Fecal incontinence

Fecal incontinence is the inability to control bowel movements, causing stool (feces) to leak unexpectedly from the rectum. Also called bowel incontinence, fecal incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control.

Common causes of fecal incontinence include diarrhea, constipation, and muscle or nerve damage. The muscle or nerve damage may be associated with aging or with giving birth.

Whatever the cause, fecal incontinence can be embarrassing. But don't shy away from talking to your doctor about this common problem. Treatments can improve fecal incontinence and your quality of life.

Symptoms

Fecal incontinence may occur temporarily during an occasional bout of diarrhea, but for some people, fecal incontinence is chronic or recurring. People with this condition may be unable to stop the urge to defecate, which comes on so suddenly that they don't make it to the toilet in time. This is called urge incontinence.

Another type of fecal incontinence occurs in people who are not aware of the need to pass stool. This is called passive incontinence.

Fecal incontinence may be accompanied by other bowel problems, such as:

• Diarrhea
• Constipation
• Gas and bloating

When to see a doctor

See your doctor if you or your child develops fecal incontinence, especially if it's frequent or severe, or if it causes emotional distress. Often, people are reluctant to tell their doctors about fecal incontinence. But treatments are available, and the sooner you're evaluated, the sooner you may find some relief from your symptoms.

Causes

For many people, there is more than one cause of fecal incontinence.

Causes can include:

• Muscle damage. Injury to the rings of muscle at the end of the rectum (anal sphincter) may make it difficult to hold stool back properly. This kind of damage can occur during childbirth, especially if you have an episiotomy or forceps are used during delivery.
• Nerve damage. Injury to the nerves that sense stool in the rectum or those that control the anal sphincter can lead to fecal incontinence. The nerve damage can be caused by childbirth, constant straining during bowel movements, spinal cord injury or a stroke. Some diseases, such as diabetes and multiple sclerosis, also can affect these nerves and cause damage that leads to fecal incontinence.
• Constipation. Chronic constipation may cause a dry, hard mass of stool (impacted stool) to form in the rectum and become too large to pass. The muscles of the rectum and intestines stretch and eventually weaken, allowing watery stool from farther up the digestive tract to move around the impacted stool and leak out. Chronic constipation may also cause nerve damage that leads to fecal incontinence.
• Diarrhea. Solid stool is easier to retain in the rectum than is loose stool, so the loose stools of diarrhea can cause or worsen fecal incontinence.
• Hemorrhoids. When the veins in your rectum swell, causing hemorrhoids, this keeps your anus from closing completely, which can allow stool to leak out.
• Loss of storage capacity in the rectum. Normally, the rectum stretches to accommodate stool. If your rectum is scarred or stiff due to surgery, radiation treatment or inflammatory bowel disease, the rectum can't stretch as much as it needs to, and excess stool can leak out.
• Surgery. Surgery to treat enlarged veins in the rectum or anus (hemorrhoids), as well as more-complex operations involving the rectum and anus, can cause muscle and nerve damage that leads to fecal incontinence.
• Rectal prolapse. Fecal incontinence can be a result of this condition, in which the rectum drops down into the anus. The stretching of the rectal sphincter by prolapse damages the nerves that control the rectal sphincter. The longer this persists, the less likely the nerves and muscles will recover.
• Rectocele. In women, fecal incontinence can occur if the rectum protrudes through the vagina.

Risk factors

A number of factors may increase your risk of developing fecal incontinence, including:

• Age. Although fecal incontinence can occur at any age, it's more common in adults over 65.
• Being female. Fecal incontinence can be a complication of childbirth. Recent research has also found that women who take menopausal hormone replacement therapy have a modest increased risk of fecal incontinence.
• Nerve damage. People who have long-standing diabetes, multiple sclerosis, or back trauma from injury or surgery may be at risk of fecal incontinence, as these conditions can damage nerves that help control defecation.
• Dementia. Fecal incontinence is often present in late-stage Alzheimer's disease and dementia.
• Physical disability. Being physically disabled may make it difficult to reach a toilet in time. An injury that caused a physical disability also may cause rectal nerve damage, leading to fecal incontinence.

Complications

Complications of fecal incontinence may include:

• Emotional distress. The loss of dignity associated with losing control over one's bodily functions can lead to embarrassment, shame, frustration and depression. It's common for people with fecal incontinence to try to hide the problem or to avoid social engagements.
• Skin irritation. The skin around the anus is delicate and sensitive. Repeated contact with stool can lead to pain and itching, and potentially to sores (ulcers) that require medical treatment.

Prevention

Depending on the cause, it may be possible to improve or prevent fecal incontinence. These actions may help:

• Reduce constipation. Increase your exercise, eat more high-fiber foods and drink plenty of fluids.
• Control diarrhea. Treating or eliminating the cause of the diarrhea, such as an intestinal infection, may help you avoid fecal incontinence.
• Avoid straining. Straining during bowel movements can eventually weaken anal sphincter muscles or damage nerves, possibly leading to fecal incontinence.

Diagnosis

Your doctor will ask questions about your condition and perform a physical exam that usually includes a visual inspection of your anus. A probe may be used to examine this area for nerve damage. Normally, this touching causes your anal sphincter to contract and your anus to pucker.

Medical tests

A number of tests are available to help pinpoint the cause of fecal incontinence:

• Digital rectal exam. Your doctor inserts a gloved and lubricated finger into your rectum to evaluate the strength of your sphincter muscles and to check for any abnormalities in the rectal area. During the exam your doctor may ask you to bear down, to check for rectal prolapse.
• Balloon expulsion test. A small balloon is inserted into the rectum and filled with water. You'll then be asked to go to the toilet to expel the balloon. If it takes longer than one to three minutes to do so, you likely have a defecation disorder.
• Anal manometry. A narrow, flexible tube is inserted into the anus and rectum. A small balloon at the tip of the tube may be expanded. This test helps measure the tightness of your anal sphincter and the sensitivity and functioning of your rectum.
• Anorectal ultrasonography. A narrow, wand-like instrument is inserted into the anus and rectum. The instrument produces video images that allow your doctor to evaluate the structure of your sphincter.
• Proctography. X-ray video images are made while you have a bowel movement on a specially designed toilet. The test measures how much stool your rectum can hold and evaluates how well your body expels stool.
• Colonoscopy. A flexible tube is inserted into your rectum to inspect the entire colon.
• Magnetic resonance imaging (MRI). An MRI can provide clear pictures of the sphincter to determine if the muscles are intact and can also provide images during defecation (defecography).

Treatment

Medications

Depending on the cause of fecal incontinence, options include:

• Anti-diarrheal drugs such as loperamide hydrochloride (Imodium A-D) and diphenoxylate and atropine sulfate (Lomotil)
• Bulk laxatives such as methylcellulose (Citrucel) and psyllium (Metamucil), if chronic constipation is causing your incontinence

Exercise and other therapies

If muscle damage is causing fecal incontinence, your doctor may recommend a program of exercise and other therapies to restore muscle strength. These treatments can improve anal sphincter control and the awareness of the urge to defecate.

Options include:

• Kegel exercises. Kegel exercises strengthen the pelvic floor muscles, which support the bladder and bowel and, in women, the uterus, and may help reduce incontinence. To perform Kegel exercises, contract the muscles that you would normally use to stop the flow of urine.

  Hold the contraction for three seconds, then relax for three seconds. Repeat this pattern 10 times. As your muscles strengthen, hold the contraction longer, gradually working your way up to three sets of 10 contractions every day.

• Biofeedback. Specially trained physical therapists teach simple exercises that can increase anal muscle strength. People learn how to strengthen pelvic floor muscles, sense when stool is ready to be released and contract the muscles if having a bowel movement at a certain time is inconvenient. Sometimes the training is done with the help of anal manometry and a rectal balloon.
• Bowel training. Your doctor may recommend making a conscious effort to have a bowel movement at a specific time of day: for example, after eating. Establishing when you need to use the toilet can help you gain greater control.
• Bulking agents. Injections of nonabsorbable bulking agents can thicken the walls of your anus. This helps prevent leakage.
• Sacral nerve stimulation (SNS). The sacral nerves run from your spinal cord to muscles in your pelvis, and regulate the sensation and strength of your rectal and anal sphincter muscles. Implanting a device that sends small electrical impulses continuously to the nerves can strengthen muscles in the bowel.
• Posterior tibial nerve stimulation (PTNS/TENS). This minimally invasive treatment stimulates the posterior tibial nerve at the ankle. In a large study, however, this therapy didn't prove to be significantly better than a placebo.
• Vaginal balloon (Eclipse System). This is a pump-type device inserted in the vagina. The inflated balloon results in pressure on the rectal area, leading to a decrease in the number of episodes of fecal incontinence.
•  Radiofrequency therapy. Known as the Secca procedure, this involves delivering temperature-controlled radiofrequency energy to the wall of the anal canal to help improve muscle tone. Radiofrequency therapy is minimally invasive and is generally performed under local anesthesia and sedation. However, this procedure isn't always covered by insurance.

Surgery

Treating fecal incontinence may require surgery to correct an underlying problem, such as rectal prolapse or sphincter damage caused by childbirth. The options include:

• Sphincteroplasty. This procedure repairs a damaged or weakened anal sphincter that occurred during childbirth. Doctors identify an injured area of muscle and free its edges from the surrounding tissue. They then bring the muscle edges back together and sew them in an overlapping fashion, strengthening the muscle and tightening the sphincter. Sphincteroplasty may be an option for patients trying to avoid colostomy.
• Treating rectal prolapse, a rectocele or hemorrhoids. Surgical correction of these problems will likely reduce or eliminate fecal incontinence. Over time, the prolapse of the rectum through the rectal sphincter damages the nerves and muscles of the sphincter. The longer the prolapse goes untreated, the higher will be the risk of fecal incontinence not resolving after surgery.
• Colostomy (bowel diversion). This surgery diverts stool through an opening in the abdomen. Doctors attach a special bag to this opening to collect the stool. Colostomy is generally considered only after other treatments haven't been successful.

Lifestyle and home remedies

Dietary changes

You may be able to gain better control of your bowel movements by:

• Keeping track of what you eat. What you eat and drink affects the consistency of your stools. Make a list of what you eat for a few days. You may discover a connection between certain foods and your bouts of incontinence. Once you've identified problem foods, stop eating them and see if your incontinence improves.

  Foods that can cause diarrhea or gas and worsen fecal incontinence include spicy foods, fatty and greasy foods, and dairy products (if you're lactose intolerant). Caffeine-containing beverages and alcohol also can act as laxatives, as can products such as sugar-free gum and diet soda, which contain artificial sweeteners.

• Getting adequate fiber. If constipation is causing fecal incontinence, your doctor may recommend eating fiber-rich foods. Fiber helps make stool soft and easier to control. If diarrhea is contributing to the problem, high-fiber foods can also add bulk to your stools and make them less watery.

  Fiber is predominately present in fruits, vegetables, and whole-grain breads and cereals. Aim for 25 grams of fiber a day or more, but don't add it to your diet all at once. Too much fiber suddenly can cause uncomfortable bloating and gas.

• Drink more water. To keep stools soft and formed, drink at least eight glasses of liquid, preferably water, a day.

Skin care

You can help avoid further discomfort from fecal incontinence by keeping the skin around your anus as clean and dry as possible. To relieve anal discomfort and eliminate any possible odor associated with fecal incontinence:

• Wash with water. Gently wash the area with water after each bowel movement. Showering or soaking in a bath also may help.

  Soap can dry and irritate the skin. So can rubbing with dry toilet paper. Premoistened, alcohol-free, perfume-free towelettes or wipes may be a good alternative for cleaning the area.

• Dry thoroughly. Allow the area to air-dry, if possible. If you're short on time, you can gently pat the area dry with toilet paper or a clean washcloth.
• Apply a cream or powder. Moisture-barrier creams help keep irritated skin from having direct contact with feces. Be sure the area is clean and dry before you apply any cream. Nonmedicated talcum powder or cornstarch also may help relieve anal discomfort.
• Wear cotton underwear and loose clothing. Tight clothing can restrict airflow, making skin problems worse. Change soiled underwear quickly.

When medical treatments can't completely eliminate incontinence, products such as absorbent pads and disposable underwear can help you manage the problem. If you use pads or adult diapers, be sure they have an absorbent wicking layer on top, to help keep moisture away from your skin.

Coping and support

For some people, including children, fecal incontinence is a relatively minor problem, limited to occasional soiling of their underwear. For others, the condition can be devastating due to a complete lack of bowel control.

If you have fecal incontinence

You may feel reluctant to leave your house out of fear you might not make it to a toilet in time. To overcome that fear, try these practical tips:

• Use the toilet right before you go out.
• If you expect you'll be incontinent, wear a pad or a disposable undergarment.
• Carry supplies for cleaning up and a change of clothing with you.
• Know where toilets are located before you need them so that you can get to them quickly.
• Use pills to reduce the smell of stool and gas (fecal deodorants) available over-the-counter.

Because fecal incontinence can be distressing, it's important to take steps to deal with it. Treatment can help improve your quality of life and raise your self-esteem.

Preparing for an appointment

You may start by seeing your primary care provider. Or, you may be referred immediately to a doctor who specializes in treating digestive conditions (gastroenterologist).

Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as fasting before having a specific test. Make a list of:

• Your symptoms, including any that seem unrelated to the reason for your appointment
• Key personal information, including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Bring a family member or friend with you if possible, to help you remember the information you're given
• Make a list of questions to ask your doctor

For fecal incontinence, some basic questions to ask your doctor include:

• What's likely causing my symptoms?
• Other than the most likely cause, what are other possible causes for my symptoms?
• What tests do I need?
• Is my condition likely temporary or chronic?
• What's the best course of action?
• What are the alternatives to the primary approach you're suggesting?
• I have other health conditions. Will treatment for fecal incontinence complicate my care for these conditions?
• Are there restrictions I need to follow?
• Should I see a specialist?
• Are there brochures or other printed material I can have? What websites do you recommend?

What to expect from your doctor

Your doctor is likely to ask you several questions, such as:

• When did your symptoms begin?
• Have your symptoms been continuous or do they come and go?
• How severe are your symptoms?
• Does anything seem to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Do you avoid any activities because of your symptoms?
• Do you have other conditions such as diabetes, multiple sclerosis or chronic constipation?
• Do you have diarrhea?
• Have you ever been diagnosed with ulcerative colitis or Crohn's disease?
• Have you ever had radiation therapy to your pelvic area?
• Were forceps used or did you have an episiotomy during childbirth?
• Do you also have urinary incontinence?

What you can do in the meantime

Avoid foods or activities that worsen your symptoms. This might include avoiding caffeine, fatty or greasy foods, dairy products, spicy foods, or anything that makes your incontinence worse.

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