Fecal (Bowel) Incontinence
What is fecal incontinence?
Fecal incontinence – also called anal incontinence – is the term used when bowel movements cannot be controlled. Stool (feces/waste/poop) leaks out of the rectum when you don’t want it too, which means not during planned bathroom breaks. This leakage occurs with or without your knowledge. Fecal incontinence happens more often in women than in men and also happens more often among older people.
The term fecal incontinence is used if any of these situations occur:
- Stool leaks out when passing gas.
- Stool leaks out due to physical activity/daily life exertions.
- Feeling like you have to go and not being able to make it to the bathroom in time.
- Stool is seen in the underwear after a normal bowel movement.
- There is complete loss of bowel control.
Why does fecal incontinence happen?
Several factors affect continence of stool or the ability to control bowel movement:
- Muscles in the rectum and anus (the very last two sections of the intestines) must be working properly.
- The rectum must be able to stretch to hold the stool. A "rectal sensation" has to be present to provide warning of the need to move bowels. When properly working, this means that you get a feeling that it is time to go to the bathroom.
- The anal muscles (sphincters) must have the ability to squeeze the anus shut. If these muscles are not working properly, stool can leave the body unexpectedly.
- You lack the physical and mental abilities to "recognize the signal" that it is time to go to the bathroom to move bowels, or the physical quickness to reach the bathroom.
- Stools are very watery or explosive or both.
If any of these body functions are not working properly, you may have fecal incontinence.
Symptoms and Causes
What causes changes in body functions that lead to fecal incontinence?
- Frequent diarrhea or constipation. These conditions cause the muscles in the rectum and anus to weaken. When these muscles weaken, the ability to hold stool within the body also weakens.
- Muscle damage. Muscle damage can occur during a difficult vaginal childbirth, when doctors have to use forceps or make a small cut (an episiotomy) to make a larger opening. Muscle damage can also result from anal or rectal surgery.
- Older age. Muscles in the rectum and anus naturally weaken with age. Other nearby structures in the pelvis area also loosen with age. This adds to the general weakness seen in that area of the body, leading to problems with stool control. Loose stool is more difficult to control than solid stool. When a large amount of loose stool arrives rapidly in the rectum, there may not be enough warning to reach the bathroom in time.
- Damage to nerves. If the nerves that control the ability of the rectum and anus muscles to contract are damaged, incontinence can result. Nerves that control "rectal sensation" can also lead to incontinence if they are damaged. Nerve damage can happen during a difficult vaginal delivery, anal surgery, constipation (resulting in bouts of frequent and severe straining), or the presence of certain health conditions (such as diabetes, multiple sclerosis, stroke or a spinal tumor).
- Inability of the rectum to stretch. If the muscles of the rectum are not as elastic as they should be, excess stool that builds up can leak out. Inflammatory bowel disease (such as Crohn's disease) can also affect the rectum's ability to stretch. The scars resulting from surgery and radiation therapy can also stiffen the muscles of the rectum.
- Other medical conditions. Certain medical conditions, such as rectal prolapse (the rectum falls down into the anus) or rectocele (the rectum pushes into the vagina), or chronic constipation where stool leaks around a large stool ball, can lead to fecal incontinence.
- Other causes: Laxative abuse, radiation treatments, certain nervous system and congenital (inherited) defects, inflammation (swelling), and inflammatory bowel disease may affect the ability to control stool.
Diagnosis and Tests
What tests are used to diagnose fecal incontinence?
You'll be evaluated by a gastroenterologist and/or a colorectal surgeon who is trained to help you. Your doctor will ask you questions about your condition and then perform a physical exam and a rectal exam. Don’t be embarrassed to talk to your healthcare provider. They understand you may feel uncomfortable talking about this problem.
The following tests may be done to diagnose fecal incontinence:
- Anal manometry: This test studies the strength of the anal sphincter muscles. A short, thin tube, inserted up into the anus and rectum, is used to measure the sphincter tightness.
- Endoluminal ultrasound or anal ultrasound: This test helps evaluate the shape and structure of the anal sphincter muscles and surrounding tissue. In this test, a small probe is inserted up into the anus and rectum to take images of the sphincters.
- Pudendal nerve terminal motor latency test: This test measures the function of the pudendal nerves, which are involved in bowel control.
- Anal electromyography (EMG): This test determines if nerve damage is the reason why the anal sphincters are not working properly. It also examines the coordination between the rectum and anal muscles.
- Flexible sigmoidoscopy or proctosigmoidoscopy: This test evaluates the end of the large bowel or colon, looking for any abnormalities — such as inflammation, tumor or scar tissue — that may cause fecal incontinence. To perform this test, a thin tube with a camera attached at the end is inserted into the rectum up to the sigmoid colon. This allows the lining of the bowel to be viewed.
- Proctography (also called defecography): This test is done in the radiology department. In this test, an X-ray video is taken that shows how well the rectum is functioning. The video shows how much stool the rectum can hold, how well the rectum holds the stool, and how well the rectum releases the stool. To make the X-ray video for this test, a small amount of liquid barium is released into colon and rectum (through a tube inserted up into the rectum).
- Magnetic resonance imaging (MRI): This test is done in the radiology department. It is an imaging test sometimes used to evaluate the pelvic organs.
Management and Treatment
How is fecal incontinence treated?
Depending on the cause of fecal incontinence, treatment can include one or more of these approaches: dietary changes, bowel training (biofeedback), medications or surgery.
What are medical treatment options for treating fecal incontinence?
The goal of dietary changes is that you avoid foods or drinks that may cause loose stools, including:
- Caffeine, alcohol, some fruit juices and prunes.
- Beans and cabbage family vegetables.
- Spicy foods and cured or smoked meats.
- Dairy products.
- Artificial sweeteners.
Other foods thicken the stool, which may help fecal control. These foods include:
- Apple sauce.
- Peanut butter.
There are two types of bowel training. The goal of the first type is to develop a "going-to-the-bathroom" pattern. By setting up a routine, you can gain greater control over your bowel movements. Taking a daily enema at consistent times will help control stool removal and decrease episodes of fecal incontinence. Don’t use an enema without checking with your doctor first.
The goal of the second type of bowel training is to learn certain exercises that can strengthen the muscles around the anus. A trained therapist will teach you how to locate the correct muscles and perform the exercises. This process is called biofeedback.
Medications that are usually prescribed include anti-diarrheal drugs and fiber supplements. These medications decrease movement of the stool through the intestine and firm up the stool. Don’t use over-the-counter medications without checking with your doctor first.
Since fecal leakage leads to anal skin irritation, moisture–barrier creams — such as those used for a baby's diaper rash — are used to protect the skin. These products can be used indefinitely. As needed, adult diapers are another consideration. Finally, loose clothing and cotton underwear can help provide comfort. Don’t use over-the-counter incontinence medications without checking with your doctor first.
What surgical options treat fecal incontinence?
- Sphincteroplasty, or overlapping sphincter repair, sews damaged anal sphincter muscles back together (see below left). The anal sphincter muscle is overlapped and stitches are used to secure the muscle on both sides. Overlapping and tightening the sphincter muscle results in a tighter anal opening.
- ACE procedure is occasionally appropriate for patients with fecal incontinence. In this procedure, the surgeon creates a small pathway from the skin on the abdomen to the bowel. A small tube is inserted through which a daily enema/washout is given to clean out the stool.
- Artificial bowel sphincter involves implanting an artificial device (prosthesis) around the anus. This device is designed to mimic the normal anal muscle.
- Sacral nerve stimulation. Sacral nerve stimulation therapy uses a small device (a neurotransmitter) that is implanted under the skin in the upper buttock area. The device sends mild electrical impulses through a lead that is positioned close to a nerve located in the lower back (the sacral nerve), which influences the bladder, the sphincter, and the pelvic floor muscles.
- Colostomy. In this operation, an opening is made in the abdomen, through which the colon is brought to the surface of the skin. Stool is collected in a special pouch attached to the abdomen around the opening. This procedure is usually considered when all other treatment options have failed.