Fecal Incontinence

Fecal incontinence is the inability to control the passage of gas or stool (feces) through the anus. More than 5.5 million Americans have the condition, and 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.^[1][2]

Illustration of the rectum and anus. Source: NDDIC

For some people the condition is limited to slight occasional soiling of underwear, but more severe 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 may be reduced with treatment that improves bowel control and makes incontinence easier to manage.

Signs and Symptoms

People with fecal incontinence have difficulty controlling the passage of gas and stool. Other symptoms may include diarrhea, gas and bloating, constipation, and abdominal cramping.

Causes^[3]

• 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.

• Damage to the anal sphincter muscles. Fecal incontinence can be caused by injury to one or both of the ring-like muscles at the end of the rectum called the anal internal and external sphincters. The sphincters keep stool inside. When damaged, the muscles are not 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.

• Damage to the nerves of the anal sphincter muscles or the rectum. 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 a person no longer feels the sensation that they 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 in the rectum. Normally, the rectum stretches to hold stool until a person 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 cannot 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.

• Pelvic floor dysfunction. Abnormalities of the pelvic foor muscles and nerves can cause fecal incontinence. Examples include:
  • Impaired ability to sense stool in the rectum
  • Decreased ability to contract muscles in the anal canal to defecate
  • Dropping down of the rectum, a condition called rectal prolapse
  • Protrusion of the rectum through the vagina, a condition called rectocele
  • General weakness and sagging of the pelvic floor

Childbirth is often the cause of pelvic floor dysfunction, and incontinence usually doesn't appear until the mid-forties or later.

Diagnosis

Diagnosis of fecal incontinence is usually straightforward and based on a medical history. Treatment might involve a medical specialist such as a gastroenterologist, proctologist, or colorectal surgeon, and may require more detailed diagnostic tests that form the first step in a comprehensive treatment plan.^[4]

Several diagnostic tests are available, including:

• 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.

Treatment

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.^[5]

Medication

If diarrhea is causing fecal incontinence, medication may help. Sometimes doctors recommend using bulk laxatives to help people develop a more regular bowel pattern. Or the doctor may prescribe antidiarrheal medicines such as loperamide or diphenoxylate to slow down the bowel and help control the problem.^[6]

Therapies

Dietary changes

Food affects the consistency of stool and how quickly it passes through the digestive system. If the stools are hard to control because they are watery, eating high-fiber foods adds bulk and may make stool easier to control. However, people with well-formed stools may find that high-fiber foods act as a laxative and contribute to the problem. Foods and drinks that containing caffeine may worsen the problem. These include foods like coffee, tea, or chocolate—which relaxes the internal anal sphincter muscles.

Adjusting what is eaten may help manage fecal incontinence.

• Keeping a food diary. A food diary lists what is eaten, how much, and when an incontinent episode occurs. After a few days, a pattern may begin to emerge involving certain foods and incontinence. After identifying foods that seem to cause problems, cutting back on them may help improve incontinence. Foods and drinks that typically cause diarrhea, and so should probably be avoided, include:
  • Drinks and foods containing caffeine
  • Cured or smoked meat such as sausage, ham, or turkey
  • Spicy foods
  • Alcoholic beverages
  • Dairy products such as milk, cheese, or ice cream
  • Fruits such as apples, peaches, or pears
  • Fatty and greasy foods
  • Sweeteners, such as sorbitol, xylitol, mannitol, and fructose, which are found in diet drinks, sugarless gum and candy, chocolate, and fruit juices
• Eating small meals more frequently. In some people, large meals cause bowel contractions that lead to diarrhea. It is possible to still eat the same amount of food in a day, but spacing it out by eating several small meals may help.
• Eating and drinking at different times. Liquid helps move food through the digestive system. Drinking something half an hour before or after meals, but not with meals, may help.
• Eating the right amount of fiber. For many people, fiber makes stool soft, formed, and easier to control. Fiber is found in fruits, vegetables, and grains. Eating 20 to 30 grams of fiber a day, but adding it to the diet slowly so that the body can adjust, may help. Too much fiber all at once can cause bloating, gas, or even diarrhea. Also, too much insoluble, or undigestible, fiber can contribute to diarrhea. If eating more fiber makes the diarrhea worse, trying to cut back to two servings each of fruits and vegetables and removing skins and seeds from the food may help.
• Eating foods that make stool bulkier. Foods that contain soluble, or digestible, fiber slow the emptying of the bowels. These foods include bananas, rice, tapioca, bread, potatoes, applesauce, cheese, smooth peanut butter, yogurt, pasta, and oatmeal.
• Getting plenty to drink. Drinking eight 8-ounce glasses of liquid a day helps prevent dehydration and keeps stool soft and formed. Water is a good choice. Drinks with caffeine, alcohol, milk, or carbonation may trigger diarrhea.

Over time, diarrhea can keep the body from absorbing vitamins and minerals. Consult with a doctor about taking a vitamin supplement is a good idea.

Bowel training

Bowel training helps some people relearn how to control their bowel movements. In some cases, bowel training involves strengthening muscles. In others, it means training the bowels to empty at a specific time of day. Biofeedback is a way to strengthen and coordinate the muscles and has helped some people with incontinence. Developing a regular pattern of bowel movements may also help. This approach is based on attempts to have bowel movements at specific times during the day, such as after every meal. The key to this approach is persistence.

Surgery

Surgery to repair the anal sphincter may be an option for people who have not responded to dietary treatment and biofeedback and for those whose fecal incontinence is caused by injury to the pelvic floor, anal canal, or anal sphincter. People who have severe fecal incontinence that doesn't respond to other treatments may benefit from injection of bulking agents in the anus or nerve stimulation in the lower pelvic area. A colostomy may be indicated for people with severe fecal incontinence who haven't been helped by other procedures. This procedure involves disconnecting the colon and bringing one end through an opening in the abdomen—called a stoma—through which stool leaves the body and is collected in a pouch. The colostomy may be temporary or permanent.

Living with Fecal Incontinence

Because fecal incontinence can cause distress in the form of embarrassment, fear, and loneliness, taking steps to deal with it is important. Treatment can improve the quality of life. Doctor and support groups can help with information and support and, in some cases, can provide eferrals to doctors who specialize in treating fecal incontinence.

Lifestyle changes

• Take a backpack or tote bag containing cleanup supplies and a change of clothing everywhere.
• Locate public restrooms before they are needed.
• Use the toilet before leaving home.
• If an episode is likely, wear disposable undergarments or sanitary pads.
• If episodes are frequent, use oral fecal deodorants.

Caring for someone with fecal incontinence

Children

If a child has fecal incontinence, he or she needs to see a doctor to determine the cause and treatment. Fecal incontinence can occur in children because of a birth defect or disease, but in most cases it is because of chronic constipation.^[7]

Potty-trained children often get constipated simply because they refuse to go to the bathroom. The problem might stem from embarrassment over using a public toilet or unwillingness to stop playing and go to the bathroom. But if the child continues to hold in stool, the feces will accumulate and harden in the rectum. The child might have a stomachache and not eat much, despite being hungry. It can be painful when he or she eventually does pass the stool, which can lead to fear of having another bowel movement.

Children who are constipated may soil their underpants. Soiling happens when liquid stool from farther up in the bowel seeps past the hard stool in the rectum and leaks out. Soiling is a sign of fecal incontinence. The child cannot control the liquid stool and may not even know it has passed.

The first step in treating the problem is passing the built-up stool. The doctor may prescribe one or more enemas or a drink that helps clean out the bowel, such as magnesium citrate, mineral oil, or polyethylene glycol.

The next step is preventing future constipation. Children play a big role in their treatment. It is important to teach the child proper bowel habits, which means training him or her to have regular bowel movements. Experts recommend that parents of children with poor bowel habits encourage them to sit on the toilet four times each day—after meals and at bedtime—for five minutes. Giving rewards for bowel movements and not punishing children for incontinent episodes helps.

Some changes in eating habits may also be necessary. A child should eat more high-fiber foods to soften stool, avoid dairy products if they cause constipation, and drink plenty of fluids every day, including water and juices such as prune, grape, or apricot, which help prevent constipation. If necessary, the doctor may prescribe laxatives.

It may take several months to break the pattern of withholding stool and constipation, and episodes may occur again in the future. The key is to pay close attention to the child's bowel habits. Some warning signs to watch for include:

• Pain with bowel movements
• Hard stool
• Constipation
• Refusal to go to the bathroom
• Soiled underwear
• Signs of holding back a bowel movement, such as squatting, crossing the legs, or rocking back and forth

Clinical Trials

• Clinical Trials of Patients With Fecal Incontinence

Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports research into many kinds of digestive disorders, including fecal incontinence. In addition, researchers throughout the country are working to find possible solutions to the problem of fecal incontinence. Some studies address fecal incontinence due to anal sphincter damage and combine surgical procedures with electrical stimulation.

References

1. ↑ [No authors listed] NIH state-of-the-science conference statement on prevention of fecal and urinary incontinence in adults. NIH Consens State Sci Statements. 2007 Dec 12-14;24(1):1-37. Abstract | Full Text | PDF
2. ↑ Landefeld CS, Bowers BJ, Feld AD, et al. National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med. 2008 Mar 18;148(6):449-58. Abstract | Full Text | PDF
3. ↑ Kamm MA. Faecal incontinence. BMJ. 1998 Feb 14;316(7130):528-32. Citation | Full Text | PDF
4. ↑ Tuteja AK, Rao SS. Review article: Recent trends in diagnosis and treatment of faecal incontinence. Aliment Pharmacol Ther. 2004 Apr 15;19(8):829-40. Abstract | Full Text | PDF
5. ↑ Shamliyan T, Wyman J, Bliss DZ, Kane RL, Wilt TJ. Prevention of urinary and fecal incontinence in adults. Evid Rep Technol Assess (Full Rep). 2007 Dec;(161):1-379. Abstract
6. ↑ Shee CD, Pounder RE. Loperamide, diphenoxylate, and codeine phosphate in chronic diarrhoea. Br Med J. 1980 Feb 23;280(6213):524. Citation | PDF
7. ↑ Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. 2007 Jun;92(6):486-9. Abstract

External Links

The [National Association for Continence (NAFC)] is the largest and most prolific consumer education and advocacy organization dedicated to bladder and bowel health.