhea) include:

• Methylcellulose (Citrucel®)
• Psyllium (Metamucil®)

Surgery

• Sphincteroplasty sews damaged anal sphincter muscles back together. A surgeon overlaps anal sphincter muscles and secures them on both sides, tightening your anal opening. Sphincteroplasty was once the most common surgery for fecal incontinence. Now, nerve stimulation is the most common.
• Artificial anal sphincter involves implanting an artificial device (prosthesis) around your anus. It mimics the action of a normal anal muscle.
• Sacral nerve stimulation implants a small device (a neurotransmitter) under your skin in the area of your upper butt. The device sends mild electrical impulses to a nerve in your lower back (the sacral nerve), which influences your bladder, sphincter and pelvic floor muscles.
• Antegrade colonic enema (ACE) surgery is occasionally appropriate for people with fecal incontinence. Your surgeon creates a small pathway from the skin on your abdomen to your bowel. They insert a small tube you use to do a daily enema or washout to get rid of the poop in your colon.
• Colostomy is an operation you may need if other treatment options haven’t helped. During this surgery, your surgeon makes an opening in your abdomen. They bring your colon to the surface of your skin through this opening. They attach a special pouch to your abdomen and around the opening that collects stool.

How can I lower my risk of fecal incontinence?

You can’t prevent all causes of fecal incontinence. But you can take steps to lower your risk of two of the most common ones: diarrhea and constipation.

Don’t delay seeking treatment if you have diarrhea. Incorporate changes to your diet that reduce your risk of constipation. And if you’re constipated, don’t strain to poop. This can damage the nerves and muscles that help you control bowel movements.

How long does fecal incontinence last?

Your experience depends on what’s causing your fecal incontinence and how treatable it is. For example, if fecal incontinence is related to an infection (as with diarrhea), relief may be as straightforward as a round of antibiotics to kill the bacteria.

Therapies like biofeedback help many people improve their bowel control, but much depends on the nature of your condition before you start treatment.

Treatments for fecal incontinence, including surgery and sacral stimulation, improve fecal incontinence for some people but not for others. Research shows symptoms improve for over half of people following sphincteroplasty or sacral stimulation. However, over time, symptoms may gradually return for some people. If you need surgery for fecal incontinence, you’ll typically also need long-term symptom management.

How do I care for myself?

You can take steps to protect your physical and emotional well-being if you’re living with fecal incontinence.

Skin protection

Fecal leakage can irritate your skin and lead to excess moisture or sores. To protect your skin:

• Avoid wiping with toilet paper. Toilet paper (when you’re using a lot of it) can damage your skin. Instead, use moist towelettes. Choose ones that are free of harsh chemicals or perfumes. Also, be sure to pat dry after use.
• Clean yourself after every bowel movement. Instead of using soap, which can dry your skin, rinse with warm water. Air dry if you can, but if you’re in a hurry, pat yourself dry instead of wiping.
• Use barrier creams. Barrier creams (creams containing zinc oxide or lanolin) protect your skin. Think of them as irritation prevention. You can use the same creams you’d use to prevent diaper rash. Avoid petroleum jelly (Vaseline®).
• Wear breathable clothing. Choose underwear fabrics that won’t hold moisture onto your skin. For example, cotton is a good idea, but nylon or polyester aren’t. Don’t wear pants that are too tight.

Caring for your mental health (and prioritizing your social life) is as important as caring for your physical health. To cope:

• Wear a pad or disposable undergarment if you’re concerned you may have leakage.
• Take nonprescription pills called flatulence medication (fecal deodorants) that can weaken the smell of poop and gas.
• Make the toilet your last stop before you leave to go out and socialize, so your bowels are empty.
• Bring extras with you, like supplies to freshen up or a change of clothes, just in case something happens.
• Scout out the bathroom first thing when you arrive at a destination so you’re not scrambling to find the toilet at the moment when you need it fast.

What questions should I ask my healthcare provider?

• What’s causing the leakage?
• What tests will I need to find what’s causing my issues?
• What treatments would you recommend?
• What are the benefits and risks associated with these treatments?
• How long will my fecal incontinence last?
• What lifestyle changes can I make to manage my condition?