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Fecal Incontinence

Fecal incontinence is the inability to control passage of liquid or solid stool from the rectum and it affects 2-15% of all adults in the United States.

condition

Definition

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Fecal incontinence is the inability to control passage of liquid or solid stool from the rectum and it affects 2-15% of all adults in the United States. Because people are embarrassed to talk about their symptoms, many people go untreated. There are effective treatments that can help, or even cure, the problem.

How the system is supposed to work

Fecal Incontinence

  • The rectum is the lowest part of the large intestine that ends just before the anus. Stool can be stored here until it is ready to be eliminated.
  • The anus is the opening of the lower intestine where solid waste is eliminated. Just on the inside of the anus are two rings of muscle around the anus or exit from the bowel. These two rings of muscle form the anal sphincter and are designed to hold in the bowel contents at all times except when you are sitting on the toilet and trying to empty the bowel.
  • The external anal sphincter is the muscle that you use to hold on when the rectum is full and you feel that you need to empty the bowel.
  • The internal anal sphincter is an internal muscle responsible for keeping the anal canal closed at all times except when there is an urge to empty the bowel. You do not have to think about keeping this muscle closed, it happens automatically.

What is fecal incontinence? - AnatomyWhen stool enters the rectum the internal anal sphincter muscle automatically relaxes and opens up the top of the anal canal. This is normal and allows stool to enter the upper anal canal to be "sampled" by the very sensitive nerve cells in the upper anal canal. People with normal sensation can easily tell the difference between wind (gas, also called flatus), which can safely be passed if it is socially convenient without fear of soiling, diarrhea (very loose or runny stools needing urgent attention and access to a toilet) and a normal stool. Most people just know what is in the rectum without really having to think about it.

If a normal stool is sensed and it is not convenient to find a toilet at that moment, bowel emptying is delayed by squeezing the external anal sphincter. Squeezing the external sphincter ensures that the stool is not simply expelled as soon as it enters the rectum, and in fact the stool is pushed back up out of the anal canal. For most people this is not a deliberate action - you should not need to think, "I must squeeze my anal sphincter muscles so that I do not have a bowel accident" - but this is actually what you do, subconsciously without really thinking about it.

This external sphincter squeeze does not need to last all the time until the toilet is found. Stool is propelled back into the rectum, and the rectum relaxes and so the urge to empty the bowel is resisted and wears off.

For most people, an urge to empty the bowel is felt, but if the time and place are not right, it is possible to delay bowel emptying, and the feeling of needing to go wears off very soon. Most people can then forget about the bowel for a while, and some can put off bowel emptying almost indefinitely, but may get reminders that the bowel is full at intervals until it is emptied. Continually resisting the urge to empty the bowel or ignoring the call to stool can lead to constipation, as the longer the stools stay in the colon and rectum, the more fluid is absorbed and the harder the stools become.

For the mechanism to work properly you need several things:

  • The nerves of the rectum and anus need to be sending the right messages to your brain so that you can feel when stool or gas arrives in the rectum and can send messages to the muscles that you want to hold on;
  • The internal and external anal sphincters need to be undamaged and working properly;
  • The stools should not be too soft or loose so that the sphincters can cope with holding on, but not so hard so that they are difficult to pass;
  • And you need the physical ability to get to and onto a toilet and to hold on until the correct place is reached.

As you can see, this is a delicate system and unfortunately there are many things that can go wrong with it.

What are the different types of fecal incontinence?

  • Flatal incontinence: the inability to control the passage of gas from the rectum
  • Fecal incontinence: the inability to control the passage of liquid or solid stool from the rectum
  • Double incontinence: the inability to control both the passage of stool from the rectum and urine from the urethra (the tube through which urine normally goes through)
  • Rectovaginal fistula: occurs when a connection develops between the vagina and rectum and results in stool being passed uncontrollably through the vagina

Causes

There are many causes and combinations of causes that cause fecal incontinence. Among them:

Birth trauma/injury

During a very difficult vaginal delivery or during a delivery that requires use of forceps, vacuum or episiotomy to help deliver your baby, a partial tear in the muscles of the anal sphincter can happen. If this tear doesn’t heal properly, it can cause incontinence. This is called a chronic third/fourth degree laceration.

If a large tear occurs during a very difficult vaginal delivery and that tear does not heal properly, a connection can form between the vagina and the rectum. This is called a rectovaginal fistula and causes incontinence because stool can pass inadvertently from the rectum into the vagina. Birth trauma is the most common cause of fecal incontinence in young women.

Age

Aging has the greatest impact on bowel control in women over the age of 40

Surgical

Certain surgeries place you at risk for developing fecal incontinence. Most of these surgeries involve manipulation of the muscles in the pelvis or the sphincter itself. They include:

  • Internal sphincterotomy
  • Fistulectomy
  • Low anterior resection

Diarrheal states

Chronic diarrhea can cause fecal incontinence. Often, your doctor may try to control your diarrhea first to see if this helps in your bowel control. Inflammatory bowel disease is a disease can cause alternating constipation and diarrhea. Often, if your diarrhea can be controlled with medication or dietary changes, and bowel control can improve.

Laxative abuse

Laxatives containing Senna can damage your bowels and cause fecal incontinence.

Infectious enteritis

This is a temporary condition that may be caused by a virus or bacteria. Your doctor may ask you for a stool sample to check if there is a "bug" causing your diarrhea. If an infection is confirmed, treatment with antibiotics may improve your bowel control.

Neurological conditions

Various medical conditions may cause fecal incontinence. Some diseases affect the nerves in the pelvis that help you control your bowel movements; if these nerves are damaged, fecal incontinence occurs.

The diseases that can cause nerve damage include:

  • Multiple sclerosis
  • Parkinson’s disease
  • Spinal cord injury
  • Stroke
  • Dementia
  • Diabetic neuropathy

Congenital anorectal malformation

Some people are born with birth defects that can cause fecal incontinence.

Symptoms

Physical symptoms

Women may complain of the inability to control passage of gas from their rectum or may complain of the inability to control their bowel movements (liquid or solid).

Emotional symptoms

Less than half of women with fecal incontinence seek help from their doctors. Many people who suffer from incontinence have a high anxiety level and often times have low self-esteem and self-hatred. The fear of loosing stool can reduce the quality of life and often leads to isolation. Because of the private nature of the condition people often do not share their feelings with others. This can lead to further anxiety and depression.

Unfortunately, this fear and anxiety can lead to upsetting the digestive system causing further issues. Most people can get significant relief from fecal incontinence. There are many treatments available that can help reduce incontinence, and for some can eliminate it all together. The best treatment for negative emotions related to fecal incontinence is to seeking medical treatment.

diagnosis

Diagnosis

When you go into see your doctor you will have a health history taken. Some of the questions you may be asked include:

  • When did your symptoms begin?
  • Did your symptoms begin after a surgery such as a hysterectomy or surgery for your hemorrhoids?
  • Do your symptoms relate to when you had children?
  • How fast did your symptoms get worse?
  • Do you feel the need to have a bowel movement, or does it just happen without your awareness?
  • Do you feel like you completely empty your rectum after a bowel movement or do you feel like your bowel movements are incomplete?
  • Do you ever have to use your hand to help the bowel movement come out by either pressing on the inside or outside of the vagina?
  • How are your symptoms affecting your quality of life?
  • Are your symptoms affecting your ability to be intimate with your partner?
  • Are you having any problems with low back pain or loss of sensation in your legs?

Pelvic exam

Your doctor will perform a pelvic exam that will look at how well your pelvic organs are supported. There will also be a careful digital examination of your rectum and anus to look for hemorrhoids, and prior scarring. Your doctor will do an exam with her finger in your rectum to check the strength of your muscles and your ability to squeeze those muscles.

Are there other tests I can expect as part of my evaluation?

Transanal ultrasound

This is an ultrasound which is done with a probe placed into your rectum. The probe is about the size of a finger and should not be uncomfortable. The ultrasound allows your doctor to see the anal sphincter which is the muscle that allows you to control your bowel movements. The sphincter may be weakened or torn and this may be the reason you are having symptoms.

MRI

This radiology test allows your doctor to carefully look at the appearance of the muscles of the pelvic floor which help you to control your bowel movements and also the nerves in your back which are important to bowel control.

Defecography

This is a test that allows your doctor to see with X-ray what is happening when you are having a bowel movement. It allows your doctor to see if there are blockages or pelvic organ prolapse. During this exam, barium paste is placed into your rectum and vagina

You will sit on a special toilet and you will be asked to bear-down, as if you are having a bowel movement. While you are bearing down, X-Ray images are taken that allows your doctor to see what happens to your pelvic muscles and bowels.

Anal Manometry

This is a test that allows your doctor to see if the muscles of the rectum are strong and able to function properly. During this exam, a small air-filled balloon is inserted into your rectum which allows your doctor to determine if the muscles react properly to different pressures.

treatment

Treatment

UVA's Female Pelvic Floor Disorders Program offers a number of treatment options.

Non-surgical treatment for fecal incontinence

Physical therapy

  • Strengthening and Retraining Pelvis and Sphincter Muscles - As part of your evaluation your doctor might find that your pelvic and anal sphincter muscles are weakened and recommend a course of physical therapy. A physical therapist will carefully evaluate muscles of your back, abdomen and pelvis. They will teach you how to correctly do pelvic floor muscle contractions, otherwise known as Kegel exercises, which are designed to strengthen the pelvic floor muscles. These muscles support the bladder and bowel openings in both men and women. Strengthening the muscles of the pelvic floor can aid in preventing leakage of urine or feces with coughing, sneezing, lifting, and other stressful movements. Other benefits of Kegels include enhanced sexual function, conditioned muscles to make childbirth easier, decrease and/or prevent prolapse of pelvic organs, and improve the ability to pass stool.
  • A course of biofeedback therapy might be recommended by the therapist. This involves using a computer or machine to show you how your muscles are working, and how well you can co-ordinate the use of these muscles with a full bowel, and to teach you how to improve your control. Sometimes the anal sphincter muscles do not relax properly when you empty the bowel, and so the rectum is not emptied completely. Biofeedback can help to teach you to use the correct muscles to empty the bowel effectively. Improvement of your symptoms will occur over a period of a few weeks to months. Provided that the sphincter muscles and nerves are not too severely damaged, biofeedback usually benefits half to three-quarters of people who try it. This is not a "quick fix" and you will need to work hard at the exercises to make them effective.
  • Electrical Stimulation - In addition, sometimes therapist will recommend electrical stimulation to further help in making your muscles stronger as part of your treatment plan. You can either purchase or rent one of these devices to use at home.

Medications

  • Loperamide (Imodium®) is a drug that is helps in thickening stool consistency and decreases the number of bowel movements per day.
  • Diphenoxylate (Lomotil®) is a drug that also used to thicken stool consistency and decrease bowel movements.
  • Increased Fiber Intake- used to increase the size of the stool to decrease loss of liquid and very soft stool. Examples: Metamucil, Benfiber (all over the counter).

Surgical treatment for fecal incontinenceInjured/separated anal sphincter muscle

Anal sphincteroplasty is a procedure which can be done if the doctor thinks that your involuntary loss of stool is caused by an injured/separated sphincter muscle. An opening in the skin is made between the vagina and anus. The separated muscles are found and put back together with stitches and the skin over the muscles is also sewn back together. A separation of skin edges occurs in about a third of patients which typically heal spontaneously over time. Some patients may also have some difficulty with bowel movements after surgery.

Rectovaginal fistula is a procedure in which the tract connecting the vagina and rectum are separated and the area between these two opening is closed in multiple tissue layers. An incision is either made between the vaginal and anus or just inside the vagina. The tract is located, the tissues separated, and the area is closed with multiple tissue layers. About a third of patients will have the skin edges of the repair separate. This separation will heal spontaneously over time.Repaired Anal sphincter muscle

A seton is a ribbon of material that is placed in a fistula to aid in healing. Thread, wire, rubber, or medicated suture can be used as a seton. A seton can sometimes be placed by a physician in clinic. On other occasions, it may be placed in an operating room, in combination with an examination under anesthesia. A seton works by draining the fistula tract in order to prevent bacteria from collecting (for example, in an abscess) and eroding more deeply into the patient’s tissues. With drainage, the infection will pass allowing operation at the site of origin. Formerly, they were also used to cut the fistula tract and/or induce scarring. None will experience significant discharge. The all setons that are inserted are sutured, or stitched, to the tissue or otherwise secured. You should not worry about the seton moving up into your body.

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