Fecal Incontinence

Overview

What is Fecal Incontinence?

Fecal incontinence is the inability to control the passage of liquid and/or solid stool1. Fecal incontinence ranges from the loss of an entire solid bowel movement in severe cases to the loss of a small amount of liquid waste. It has been estimated that more than 6.5 million Americans have fecal incontinence2. However, many people with fecal incontinence never report it to their healthcare provider because of embarrassment or because they do not feel anything can be done to help the problem. Fortunately, this idea is incorrect – there are many treatment options available and most people can be helped significantly!

Caution: Most bowel problems are benign in nature, but a change in your normal bowel function could be an early symptom of cancer. If you are experiencing a constant urge to have a bowel movement, diarrhea, constipation, or blood in or on your stool, it could be an indication of colorectal cancer, and you should notify your healthcare provider immediately. Colorectal cancer is fairly common and very curable in the early stages; however, colorectal cancer may not show symptoms until advanced stages. For this reason, both men and women at age 50 are encouraged to receive a baseline screening examination; this should be done even earlier for those who have a family history of colorectal cancer. To support this effort, many states cover Medicaid beneficiaries for rectal and colon screenings to help detect this cancer in its early stages.

What is Constipation?

Chronic constipation is the passage of small amounts of hard, dry stool fewer than three times per week and is associated with both fecal and urinary incontinence3. There may be leakage of liquid stool around hard impacted stool, leading to the apparent occurrence of "diarrhea" that is in fact due to severe constipation. Chronic constipation and the pressure and strain resulting from it may weaken the muscles supporting the pelvic organs. The impacted stool may also press on the bladder or the urethra (the tube that releases urine from the body) weakening urine flow, causing unnatural retention of urine, or heightening the urge to urinate.

Normal Function

Bowel control requires normal function of the small intestine, large intestine (colon), rectum, anal sphincter muscles (the muscles around the anus), and the nervous system. The amount of stool and its consistency also affects a person’s ability to control the bowel movement.

  • Normal function of the small and large intestine produces soft formed stool, which is delivered to the rectum at regular intervals, usually once or twice a day.
  • Normal nervous system function allows you to recognize when your rectum is full of stool and also allows you to contract the sphincter muscles to hold the stool in until you can get to the toilet.
  • A normal sphincter muscle gives you the ability to keep the anus closed so you can hold the stool in; if the sphincter muscle is damaged, it is much harder to hold the stool in and you are much more likely to leak, especially when the stool is liquid.
  • A normal rectum can serve as a temporary storage area for the stool; however, if the rectum is very inflamed it will be unable to relax and store the stool. This explains why people with inflammatory bowel conditions have more problems with incontinence.

Causes of fecal incontinence include, but are not limited to: severe constipation, damage to the anal sphincter muscles or nerves during child delivery, anal surgery, spinal cord injury, stroke, systemic disease (such as multiple sclerosis and Parkinson’s disease), rectal prolapse, and chronic diarrhea. Also, fecal incontinence can be drug-induced; for example, the overuse of laxatives can cause diarrhea which may result in incontinence. It is also associated with old age, major depression, urinary incontinence, and Irritable Bowel Syndrome (IBS). Symptoms of IBS may include abdominal pain, constipation, diarrhea, gas, and indigestion.

What is the Link Between Constipation and Incontinence?

Chronic constipation is the passage of small amounts of hard, dry stool fewer than three times per week; other symptoms associated with constipation are difficult evacuation of stool and the sensation of incomplete emptying3. In severe cases hard dry stool becomes impacted in the rectal vault; when this occurs, the individual may experience leakage of liquid stool around the hard impacted stool. This leads to the apparent occurrence of "diarrhea" that is in fact due to severe constipation. Chronic constipation and the resulting “straining at stool” may weaken the muscles supporting the pelvic organs. The impacted stool may also press on the bladder or the urethra (the tube that releases urine from the body), causing unnatural retention of urine, or heightening the urge to urinate.

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Causes of Fecal Incontinence

Incontinence in the Elderly

Anal sphincter dysfunction is a common cause of fecal incontinence for men and women in old age. This can be caused by the natural weakening of the anal sphincter muscles as a result of aging. Another factor contributing to fecal incontinence in frail, older people is constipation. Two very important things to remember about fecal incontinence are that it often indicates a more serious underlying medical problem that should be investigated and that fecal incontinence is not an inevitable consequence of aging4. While incontinence affects both men and women, many studies show more women are affected because of injury to the anal sphincter muscles and nerves that can occur during childbirth5,6. Recent data suggest that 2.2% of women who have delivered more than one child experience fecal incontinence due to the stress of labor on sphincter muscles. Percentages of fecal incontinence increase to 7% of 65 year-olds in healthy condition and to 23% of all stroke patients. Finally, 33% of elderly people at home or in a hospital experience bowel control problems8.

Incontinence in Women

Researchers have concluded that more than one out of ten adult women in the general population has fecal incontinence. Almost one in fifteen of these women has moderate to severe symptoms 7. It has also been estimated that the prevalence of fecal incontinence in the community ranges from 6% in those women younger than 40 years to 15% in older women7.

The natural stress and pressure that occurs during childbirth can lead to pelvic floor damage and fecal incontinence and this injury is not always preventable. In fact, fecal incontinence may not present itself until decades later, when normal aging causes loss of muscle tone; the weakened muscles may lose the ability to compensate for the earlier injury and incontinence is the result. The pelvic floor includes the urinary and anal sphincters and multiple muscles and ligaments; these structures serve to supports the pelvic organs (bladder, rectum, and uterus). Therefore proper functioning of the pelvic floor is crucial to maintaining continence. It has been documented that a planned cesarean section prevents fecal incontinence by protecting the pelvic floor. But a C-section is a surgery and as with any surgery, there is considerable risk. In addition, vaginal delivery with forceps has been shown to be a cause of clinically significant pelvic floor dysfunction, which can lead to fecal incontinence9. All of these concerns and considerations should be discussed by a woman and her healthcare provider prior to delivery.

Damage to the Nervous System

Improper nerve functioning may lead to fecal incontinence and can also be caused by injury to the nervous system, such as spinal cord injury or spina bifida, and by diseases that damage nerves, such as multiple sclerosis, Parkinson’s disease, and stroke.

Healthy Bowel Habits

While prevention is not always possible, leading a healthy lifestyle is always recommended to improve bowel health and bowel control. Eating a balanced diet in combination with regular exercise should help promote regular stool elimination. Constipation can usually be prevented by adequate daily fiber and fluid intake. Recommended daily fiber intake is 25-35 grams; this can be obtained through fruits, vegetables, and whole grains, or through regular use of a fiber supplement (granules, wafers, caplets, or chewable tablets). Proper fiber intake should always be accompanied by proper fluid intake, which is usually defined as 30ml per kilogram of body weight for a moderately active person in a temperate climate. (This translates into about ½ ounce per pound of body weight.)

Regular exercise also contributes to normal bowel function, so incorporate exercise into your daily activities whenever possible.

Respond promptly to the urge to have a bowel movement. If you are able to go to the bathroom when you have the “urge to go”, the stool is much easier to eliminate. If you delay going to the toilet, the stool gets hard and is difficult to eliminate.

In cases of diarrhea, you should limit alcohol, caffeine, spicy foods, and leafy green vegetables. Until the diarrhea has resolved, you should add constipating foods such as cheese, yogurt, boiled white rice, pasta, bananas, and applesauce.

Diagnosis

If you are experiencing fecal incontinence, you should mention it to your primary care provider. At the initial visit with a healthcare provider, you should be prepared to supply a detailed history of your medical problems, medications, surgeries, childbirth history, and stool leakage. Keeping a bowel chart and symptom diary prior to your appointment may be helpful. You should also be prepared for physical diagnostic procedures and possibly blood testing.

After their evaluation and initial recommendations, you may need to see one of the following professionals:

  • Gastroenterologist (digestive and intestinal system)
  • Urogynecologist (pelvic floor dysfunction in women)
  • Colorectal Surgeon (colon, rectum and anal disorders)

Your primary care provider or specialist may order one or more of the following diagnostic procedures:

  • Endosonography (rectal ultrasound): involves placement of a small, balloon-tipped ultrasound probe into the rectum to view anal sphincter muscles.
  • Flexible sigmoidoscopy/colonoscopy:involves visual inspection of the intestinal tract through a thin lighted tube inserted through the anus.
  • Manometry (anorectal): involves insertion of small tube into the anal canal to tests the response of the anal sphincter muscles to rectal distention, and the pressure and strength of the anal muscles.
  • Electromyolography (EMG): tests nerve function with tiny needle electrodes inserted into muscles around the anus.
  • Defecography: uses X-rays to evaluate the process of stool elimination; helps to identify problems with stool evacuation such as rectocele or rectal prolapse.

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Treatment

Sometimes even small lifestyle changes such as dietary modifications or the elimination of certain medications can be helpful in regaining bowel control. Taking medications or increasing fiber to change the consistency of the stool may provide relief, since firm stool is easier to control than loose or liquid stool. The first steps to controlling incontinence are to normalize stool consistency with increased fiber intake or other bulking measures, and to strengthen the sphincter muscles with pelvic floor exercises. Often, treatment includes both medical and behavioral therapy.

  • Lifestyle Modifications— If your fecal incontinence is associated with constipation, then good fluid intake, regular exercise, and regular bowel habits can be helpful. Having a good breakfast with tea or coffee and then routinely going to the bathroom may help you to establish regular bowel elimination. Alternatively, for some people avoiding caffeine may be helpful. The key elements are to work with fiber and fluid intake to establish stool that is soft but formed, and to respond promptly to the urge to defecate.
  • Medications— Your provider will review your prescribed and over-the-counter medication to determine if any of them are causing or contributing to constipation or diarrhea. If you are constipated, then regular laxative and stool softeners as recommended by your provider will be important. If you have diarrhea, supplements to firm stool can increase bowel control since firmer stool is usually easier to control than liquid stool. Over-the-counter anti-diarrhea medications include loperamide (Immodium) and prescription medications may include diphenoxylate with atropine (Lomotil), hyoscyamine sulfate (Nulev), alosetron (Lotronex), or cholestyramine (Questran). None of these should be taken, however, without recommendation of a healthcare provider.
  • Exercise — Pelvic floor muscle exercises (Kegel exercises), when performed regularly and correctly, can greatly improve anal sphincter muscle tone and function. This often leads to increased bowel control and a reduction or elimination of fecal incontinence episodes within a few weeks. To perform the exercise, contract the muscles of the anus as tightly as possible (as if you are trying to prevent the passage of gas) for a count of five and then relax. Repeat 30 times, three times daily.
  • Biofeedback— Biofeedback is a non-invasive technique that converts anal sphincter muscle contractions to a visual display on a computer screen to help a patient become more aware of their anal sphincter muscles. This technique can be used to teach or supplement pelvic muscle exercises.
  • Stimulated defecation programs-- People who lack sensory awareness of rectal filling and who are unable to control their sphincter muscles to delay defecation need to establish a routine program for bowel elimination. Most people will need to use a stimulus such as a suppository, digital stimulation, or a “mini-enema” to promote rectal evacuation. This program should be established in collaboration with your healthcare provider.

People who continue to experience fecal incontinence despite other treatments may require surgery to regain control. Surgery may especially be needed for those who have experienced anal muscle injuries. Surgical options depend on the cause of the incontinence, the severity of the problem, the health and age of the patient, and the clinical judgment of the surgeon.

Historically used surgical options include:

  • Sphincteroplasty — Rectal sphincter repair was the first treatment developed to treat fecal incontinence. It corrects a defect and involves re-attaching the rectal muscles to tighten and strengthen the sphincter.
  • Artificial Anal Sphincter — This synthetic sphincter is a small implant that imitates the natural function of the anal sphincter muscle and is manually controlled by the patient with a bulb pump placed discretely in the body.
  • ACE Procedure— This procedure is sometimes helpful for patients with persistent incontinence due to a neurological process or to severe constipation that does not respond to other treatment. A one-way path is created into the colon; the patient inserts a small tube through this one-way path to flush the colon out on a routine basis.
  • Colostomy— This procedure involves creation of a stoma, or a surgically created opening, in the abdominal wall; the stool is eliminated through this opening, and an odor proof collection device is worn over the stoma.

More recent, less invasive surgical options offer promise for selected patients:

  • Sacral Nerve Stimulation (InterStim®) - Often compared to a cardiac pacemaker, this treatment involves electrical stimulation of sacral nerves from a matchstick size device implanted at the base of the spine. This can be effective for both urinary and fecal symptoms.
  • Injectable Bulking Agents (Solesta®) - The technique of injecting non-absorbable materials around the anus which may bulk the muscle and improve sensation performed by some surgeons.
  • Procon2® - Functioning as a management device, this silicone balloon cuff is designed to prevent fecal matter from passing out of the rectum until such time a bowel movement is planned. Manual release of the cuff permits a bowel movement.
  • SECCA® Procedure - A physician delivers precisely controlled radiofrequency energy to the anal canal to thicken the tissue and thereby improve the function of the sphincter muscle.

Treatments undergoing testing:

  • Phenylephrine Gel — This treatment is currently being tested for improvement in resting tone of anal muscles.
  • Anal encirclement and sphincter reinforcement with biologic mesh - this involves modifications to the traditional anal muscular repair with biological mesh augmentation
  • Placement of a rectal sling to improve the angle of the anal canal and thereby minimizing leakage of stool.
  • Surgical implantation of a ring of a magnets around the anal sphincter which keeps the anus closed and prevents the leakage of stool.
  • Stem cells to augment the native anal muscles through growth of a new anal sphincter tissue

Management Options

  • Fecal Incontinence Collection Systems — With multiple options ranging from bags adhered directly to the skin to catheters and tubes attached to a collection bag, there are many management options for fecal incontinence. These are primarily indicated for short-term management of patients with diarrhea and fecal incontinence.
  • Absorbent Products — A variety of disposable or reusable absorbent products that may be used during treatment exist.
  • Skin Products — Fecal material can cause many problems including skin irritation and breakdown, which increase the risk of infection and are often painful for the patient. Many products exist to help maintain skin integrity including pH-balanced cleansers, moisturizers, and moisture barriers that help protect the skin from irritants or moisture. Many also include fragrances and anti-bacterial components, both of which should be used with caution. Fragrance can often increase irritation, exacerbating the problem, and routine anti-bacterial use remains controversial as little evidence exists about its effectiveness.

Fecal incontinence is a difficult condition to face. However, awareness has increased tremendously over the past 10 years. Treatment continues to expand and provide patients and their healthcare provider options specific to their needs. Talk to your doctor about treatment options that are right for you.

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References

Aside from specific references, general information was also obtained from WebMd's page on Bowel Incontinence (see reference below)

  1. Haines, Md, Cynthia, ed. "Bowel Incontinence." WedMD . 2004. Cleveland Clinic. 13 July 2006.
  2. US. National Institutes of Health. Department of Health and Human Services. Fecal Incontinence . Bethesda, MD: National Digestive Diseases Information Clearinghouse, 2001.
  3. National Institutes Of Health. "Definition and Causes of Diarrhea." HealthLink . 28 June 1999. Medical College of Wisconsin. 14 July 2006.
  4. Fonda D, DuBeau C, Harari D, Palmer M, Ouslander J, Roe B. Incontinence in the Frail Elderly. In: Incontinence, 3rd edition. Abrams P, Cardozo L, Khoury S. Wein A, eds. Plymouth, UK:Health Publication Ltd, 2005, pp1163-1239.
  5. Haines, Md, Cynthia, ed. "Bowel Incontinence." WedMD . 2004. Cleveland Clinic. 13 July 2006.
  6. Palmieri Md, Beniamino, Giorgia Benuzzi, Bsc, and Nicola Bellini, Bsc, Phd. "The Anal Bag: a Modern Approach to Fecal Incontinence Management." OstomyWoundManagement 51.12 (2005): 44-52
  7. Bharucha AE, Zinsmeister AR, Locke GR, Seide BM, McKeon K, Schleck CD, Melton LJ. Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN. Gastroenterology. 2005; 129(1):42-9.
  8. Palmieri Md, Beniamino, Giorgia Benuzzi, Bsc, and Nicola Bellini, Bsc, Phd. "The Anal Bag: a Modern Approach to Fecal Incontinence Management." OstomyWoundManagement 51.12 (2005): 44-52
  9. Farrell, Scott A. "Cesarean Section Versus Forceps-Assisted Vaginal Birth: It's Time to Include Pelvic Injury in the Risk-Benefit Equation." Canadian Medical Association Journal (CMAJ) (2002): 166-169. 26 May 2006.
  10. Wexner, Steven D. MD; Coller, John A. MD; Devroede, Ghislain MD; Hull, Tracy MD; McCallum, Richard MD; Chan, Miranda MD; Ayscue, Jennifer M. MD; Shobeiri, Abbas S. MD; Margolin, David MD; England, Michael MD; Kaufman, Howard MD; Snape, William J. MD; Mutlu, Ece MD; Chua, Heidi MD; Pettit, Paul MD; Nagle, Deborah MD; Madoff, Robert D. MD; Lerew, Darin R. PhD; Mellgren, Anders MD, PhD. Sacral Nerve Stimulation for Fecal Incontinence: Results of a 120-Patient Prospective Multicenter Study." Annals of Surgery 251.3 (March 2010): 441-449.
  11. Kim DH, Faruqui N, and Ghoniem GM (2010). Sacral neuromodulation outcomes in patients with urinary urge incontinence and concomitant urge fecal incontinence. Female Pelvic Medicine and Reconstructive Surgery, 16(3), 171-178.