Fecal Incontinence

Overview

Fecal incontinence is the inability to control your bowels. When you feel the urge to have a bowel movement, you may not be able to hold it until you get to a toilet. Or stool may leak from the rectum unexpectedly, sometimes while passing gas.

It is estimated that more than 18 million - 1 in 12 - Americans have fecal incontinence. It affects people of all ages—children and adults. Fecal incontinence is more common in women and older adults, but it is not a normal part of aging.

Loss of bowel control can be devastating. People who have fecal incontinence may feel ashamed, embarrassed, or humiliated. Some don’t want to leave the house out of fear they might have an accident in public. Most try to hide the problem as long as possible, so they withdraw from friends and family. The social isolation is unfortunate but is reduced with treatment that improves bowel control and makes incontinence easier to manage.

Causes

 Fecal incontinence can have several causes:

  • Constipation
  • Damage to the anal sphincter muscles
  • Damage to the nerves of the anal sphincter muscles or the rectum
  • Loss of storage capacity in the rectum
  • Diarrhea
  • Rectovaginal fistula 

Constipation

Constipation is one of the most common causes of fecal incontinence. Constipation causes large, hard stools to become lodged in the rectum.

Watery stool can then leak out around the hardened stool. Constipation also causes the muscles of the rectum to stretch, which weakens the muscles so they can’t hold stool in the rectum long enough for a person to reach a bathroom.

Muscle Damage

Fecal incontinence can be caused by injury to one or both of the ring-like muscles at the end of the rectum called the internal and external anal sphincters. The sphincters keep stool inside. When damaged, the muscles aren’t strong enough to do their job and stool can leak out. In women, the damage often happens when giving birth. The risk of injury is greatest if the doctor uses forceps to help deliver the baby or performs an episiotomy, which is a cut in the vaginal area to prevent it from tearing during birth. Hemorrhoid surgery can also damage the sphincters.

Nerve Damage

Fecal incontinence can be caused by damage to the nerves that control the anal sphincters or the nerves that sense stool in the rectum. If the nerves that control the sphincters are injured, the muscles don’t work properly and incontinence can occur. If the sensory nerves are damaged, they don’t sense that stool is in the rectum so you won’t feel the need to use the bathroom until stool has leaked out. Nerve damage can be caused by childbirth, a long-term habit of straining to pass stool, stroke, physical disability due to injury, and diseases that affect the nerves such as diabetes and multiple sclerosis.

Loss of Storage Capacity

Normally, the rectum expands to hold stool until you can get to a bathroom. But rectal surgery, radiation treatment, and inflammatory bowel disease can cause scarring that makes the walls of the rectum stiff and less elastic. The rectum then can’t stretch as much to hold stool and fecal incontinence results. Inflammatory bowel disease also can irritate rectal walls, making them unable to contain stool.

Diarrhea

Diarrhea, or loose stool, is more difficult to control than solid stool because with diarrhea the rectum fills with stool at a faster rate. Even people who don’t have fecal incontinence can leak stool when they have diarrhea.

Rectovaginal Fistula 

A communication between the rectum and vagina that can result from trauma, childbirth, infection, or previous surgery.

Symptoms

Symptoms include:

  • Inability to control the passage of stools or gas (in both liquid and solid forms)
  • Inability to make it to the toilet in time

Diagnosis

Doctors understand the feelings associated with fecal incontinence, so you can talk freely with your doctor. The doctor will ask some health-related questions, do a physical exam, and possibly run some medical tests. Your doctor may refer you to a specialist, such as a gastroenterologist, proctologist, or colorectal surgeon.

The doctor or specialist may conduct one or more tests:

  • Anal manometry checks the tightness of the anal sphincter and its ability to respond to signals, as well as the sensitivity and function of the rectum. Magnetic resonance imaging (MRI) is sometimes used to evaluate the sphincter.
  • Anorectal ultrasonography evaluates the structure of the anal sphincters.
  • Proctography, also known as defecography, shows how much stool the rectum can hold, how well the rectum holds it, and how well the rectum can evacuate it.
  • Proctosigmoidoscopy allows doctors to look inside the rectum and lower colon for signs of disease or other problems that can cause fecal incontinence, such as inflammation, tumors, or scar tissue.
  • Anal electromyography tests for nerve damage, which is often associated with injury during childbirth.

Treatments

Effective treatments are available for fecal incontinence and can improve or restore bowel control. The type of treatment depends on the cause and severity of fecal incontinence; it may include dietary changes, medication, bowel training, or surgery. More than one treatment may be necessary for successful control because continence is a complicated chain of events.

Dietary Changes

Food affects the consistency of stool and how quickly it passes through the digestive system. If your stools are hard to control because they are watery, you may find that eating high-fiber foods adds bulk and makes stool easier to control. But people with well-formed stools may find that high-fiber foods act as a laxative and contribute to the problem. Foods and drinks that may make the problem worse are those containing caffeine, alcohol, dairy, and artificial sweeteners, which can trigger diarrhea in some people.

Improving pelvic floor muscle strength can help with fecal incontinence.

Patients can do exercises on their own but often have the most improvement when they work with a physical therapist. There are many specially trained physical therapists with the skills to help in Portland and the Pacific Northwest.  Different medications, including fiber supplementation and Imodium can help.

There are certain instances when surgery can help.

Some tears in the anal sphincter muscles can be surgically repaired, as can rectovaginal fistulas.  Interstim, neuromodulation of the sacral nerves, has also been shown to help fecal incontinence. Studies have shown that one year after placement, 40% of patients are completely continent and >80% are markedly improved.

 

Resources

National Institute of Diabetes and Digestive and Kidney DIseases (NIDDK): More information on fecal incontinence

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