Fecal Incontinence

Fecal incontinence, also called a bowel control problem or bowel incontinence is the unexpected passing of solid or liquid stool or mucus from the rectum due to the inability to hold a bowel movement until getting into a toilet.

Fecal incontinence ranges from an occasional leak of stool while passing gas to a total loss of bowel control in which the person is unaware of passing stools in the underwear. Common causes of fecal incontinence are:

• Diarrhea
• Constipation
• and Muscle or nerve damage that may be associated with aging or childbirth

Fecal incontinence can be very embarrassing and upsetting, regardless of the cause. But do not feel ashamed and try to hide your problem from your doctor. There are treatments available to improve fecal incontinence and your quality of life.

The symptoms of fecal incontinence may range from the inability to hold gas, “silent” leakage of stool during daily activities, or being unable to reach the toilet in time.

Most of the times, adults experience fecal incontinence only during an occasional episode of diarrhea. But, in some people, recurrent or chronic fecal incontinence may occur. They are unable to resist the urge to defecate, which occurs so suddenly that they fail to reach the toilet in time. This is called urge incontinence. Another type of fecal incontinence may occur in people who are not aware of their need to pass stools. This is called passive incontinence.

Fecal incontinence may be associated with other bowel problems, such as:

• Diarrhea
• Constipation
• Abdominal gas and bloating sensation

When to see a doctor.

You may consult your doctor if you or your child develop fecal incontinence. Often, new mothers and elderly adults hesitate to tell their doctors about fecal incontinence. But as treatments are available, the sooner you are evaluated, the sooner you find relief from your symptoms.

Most people have more than one cause of fecal incontinence, which include the following:

Diarrhea: Loose stools are more difficult to hold back in the rectum than solid stools, and it can increase your chances of not reaching the toilet in time leading to fecal incontinence.

Constipation: Chronic constipation leads to formation of a large mass of dry, hard stools in the rectum (impacted stool) that is too difficult to pass. The hard stools stretch the rectum and cause relaxation of the internal sphincter muscles by reflex. This allows watery stool that collects farther up the digestive tract to move around the hard impacted stool and leak out, leading to fecal incontinence. Chronic constipation may also cause nerve damage that leads to fecal incontinence.

Muscle damage or weakness: Injury to the rings of muscle located at the end of the rectum (anal sphincter muscles) weakens these muscles making it difficult to hold back the stools properly. This type of sphincter damage may occur during childbirth, especially if you have had an episiotomy or forceps delivery, trauma, and surgery to treat cancer and hemorrhoids.

Nerve damage: The anal sphincter muscles do not function properly if there is injury to the nerves that control them. If the nerves that sense stool in the rectum are damaged, you may not be able to feel the urge to go to the restroom. Both the types of nerve damage can lead to fecal incontinence. Possible causes of nerve damage are childbirth, a chronic habit of straining while passing stools, spinal cord injury, stroke, and diseases such as diabetes and multiple sclerosis that affect the nerves that go to the sphincter muscles and rectum.

Loss of storage capacity in the rectum: Normally, the rectum has the ability to stretch and accommodate stool until a person has bowel movement. Rectal surgery, radiation treatment, and inflammatory bowel disease —chronic disorder that causes irritation and sores on the lining of the digestive system can cause scarring and stiffness of your rectal walls. Then, the rectum cannot stretch as much as it needs to resulting in leakage of excess stool.

Surgery: Surgery that is performed to treat enlarged veins in the rectum or anus (hemorrhoids) and more complex operations involving the rectum and anus can cause muscle and nerve damage that leads to fecal incontinence.

Rectal prolapse: Rectal prolapse, a condition in which the rectum drops down through the anus can prevent the anal sphincter muscles from closing properly, thus causing leakage of stools.

Rectocele: Rectocele is a condition in which the rectum protrudes through the vagina. It happens if the thin muscle layer separating the rectum from the vagina becomes weak. For women with rectocele, straining to pass stools may be less effective as rectocele decreases the amount of downward force through the anus. As a result, retention of stool in the rectum occurs, which also increases the risk of fecal incontinence.

Inactivity: People who follow an inactive lifestyle by spending most of the time in a day either sitting or lying down are at an increased risk of retaining a large amount of stool in the rectum. Liquid stool then leaks around the more solid stool. For this reason, frail, older adults are most likely to develop constipation-related fecal incontinence.

Discussing fecal incontinence may be embarrassing, but it can provide clues for a doctor to help make the diagnosis.

You may consult your primary care physician initially. Then, after evaluation, you may be referred immediately to a doctor who specializes in treating digestive conditions (gastroenterologist). Here is some information that helps you get ready for your appointment.

What you can do?

When you make the appointment, ask if there is something you need to know in advance, such as fasting before having a specific test. Make a list of:

• Your symptoms, including those that seem unrelated to the reason of your appointment
• Key personal information, including major stresses, recent life changes, and family medical history
• All the medications, vitamins or other supplements you take, including the doses

Ask a family member or friend to come along, if possible, to help you remember the information you have been given.

Questions to ask your doctor.

• For fecal incontinence, some basic questions to ask your doctor include:
• What is the most likely cause of my symptoms?
• What are other possible causes for my symptoms?
• What kind of tests do I need?
• Is my condition, temporary or chronic?
• What may be the best course of action?
• Are there any alternatives to the primary approach you have suggested?
• Will treatment for fecal incontinence complicate my care for other conditions I have?
• Are there any restrictions that I need to follow?

What to expect from your doctor?

Your doctor may ask you a number of questions, such as:

• From when do you have your symptoms?
• Are your symptoms continuous or occasional?
• How severe are your symptoms?
• Is there anything that seems to improve or worsen your symptoms?
• Do you avoid performing any activities because of your symptoms?
• Do you have diarrhea, and other conditions such as diabetes, multiple sclerosis or chronic constipation?
• Have you ever been diagnosed with ulcerative colitis or Crohn's disease?
• Have you ever had radiation therapy to your pelvic area?
• Were forceps used or did you have an episiotomy during childbirth?
• Do you have urinary incontinence?

What you can do in the meantime?

Avoid foods or activities that make your symptoms worse. Avoid caffeine, spicy, fatty or greasy foods, dairy products or anything that worsens your incontinence.

Your doctor will ask some questions about your condition and perform a physical exam that usually includes a visual inspection of your rectal area to check for abnormalities. A probe may be used to examine this area for nerve damage.
Digital rectal examination: Your doctor will insert a gloved and lubricated finger into your rectum and evaluate the strength of your sphincter muscles.

A number of tests may be done to determine the cause of fecal incontinence, which include:

• Balloon expulsion test: A small balloon is inserted through the anus and filled with water. You are then asked to go to the toilet and expel the balloon. The time required to expel the balloon is recorded. If the time taken is one minute or longer, it is a sign of defecation disorder.
• Anal manometry: In this test, a thin, flexible tube with a balloon on its tip and pressure sensors below the balloon is inserted into the anus such that the balloon is in the rectum and pressure sensors are located in the anal canal. Then, the tube is slowly withdrawn through the sphincter muscle during which the muscle tone and contractions are measured. This procedure takes about 30 minutes, and no anesthesia is required.
• Anorectal ultrasonography: A narrow, wand-like instrument called a transducer is inserted into the anus and rectum. This instrument bounces safe, painless sound waves towards organs to create video images that allow your doctor to evaluate the structure of your anal sphincter muscles.
• Proctography: X-ray video images are taken while you are having a bowel movement on a specially designed toilet. The test can measure how much stool your rectum holds and evaluates how well your body expels stool.
• Proctosigmoidoscopy: A flexible tube is passed into your rectum to check the last two feet of the colon (sigmoid) for signs of inflammation, tumors or scar tissue that may cause fecal incontinence.
• Colonoscopy: A flexible tube is inserted into your rectum to inspect the entire colon.
• Magnetic resonance imaging (MRI): An MRI may include the injection of special dye, called the contrast medium. During the procedure, the person lies on a table that slides into a tunnel-shaped device. MRI can provide detailed pictures of the anal sphincter, especially about the external anal spincter, to determine if the muscles are intact and it can also create images during defecation (defecography).
• Anal EMG: Anal EMG is done to evaluate the health of the pelvic floor muscles and the nerves that control these muscles. Your doctor will insert a fine needle electrode through the skin into your muscle. The electrode on the needle detects the electrical activity produced by the muscles and transforms into images on a monitor or sounds through a speaker. The amount of electrical activity during relaxation, when a person squeezes to prevent a bowel movement, and strains to have a bowel movement reveals if there is any damage to the nerves that control the external sphincter and pelvic floor muscles.

Treatment for fecal incontinence may include the following:

Dietary Changes.

• Eat adequate amount of fiber: Fiber can help with diarrhea and constipation. If constipation is the reason of fecal incontinence, your doctor may recommend drinking plenty of fluids and eating fiber-rich foods. Fiber is found in fruits, vegetables, whole grains, and beans. Fiber supplements sold in a pharmacy or in a health food store are another common source of fiber to treat fecal incontinence. The Academy of Nutrition and Dietetics recommends consuming 20 to 35 grams of fiber a day for adults and “age plus five” grams for children. For instance, a 7-year-old child should get “7 plus five,” or 12, grams of fiber each day. Fiber should be added gradually to the diet to prevent bloating. If diarrhea is contributing to fecal incontinence, high-fiber foods can add bulk to your stools making them less watery.
• Drink plenty of fluids: Drink at least eight 8-ounce glasses of fluids a day to prevent constipation. Water is a good choice. Drinks containing caffeine, alcohol, milk, or carbonation should be avoided if they trigger diarrhea.

Medications.

Depending on the cause of fecal incontinence, options include:

• Anti-diarrheal drugs such as:
  • Loperamide hydrochloride (Imodium) and
  • Diphenoxylate and atropine sulfate (Lomotil) to slow down the bowel movements and control the problem.
• Bulk laxatives such as:
  • Methylcellulose (Citrucel) and
  • Psyllium (Metamucil), if chronic constipation is causing your incontinence.
• Injectable bulking agents such as:
  • Dextranomer Microspheres/Hyaluronate Sodium in 0.9 % Nacl (Solesta) are injected directly into the anal canal

Exercise and other therapies.

If muscle damage is the cause of your fecal incontinence, your doctor may recommend a program of exercises and other therapies to restore muscle strength. These treatments improve anal sphincter control and the awareness of the urge to defecate. Options include:

Exercises that strengthen the pelvic floor muscles help improve your bowel control. Pelvic floor exercises involve squeezing and relaxing pelvic floor muscles 50 to 100 times a day.

Biofeedback therapy: This helps a person perform the exercises properly, and also improves awareness of sensations in the rectum, teaching how to coordinate squeezing of the external sphincter muscle with the sensation of rectal filling. Biofeedback training employs special sensors to measure the bodily functions. Sensors include pressure or EMG sensors in the anus, pressure sensors in the rectum, and a balloon in the rectum to develop graded sensations of rectal fullness. People learn how to strengthen pelvic floor muscles, sense when stool is ready to be released and contract the muscles if having a bowel movement at a certain time is inconvenient.

Bowel training: Your doctor will advise you to make a conscious effort to have a bowel movement at a specific time of day: for example, after eating. Developing a regular bowel movement pattern can help you gain greater control and improve fecal incontinence, especially fecal incontinence due to constipation. It may take several weeks to months to achieve a regular bowel control pattern.

Sacral nerve stimulation (SNS) or neuromodulation: The sacral nerves run from your spinal cord to the muscles in your pelvis. These nerves regulate the sensation and strength of your rectal and anal sphincter muscles. This technique involves placement of electrodes in the sacral nerves and continuously stimulating the nerves with electrical impulses. A battery-operated stimulator is placed just below the skin. Depending upon your response, your doctor will adjust the amount of stimulation such that it works best for you. You may turn the stimulator on or off at any time you need to. This procedure is performed on an outpatient basis using local anesthesia, and is usually done only when other treatments are ineffective.

Posterior tibial nerve stimulation (PTNS/TENS): This is a minimally invasive treatment, which may be helpful in some people with fecal incontinence, but further studies are needed.
Vaginal balloon (Eclipse System): This is a pump-type device that is inserted into the vagina. The inflated balloon exerts pressure on the rectal area, which leads to a decrease in the number of episodes of fecal incontinence. Results for women have been very promising, but more supporting data are needed.

Surgery.

Surgery to treat fecal incontinence may be considered for correction of an underlying problem, such as rectal prolapse or sphincter damage caused by childbirth. In addition, surgery may be an option in fecal incontinence caused by pelvic floor or anal sphincter muscle injuries or for fecal incontinence that does not improve with other treatments. The options include:

Sphincteroplasty: This procedure reconnects the separated ends of anal sphincter muscle that is during childbirth or other injury. Doctors identify an injured area of muscle and free its edges from the surrounding tissue. Then, the muscle ends are brought back together and sewn in an overlapping fashion. This strengthens the muscle and tightens the sphincter. The procedure is used in women who experience fecal incontinence right after childbirth.

Correction of rectal prolapse, a rectocele or hemorrhoids: Surgical correction of these problems can reduce or eliminate fecal incontinence.

Replacement of sphincter: A damaged anal sphincter can be replaced with an artificial anal sphincter, which is essentially an inflatable cuff that is implanted around your anus. A small pump is placed beneath your skin, which can be activated to inflate or deflate the cuff. When inflated, the device keeps your anal sphincter closed until you are ready to defecate. When you want to defecate, you may deflate the device and allow stool to be released. The device then reinflates itself.

Repair of sphincter (dynamic graciloplasty): In this surgery, doctors harvest a muscle from the inner thigh and wrap it around the sphincter. This restores the muscle tone of the sphincter.

Colostomy (bowel diversion): This is a surgery that diverts the stools from the lower part of the small intestine or colon to an opening in the wall of the abdomen—the area between the chest and hips. Doctors attach a external bag to this opening to collect the stool. Colostomy is usually done only after other treatments have failed.

Sometimes, fecal incontinence can be prevented depending upon its cause. The following actions may be helpful:

• Treat constipation: Eat fiber rich foods, drink lots of fluids, especially water, and increase your exercise to reduce constipation.
• Control diarrhea: Eliminating the cause of diarrhea, such as an intestinal infection, may help you prevent fecal incontinence.
• Avoid straining: Excessive straining during bowel movements may gradually weaken the anal sphincter muscles or cause damage to the nerves, which eventually leads to fecal incontinence.

Lifestyle modifications are necessary in order to cope with fecal incontinence.

Lifestyle and home remedies

• Kegel exercises: Kegel exercises help in strengthening your pelvic floor muscles, which support the bladder and bowel, and in women, the uterus. This reduces incontinence. To perform Kegel exercises, you must contract the muscles that you would normally use to stop the flow of urine. Hold this position for three seconds, and then relax for three seconds. Perform this exercise at least 10 times in a day. As your muscles gain strength, hold the contraction for a longer time, gradually working your way up to three sets of 10 contractions each day.

Dietary changes

It may be possible to gain better control over your bowel movements by making certain dietary modifications such as:

• Keep a track of what you eat: Make a list of the foods that you eat for a week. You may find a connection between certain foods and your bouts of incontinence. Once you know the problematic foods, avoid them and see whether your incontinence improves. Foods that can cause diarrhea or gas and lead to fecal incontinence include spicy foods, greasy foods, cured or smoked meat, carbonated beverages, and dairy products (if you have lactose intolerance). Caffeine-containing beverages and alcohol can act as laxatives, as can products such as sugarless gum and diet soda containing artificial sweeteners.
• Add adequate fiber in your diet: Eating fiber-rich foods makes the stools soft and easy to control. Fiber is predominantly present in fruits, vegetables, and whole-grain breads and cereals. You should have at least 20 to 30 grams of fiber a day, but avoid adding it to your diet all at once, because large amounts of fiber suddenly may cause uncomfortable abdominal bloating sensation and flatulence.
• Drink plenty of water: To keep stools soft and formed, drink at least eight glasses of liquid in a day, preferably water.

Skin care

You can avoid further discomfort from fecal incontinence by keeping the skin around your anus as clean and dry as possible. To relieve anal discomfort and eliminate any possible odor associated with fecal incontinence:

• Wash with water: Gently wash the area around your anus with water after every bowel movement. Showering or soaking in a bath may be helpful. Use of soap can make the skin dry and further irritate the skin, and so does rubbing with dry toilet paper. Instead, you can use premoistened, alcohol-free, perfume-free towelettes or wipes as an alternative to clean the area.
• Dry thoroughly: You may allow the area to air-dry, if possible. Otherwise, you can gently pat the area dry using a toilet paper or a clean washcloth.
• Apply a cream or powder: Moisture-barrier creams avoid irritated skin from having direct contact with feces. Ensure that the area is clean and dry before applying any cream. Nonmedicated talcum powder or cornstarch may be applied to reduce anal discomfort.
• Wear clean cotton underwear and loose clothing: Tight clothes restrict airflow, making the skin problems worse. Change your soiled underwear immediately.

When medical treatments cannot resolve your incontinence problem completely, use of products such as absorbent pads and disposable underwear helps manage the problem. If you use these pads or adult diapers, ensure that there is an absorbent wicking layer on the topmost layer, which can keep the moisture away from your skin.

Coping and support

In some people, including children, fecal incontinence can be a relatively minor problem that is limited to occasional soiling of their underwear. But, for others, the condition can be overwhelming due to a complete lack of bowel control, which can lead to embarrassment, loneliness, and fear. You may feel reluctant to go out of your house fearing that you might not be able to make it to a toilet in time. Taking steps to cope with this fear is important. You can try the following practical tips:

• Use the toilet right before leaving your home.
• If you expect that you will be incontinent, wear an absorbent pad in your underwear or a disposable underwear.
• Carry a bag with all your cleanup supplies and an extra set of clothes when leaving the house.
• Find where a public restroom is located before one is needed so that you can get to it quickly.
• Use pills that reduce the smell of stool and gas (fecal deodorants), which are available over-the-counter.
• Avoid eating at restaurants or at social gatherings: Food intake triggers contraction of the large intestine that pushes the stools toward the rectum and also causes the rectum to contract for about 30 to 60 minutes. Both these contractions can increase the likelihood of passing gas and having a bowel movement soon after eating. Anxiety can further aggravate this activity. People with fecal incontinence may avoid eating outside or may take antidiarrheal medications before eating in these situations.

As fecal incontinence can be distressing, it is very important to take proper steps to deal with it. With treatment, you can boost your self-esteem and improve your quality of life.

The following factors can increase your risk of developing fecal incontinence:

Age: Fecal incontinence occurs more commonly in middle-aged and elderly adults, though it can occur at any age.

Gender: Fecal incontinence is a bit more common among women. One reason may be a difficult childbirth causing injuries to the pelvic floor (the muscles, ligaments, and tissues that support the uterus, vagina, bladder, and rectum). The connection between fecal incontinence and pelvic floor injury during childbirth is not clear because most women develop the problem only after the age of 40. It may be possible that the pelvic floor injury causes symptoms only at a later stage.

Nervous system damage or injury: People with long-standing diabetes or multiple sclerosis — conditions that damage the nerves controlling defecation — may be at a higher risk of developing fecal incontinence.

Dementia: Fecal incontinence is often present in late-stage Alzheimer's disease and dementia.

Physical disability: Physically disabled people find it difficult to reach a toilet in time. An injury that has caused a physical disability may also cause damage to the rectal nerve, which leads to fecal incontinence. In addition, inactive lifestyle can lead to constipation and fecal incontinence.

Poor general health: People with several chronic, long-lasting disorders are at a higher risk of developing fecal incontinence.

Complications.

Complications of fecal incontinence may include:

Emotional distress: Loss of control over bodily functions can cause loss of dignity that can lead to a feeling of shame, frustration, anger, embarrassment, and depression.

Often, people with fecal incontinence try to hide their problem or avoid social engagements.

Skin irritation: The skin surrounding the anus is very sensitive and delicate. Continual contact with the fecal matter can cause itching and pain, and potentially lead to development of sores (ulcers) that need to be treated.