Fecal incontinence

bowel incontinence, anal incontinence, accidental bowel leakage

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Inability to control the bowel movements, which results in stools leaking from the rectum unexpectedly, is called Fecal incontinence. Fecal incontinence is also known as bowel incontinence, and it can range from an occasional leakage of the stool while passing gas to sometimes losing complete control of the bowel. Fecal incontinence is more common in females and the elderly.

Symptoms of Fecal Incontinence

Fecal incontinence can be of two types:

a.    Urge fecal incontinence – You will know that you have to pass the stool, but you cannot control it before reaching the toilet.

b.   Passive fecal incontinence – You will pass stool without knowing it.

Facts about Fecal Incontinence

1.     Studies show that fecal incontinence is a common problem and affects 1 in 3 individuals (Whitehead WE et al.,2016).

2.     Fecal incontinence occurs in 2 out of 100 children (Lewis ML,2016).

When should you see a doctor?

When you have severe or frequent fecal incontinence, you should see a doctor. If fecal incontinence is affecting the quality of your life and causing stress, you should not delay taking a doctor’s appointment.

Causes of Fecal Incontinence

There are many causes of fecal incontinence, including:

a.    Damage to the muscle – Muscles present at the end of the rectum can get damaged, which makes it difficult for people to hold the stool. Such damage is more commonly seen during childbirth when there is forceps delivery or when an episiotomy is performed.

Source: Webmed.com

b.   Damage to the nerve – When there is damage to the nerves supplying the rectum, fecal incontinence can occur. Such nerves are responsible for the control of the anal sphincter. The damage can occur due to childbirth, spinal cord injury, and constant straining to pass the stool. Sometimes diseases like multiple sclerosis and diabetes can also damage the nerves resulting in fecal incontinence.

c.   Diarrhea – For people, the solid stool is easy to retain than loose stool. So loose stool can worsen fecal incontinence.

d.   Constipation – Chronic constipation can make the stool dry, hard, and too large to pass from the rectum. This makes the muscles of the rectum stretch and get weak, causing the loose or watery stool to move from the impacted stool and then leak out. Constipation can also cause damage to the nerve leading to fecal incontinence.

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e.      Hemorrhoids – Sometimes, when the veins in your rectum swell due to constipation or hard stool, hemorrhoids can occur. These hemorrhoids avoid your anus to completely close allowing the stool to pass involuntarily.

f.      Problem with rectum – Normally, to accommodate the stool rectum stretches. However, if your rectum is damaged, scarred, or stiff due to surgery, any bowel disease, or radiation treatment, it can’t stretch properly, resulting in the stool leaking out.

g.   Surgery – Surgeries involving the rectum or anus can cause muscle or nerve damage resulting in fecal incontinence. Even surgeries performed for hemorrhoids can damage the rectum or anus, leading to fecal incontinence.

h.   Prolapse of the rectum – Rectal prolapse is the condition where the rectum drops down from the anus. This stretches the rectal sphincter and damages the nerves that control them. Recovery depends on the duration of the rectal prolapse. The longer the prolapse persists, the less likely the nerves are to recover.

i.   Rectocele – Sometimes in women rectum can protrude from the vagina. The condition is called rectocele and can cause fecal incontinence.

Risk factors of Fecal incontinence

There are so many risk factors that contribute to fecal incontinence like:

1.    Age – Though fecal incontinence can occur at any age, it is commonly seen in the elderly over 65 years.

2.   Females – In most cases, fecal incontinence is a complication of childbirth. In addition, recent research has indicated the increased risk of fecal incontinence in women who take hormone replacement therapy.

3.  Damage to the nerve – As Fecal incontinence is caused by nerve damage, people with diabetes, spinal cord injury, and multiple sclerosis are at high risk.

4.   Dementia – Fecal incontinence can also present in patients with late stages of Alzheimer’s disease and dementia.

5.    Physical disability – People with physical disabilities may not reach the toilet on time which may result in the involuntary passing of the stools. Injury resulting in physical disability may also cause damage to the rectal nerve giving rise to fecal incontinence.

Complications of Fecal incontinence

1.     Distress – Losing control over ones’ bodily function can result in loss of dignity, depression, frustration, and embarrassment. People with fecal incontinence try to avoid social gatherings or try to hide the problem with their closed ones which only delays the treatment.

2.   Skin trouble – The area around the anus has delicate skin, which is also sensitive. When this skin repeatedly comes in contact with stool, it can cause pain, itching, and sores which need medical treatment.

Ways to prevent Fecal incontinence

You can prevent fecal incontinence by following ways. However, it depends on the factors that are causing it:

a.   Prevent constipation – By preventing constipation, you can reduce your risk of fecal incontinence. To prevent constipation, you can increase your exercise, boost your fiber intake and increase your fluid intake.

b.   Treat your diarrhea – By eliminating the cause of diarrhea like intestinal infection, it may help you in preventing fecal incontinence.

c.    Avoid straining during bowel movement – Straining while bowel movement can make your anal muscles weak and can also damage the nerves leading to fecal incontinence.

Tests used to diagnose Fecal incontinence.

When you have fecal incontinence, your doctor will evaluate the condition by performing physical and rectal exams. There are a few tests that help in diagnosing fecal incontinence:

a.     Anal manometry – The test checks the strength of the muscles of the anal sphincter. With the help of a thin tube, the sphincter tightness is measured.

b.   Anal ultrasound – The test allows the evaluation of the structure and the shape of the anal sphincter muscles along with the surrounding tissue. A small probe is inserted in the anus, which takes pictures of the sphincters.

c.    Anal EMG – The test identifies if there is nerve damage causing the anal sphincter to not function. It also evaluates the coordination between the anal and rectal muscles.

Treatment

Depending on the cause of fecal incontinence, treatment can include – dietary changes, medications, surgery, and physiotherapy involving bowel training.

a.  Dietary changes – Dietary changes help in preventing fecal incontinence (Bliss DZ et al.,2000). The main aim of the dietary changes is to avoid the food that causes loose stools like – caffeine, fruit juices, alcohol, prunes, spicy food, dairy products, artificial sweeteners, beans, etc. You will be suggested to eat food that helps in the thickening of the stool like – Bananas, pasta, potatoes, cheese, peanut butter, apple sauce, etc.

b.     Medication – Medicines that are prescribed for fecal incontinence include anti-diarrheal and fiber supplements. These drugs reduce stool movement by making the stool hard. Always ensure to consult your doctor before starting any medication.

c.    Surgery – Sphincteroplasty is performed for fecal incontinence. In the surgery, the damaged anal sphincter muscle is sewed back together. This tightens the anal opening. Other surgical procedures are artificial bowel sphincter, colostomy, ACE procedure, and Sacral nerve stimulation.

d.   Bowel training – There are two ways of bowel training. In the first type, you need to create a a-going-to-bathroom pattern. When you set a routine, you get to control your bowel movements. You can also take an enema daily which will remove the stool and reduce the chances of fecal incontinence.

The other type of bowel training includes exercises to strengthen the muscles of the anus (Jelovsek et al., 2019). A physiotherapist can teach you the use of the correct muscles while performing the exercises. A therapist can teach you the best ways to activate the deep pelvic floor and anal sphincters.

e.  Electrical stimulation – Electrical stimulation may have a therapeutic effect on fecal incontinence (Hosker et al., 2007). When a person is not able to feel the pelvic floor contraction on his own, the therapist may use the rectal probe to stimulate the pelvic floor and anal sphincter directly.

f.     Balloon retraining – It is biofeedback that will help the patient to learn to defecate and to identify the normal sensation in the rectum. This also allows the patients to retrain the coordination of defecation muscles themselves.

Physiotherapy under the guidance of a Progressive Care specialist can help you in determining the issues leading to fecal incontinence while also proscribing a management plan for the same so that you can embrace your life.

References:

1.   Whitehead WE, Palsson OS, Simren M. Treating fecal incontinence: an unmet need in primary care medicine. North Carolina Medical Journal. 2016;77(3):211–215.

2.     Lewis ML, Palsson OS, Whitehead WE, van Tilburg MAL. Prevalence of functional gastrointestinal disorders in children and adolescents. The Journal of Pediatrics. 2016;177:39–43.e3.

3. Bliss DZ, McLaughlin J, Jung HJ, Lowry A, Savik K, Jensen L. Comparison of the nutritional composition of diets of persons with fecal incontinence and that of age-and gender-matched controls. Journal of Wound, Ostomy and Continence Nursing. 2000;27(2):90–7.

4. Jelovsek, J. E., Markland, A. D., Whitehead, W. E., Barber, M. D., Newman, D. K., Rogers, R. G., Dyer, K., Visco, A. G., Sutkin, G., Zyczynski, H. M., Carper, B., Meikle, S. F., Sung, V. W., Gantz, M. G., & National Institute of Child Health and Human Development Pelvic Floor Disorders Network (2019). Controlling fecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomized clinical trial. The lancet. Gastroenterology & hepatology, 4(9), 698–710. 

 

5.     Hosker, G., Cody, J. D., & Norton, C. C. (2007). Electrical stimulation for fecal incontinence in adults. The Cochrane database of systematic reviews, 2007(3), CD001310. 

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