What is Fecal Incontinence?
Fecal incontinence refers to the unintentional release of stool or the inability to control bowel movements. This can vary in severity, from accidentally passing gas to a complete loss of bowel control. The severity of the condition significantly affects a person’s quality of life.
People suffering from fecal incontinence unintentionally lose liquid or solid stool. In some cases, known as true anal incontinence, there is a loss of control of the muscle (anal sphincter) that helps hold in stool, causing unexpected bowel movements. However, fecal incontinence can also be a result of several other conditions, such as enlarged skin tags around the anus, poor hygiene, hemorrhoids (swollen blood vessels in the rectum), rectal prolapse (when the rectum, the lower end of the bowel, slips outside the anus), and fistula in ano (an abnormal connection between the anus and the skin). Other typical causes include the use of medications that loosen the stool (laxatives), inflammatory bowel disease (a group of conditions that cause inflammation in the digestive tract), and infections caused by parasites.
What Causes Fecal Incontinence?
Fecal incontinence, or the inability to control bowel movements, can be triggered by different things such as:
* Damage or disease in the central nervous system, which includes the brain and spinal cord
* Damage or disease in the autonomic nervous system, which controls involuntary body functions
* Inflammatory bowel disease, which causes inflammation in the digestive tract
* Irritable bowel syndrome, a common disorder that affects the large intestine
* Diabetes mellitus, a condition where your body is unable to properly process food for use as energy
* Multiple sclerosis, a disease of the brain and spinal cord in which the immune system eats away at the protective covering of nerves
* Cerebrovascular accident, also known as a stroke, which happens when blood flow to a part of your brain is stopped
* Anal surgery, which is done to fix problems with the muscles that help you control your bowel movements
* Spinal cord trauma, which is a severe type of injury that affects all the nerves of the spinal cord
* Vaginal delivery, because giving birth can sometimes cause injury to the muscles or nerves that control bowel movements.
Risk Factors and Frequency for Fecal Incontinence
Fecal incontinence, or the lack of control over bowel movements, is a condition that is often not reported due to the embarrassment it can cause. Its reported occurrence varies, with anywhere from 2% to 21% of people experiencing it, with the average being around 7.7%. The occurrence does vary with age:
- Around 7% of women under 30 years old experience it.
- The rate goes up to 22% by the time they reach their 70s.
- For elderly people in nursing homes, it affects 25% to 35% of residents.
- For hospitalized elderly patients, it affects 10% to 25%.
In fact, fecal incontinence is the second most common reason why elderly people are placed in nursing homes. The number of people dealing with fecal incontinence seems to be going up. After a cesarean section, many women experience this issue. It’s also more common in older people, those who have given birth vaginally, and those suffering from depression. On top of the personal difficulty, there is also a high societal cost, with hundreds of millions of dollars spent on adult diapers every year to manage it.
Signs and Symptoms of Fecal Incontinence
Fecal incontinence refers to the inability to control bowel movements, and there are three main types:
- Passive incontinence: This involves the unaware and accidental release of stool, often pointing to complications like neurological diseases or dysfunctional anorectal reflexes and sphincters.
- Urge Incontinence: This refers to the inability to hold in stool despite trying, especially when sensation is still intact. This could suggest impaired sphincter function or a rectum that can’t contain stool.
- Fecal seepage: This is the unpleasant leakage of stool, typically following a normal bowel movement.
Understanding the underlying cause of fecal incontinence involves looking at:
- The nature of incontinence (gas, stool consistency), history of urgency
- When it started, how long it’s been happening and its timing
- How fecal incontinence has affected someone’s quality of life
- Any history of constipation
- Prescription medication that might cause constipation or diarrhoea
- General medical history (such as irritable bowel disease, diabetes, thyroid issues, spinal problems, neurological diseases, urinary incontinence)
- In women, things like the use of forceps during childbirth, any tears in the perineum, and the number of children born
Physical examination may include:
- An inspection, which is when doctors look for signs of complications such as hemorrhoids, fecal matter, scarring, skin damage, prolapse and more than usual perineal descent.
- Testing the anal wink reflex: Doctors will lightly touch the area around the anus with a cotton ball, prompting a quick contraction of the external anal sphincter. The lack of a response could mean a loss of spinal arc and potential underlying neurological disease.
- A digital rectal examination: Doctors evaluate the resting tone of the rectum to assess the internal anal sphincter. Then they ask the patient to bear down so they can judge how the puborectalis and pelvic floor muscles are functioning. Lastly, they will ask the patient to tighten the anal sphincter, allowing them to gauge the muscle’s tone.
Testing for Fecal Incontinence
If you are experiencing incontinence (unwanted leakage of stool), your doctor will need to understand the nature of your condition to offer the best treatment. Depending on the main symptoms, different tests may be recommended.
If diarrhea is thought to be one of the main causes of incontinence, your doctor may suggest several tests:
- Stool tests to check for things like infections, nutrient absorption issues, and whether your pancreas is working correctly
- Tests to check for diabetes and thyroid disorders, as these can influence digestion
- Tests for bacterial overgrowth, and intolerances to certain sugars like lactose and fructose
- A colonoscopy to look for any inflammation in the bowel, masses, ulcers, or narrowing of the colon
If your incontinence is not related to diarrhea, your doctor may recommend more specific tests. Some useful tests in these cases can measure things like muscle strength around the rectum and how well you can empty your bowel. They include:
- An endoscopic ultrasound to measure the thickness of the muscles controlling the rectum
- A magnetic resonance imaging (MRI) scan to get a detailed image of the area
- Anal manometry which measures the pressure in the rectum both at rest and when squeezing
- Pudendal nerve latency measurement to check the health of the nerve controlling the bowel
Based on the result of these tests, your doctor may recommend further specialized tests. These include:
- An electromyography to measure the electrical activity in the muscles when you’re at rest and straining
- Defecography, a test which involves using a contrast dye to take images of the rectum during a bowel movement
These tests will give your doctor a clearer understanding of why you are experiencing incontinence, allowing for the most effective treatment to be planned.
Treatment Options for Fecal Incontinence
Fecal incontinence, which is the inability to control bowel movements, can be managed in various ways. The following are some methods that may help:
Improving your overall health and nutrition can help manage symptoms. You must also maintain hygiene around the anus by regular cleaning, applying zinc oxide, and using incontinence pads. Additionally, try to avoid foods that can cause diarrhea, like those high in lactose or fructose. For those struggling with mild memory problems, sticking to a regular toilet schedule may help.
Medication can also play a role in managing fecal incontinence. Bulking agents, like methylcellulose, help to harden the stools. Medicines like Imodium and Lomotil can reduce stool frequency and lessen the urgency to go to the bathroom. If you have underlying health conditions, such as irritable bowel syndrome, it is crucial to treat them as well. Hormone replacement therapy could help postmenopausal women, and medicines like amitriptyline could aid those experiencing both urinary and fecal incontinence.
If these treatments are not effective, further tests, such as an anorectal manometry accompanied by ultrasound or MRI imaging, may be needed. Methods such as biofeedback therapy, which retrains the pelvic and abdominal muscles that control bowel movements, have shown success, though rates of success can vary significantly.
Surgery can be considered for severe cases that do not respond to other treatments. Surgical options depend on the case, but they can range from repairing a defect in the muscles that control the bowel (the “sphincters”), building a new sphincter using your own muscle or prosthetic materials, or creating a pouch in the digestive system to collect waste. Other treatments include injecting silicone or small beads into the sphincter to improve its function.
Fecal incontinence can also be managed with a device called the sacral nerve stimulator, which enhances the muscle strength and function in the rectum. It does have side effects, however, such as bleeding, fluid collection, and possible nerve damage.
Another emerging treatment involves injecting a bulking agent into the rectal lining. Initial results show a reduction in incontinence episodes for some patients. Also, a vaginal bowel control device has shown promise by using a balloon to apply pressure on the rectum through the vaginal wall, reducing incontinence. This device needs to be cleaned regularly and can be adjusted as needed.
What else can Fecal Incontinence be?
The possible causes for loss of bowel control, also known as fecal incontinence, can be a number of conditions including:
- Foreign objects in the vagina or anus
- Abnormal connection between the rectum and vagina (rectovaginal fistula)
- Abnormal connection between the anus and skin (fistula in ano)
- An abscess near the anus (anorectal abscess)
- Condition where the rectum slips out of place (rectal prolapse)
What to expect with Fecal Incontinence
The outlook for most patients with fecal incontinence, which is the inability to control bowel movements, can be uncertain. Immediate results after a surgical procedure called sphincteroplasty, which is done to repair the sphincter muscles, vary greatly, with success rates ranging from 30% to 60%. In the long run, less than half of the patients experience satisfying results. This condition can severely impact the quality of life and often leads to mental distress.
Possible Complications When Diagnosed with Fecal Incontinence
Fecal incontinence, or the inability to control bowel movements, is a challenging issue to handle. The vast array of treatments available shows that there’s no one-size-fits-all solution. People with this condition often experience severe mental distress, including feelings of depression and anxiety, and their overall life quality can suffer significantly.
Notably, there are potential complications tied to any surgical interventions performed for fecal incontinence:
- Separation of skin and underlying fat tissue
- Loss of blood supply to tissues, causing tissue death
- Infections
- Bleeding and blood clot formation
- Pain in the rectum and anus
- Persistent inability to control bowel movements
